Successful surgical correction of ascending aortic dissection in a kidney transplant patient

Cardiovascular disease is the leading cause of death in patients with a transplanted kidney and in graft loss. We present the first clinical case of successful surgical correction of ascending aortic dissection (DeBakey type I) in a young patient with a functioning kidney graft. The patient underwent the first cadaveric kidney transplantation (KTx), which was complicated by acute humoral rejection and suboptimal graft function. High blood pressure, anemia, elevated blood levels of triglycerides, phosphorus, parathyroid hormone, and uric acid were recorded. A repeat KTx was performed five years later; the patient’s condition and kidney function were satisfactory. Three years later,the patient started experiencing severe pain along the thoracic and lumbar spine; his blood creatinine level was 408 μmol/L. Computed tomography and echocardiography diagnosed DeBakey type I aortic dissection (AD) with critical narrowing of the true aortic lumen at certain levels, dissection of aortic branches. Aortic resection surgery with prosthetic replacement of the ascending aorta according to David procedure with reimplantation of coronary artery orifices according to Kouchoukos technique, prosthetic replacement of the aortic arch with debranching of brachiocephalic artery and left common carotid artery were successfully performed as planned under endotracheal anesthesia, cardiopulmonary bypass and selective pharmacological cold cardioplegia. The peculiarities of the course, possible causes and outcomes of surgical correction of thoracic AD in the patient are discussed.

1. Gautier SV, Khomyakov SM. Organ donation and transplantation in the Russian Federation in 2020. 13th Report from the Registry of the Russian Transplant Society. Russian Journal of Transplantology and Artificial Organs. 2021; 23 (3): 8–34. (In Russ., English abstract). doi: 10.15825/1995-1191-2021-3-8-34.

2. Andrusev AM, Tomilina NA, Peregudova NG, Shinkarev MB. Kidney replacement therapy for end Stage Kidney Disease in Russian Federation, 2015–2019. Russian National Kidney Replacement Therapy Registry Report of Russian Public Organization of Nephrologists «Russian Dialysis Society». Nephrologу and Dialуsis. 2021; 23 (3): 255–329. (In Russ., English abstract). doi: 10.28996/2618-9801-2021-3-255-329.

3. Boenink R, Astley ME, Huijben JA, Stel VS, Kerschbaum J, Rosenberg-Ots M et al. The ERA Registry Annual Report 2019: summary and age comparisons. Clin Kidney J. 2021 Dec 15; 15 (3): 452–472. doi: 10.1093/ckj/sfab273.

4. Rangaswami J, Mathew RO, Parasuraman R, Tantisattamo E, Lubetzky M, Rao S et al. Cardiovascular disease in the kidney transplant recipient: epidemiology, diagnosis and management strategies. Nephrol Dial Transplant. 2019; 34: 760–773. doi: 10.1093/ndt/gfz053.

5. Ying T, Shi B, Kelly PJ, Pilmore H, Clayton PA, Chadban SJ. Death after kidney transplantation: an analysis by era and time post-transplant. J Am Soc Nephrol. 2020; 31 (12): 2887–2899. doi: 10.1681/ASN.2020050566.

6. Reutersberg B, Salvermoser M, Trenner M, Geisbűsch S, Zimmermann A, Eckstein H-H, Kuehnl A. Hospital incidence and in-hospital mortality of surgically and interventionally treated aortic dissections: Secondary data analysis of the Nationwide German Diagnosis-Related Group Statistics from 2006 to 2014. J Am Heart Assoc. 2019; 8: e011402. doi: 10.1161/JAHA.118.011402.

7. Malaisrie C, Szeto WY, Halas M, Girardi LN, Coselli JS, Sundt TM 3rd et al. AATS Clinical Practice Standards Committee: Adult Cardiac Surgery. 2021 The American Association for Thoracic Surgery expert consensus document: Surgical treatment of acute type A aortic dissection. J Thorac Cardiovasc Surg. 2021; 162 (3): 735–758. doi: 10.1016/j.jtcvs.2021.04.053.

8. Takeda K, Harada A, Okuda S, Fujimi S, Oh Y, Hattori F et al. Sudden death in chronic dialysis patients. Nephrol Dial Transplant. 1997; 12 (5): 952–955. doi: 10.1093/ndt/12.5.952.

9. Ogami T, Zimmermann E, Zhu RC, Zhao Y, Ning Y, Kurlansky P et al. Proximal aortic repair in dialysis patients: A national database analysis. J Thorac Cardiovasc Surg. 2021; 1–9. doi: 10.1016/j.jtcvs.2021.02.086.

10. Englum BR, He X, Gulack BC, Ganapathi AM, Mathew JP, Brennan JM et al. Hypothermia and cerebral protection strategies in aortic arch surgery: a comparative effectiveness analysis from the STS Adult Cardiac Surgery Database. Eur J Cardiothorac Surg. 2017; 52(3): 492–498. doi: 10.1093/ejcts/ezx133.

11. Hemli JM, Scheinerman SJ, Lesser ML, Ahn S, Mihelis EA, Jahn LA et al. Transfusion in elective aortic root replacement: analysis of the STS Adult Cardiac Surgery Database. Ann Thorac Surg. 2020; 110 (4): 1225–1233. doi: 10.1016/j.athoracsur.2020.01.035.

12. Lee TC, Kon Z, Cheema FH, Grau-Sepulveda MV, Englum B, Kim S et al. Contemporary management and outcomes of acute type A aortic dissection: an analysis of the STS adult cardiac surgery database. J Card Surg. 2018; 33: 7–18. doi: 10.1111/jocs.13511.

13. Evangelista A, Isselbacher EM, Bossone E, Gleason TG, Eusanio MD, Sechtem U et al. IRAD Investigators. Insights from the International Registry of Acute Aortic Dissection: a 20-year experience of collaborative clinical research. Circulation. 2018; 137 (17): 1846–1860. doi:10.1161/CIRCULATIONAHA.117.031264.

14. Fang M, Yu C, Chen S, Xiong W, Li X, Zeng R et al. Identification of novel clinically relevant variants in 70 southern chinese patients with thoracic aortic aneurysm and dissection by next-generation sequencing. Scientific Reports. 2017; 7 (1): 10035. doi: 10.1038/s41598-017-09785-y.

15. Li J, Yang L, Diao Y, Zhou L Xin Y, Jiang L et al. Genetic testing and clinical relevance of patients with thoracic aortic aneurysm and dissection in northwestern China. Mol Genet Genomic Med. 2021 Oct; 9 (10): e1800. doi:10.1002/mgg3.1800.

16. Podestà MA, Cucchiari D, Ciceri P, Messa P, Torregrosa J-V, Cozzolino M. Cardiovascular calcifications in kidney transplant recipients. Nephrol Dial Transplant. 2021 Feb 23; gfab053. doi: 10.1093/ndt/gfab053.

17. Hernández D, Alonso-Titos J, Armas-Padrón AM, Lopez V, Cabello M, Sola E et al. Waiting list and kidney transplant vascular risk: An ongoing unmet concern. Kidney Blood Press Res. 2020; 45: 1–27. doi:10.1159/000504546.

18. Liu ZH, Yu XQ, Yang JW, Jiang AL, Liu BC, Xing CY et al. China Dialysis Calcification Study Group. Prevalence and risk factors for vascular calcification in Chinese patients receiving dialysis: baseline results from a prospective cohort study. Curr Med Res Opin. 2018; 34(8): 1491–1500. doi: 10.1080/03007995.2018.1467886.

19. Reiss AB, Miyawaki N, Moon J, Kasselman LJ, Voloshyna I, D’Avino R Jr, De Leon J. CKD, arterial calcification, atherosclerosis and bone health: Interrelationships and controversies. Atherosclerosis. 2018; 278: 49–59. doi: 10.1016/j.atherosclerosis.2018.08.046.

20. Ejaz AA, Nakagawa T, Kanbay M, Kuwabara M, Kumar A, Arroyo FEG et al. Hyperuricemia in kidney disease: A major risk factor for cardiovascular events, vascular calcification, and renal damage. Semin Nephrol. 2020; 40 (6): 574–585. doi: 10.1016/j.semnephrol.2020.12.004.

21. Alappan HR, Vasanth P, Manzoor S, O’Neill WC. Vascular calcification slows but does not regress after kidney transplantation. Kidney Int Rep. 2020; 5 (12): 2212–2217. doi: 10.1016/j.ekir.2020.09.039.

22. Garnier AS, Duveau A, Planchais M, Subra JF, Sayegh J, Augusto JF. Serum magnesium after kidney transplantation: a systematic review. Nutrients. 2018; 10 (6): 729. doi: 10.3390/nu10060729.

23. Massimetti C, Cardello P, Brescia F, Imperato G, Feriozzi S. Association between low serum magnesium levels and the extent of abdominal aortic calcification in renal transplant recipients. G Ital Nefrol. 2020 Feb 12; 37 (1). (In Ital., English abstract).

24. Temimović R, Rašić S, Džubur A. Cardiovascular remodeling in patients with pre-dialysis chronic kidney disease and renal transplant recipients. Med Glas (Zenica). 2019 Aug 1; 16 (2): 216–223. doi: 10.17392/1009-19.

25. Maréchal C, Coche E, Goffin E, Dragean A, Schlieper G, Nguyen P et al. Progression of coronary artery calcification and thoracic aorta calcification in kidney transplant recipients. Am J Kidney Dis. 2012; 59 (2): 258–269. doi:10.1053/j.ajkd.2011.07.019.

26. Cozzolino М, Ciceri P, Galassi A, Mangano M, Carugo S, Capelli I, Giuseppe Cianciolo G. The key role of phosphate on vascular calcification. Toxins. 2019; 11 (4):213. doi: 10.3390/toxins11040213.

27. Surman TL, Abrahams JM, Manavis J, Finnie J, O’Rourke D, Reynolds KJ et al. Histological regional analysis of the aortic root and thoracic ascending aorta: a complete analysis of aneurysms from root to arch. J Cardiothorac Surg. 2021; 16: 255–264. doi: 10.1186/s13019-021-01641-5.

28. David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg. 1992; 103 (4): 617–621. doi: 10.5152/akd.2012.019.

29. David TE, Armstrong S, Manlhiot C, McCrindle BW, Feindel CM. Long-termresults of aortic root repair using the reimplantation technique. J Thorac Cardiovasc Surg. 2013; 145: S22–S25. doi: 10.1016/j.jtcvs.2012.11.075.

30. Wallen T, Habertheuer A, Bavaria JE, Hughes GC, Badhwar V, Jacobs JP et al. Elective Aortic Root Replacement in North America: Analysis of STS Adult Cardiac Surgery Database. Ann Thorac Surg. 2019; 107 (5): 1307–1312. doi: 10.1016/j.athoracsur.2018.12.039.

31. Pan E, Kytö V, Savunen T, Gunn J. Early and late outcomes after open ascending aortic surgery: 47-year experience in a single center. Heart Vessels. 2018; 33 (4): 427–433. doi: 10.1007/s00380-017-1075-3.

32. Beckmann E, Martens A, Krűger H, Korte W, Kaufeld T, Stettinger A et al. Aortic valve-sparing root replacement with Tirone E. David’s reimplantation technique: single-centre 25-year experience. Eur J Cardiothorac Surg. 2021 Sep 11; 60 (3): 642–648. doi: 10.1093/ejcts/ezab136.