Hi Deborah!

I'm afraid I won't be able to help you with the prosthetic conduits, however I have a suggestion. We have started a study on shunts created from allogenic arterial grafts in ESRD patients a few years ago. Infection of prosthetic coduits is a common complication and still a significant problem, so we performed a literature search. Gacko et al. and some other authors confirmed that use of arterial allografts was a success in treating vascular prosthesis infections. Therefore we gave up the idea to use prosthetic conduits and used arterial allografts instead. We developed a good way of their preservation. Unfortunately we had no funds and the study ended before we tried to use the arterial graft in vivo. In summary, my suggestion is to use rather allogenic arterial graft (same immunosuppressive treatment), than prosthetic conduits in solid organ transplantation. But obviously, treat this suggestion with caution, since I have no hard evidence. Good luck in your research!

Fortunately I have no experience with infections of prosthetic grafts in transplantation and even in literature there are very few case reports dealing with this issue. However some general comments. Any kind of non-autologous conduit should be avoided, as far as possible, in patients under immunosuppression. If not possible under acute circumstances, allografts are suggested the preferable choice. However, any treatment for preservation has a negative influence on the typical and beneficial biological properties of allografts and reduces their resistance against infections, one of the most important factors being the loss of the endothelial integrity. Alternatively, grafts being soaked in antibiotic solutions and even more, being covered by autologous fibrin glue enriched with antibiotics and/or by local antibiotic sponges may be considered. Above that, areas prone to infection should be covered with omentum or muscle flaps.

I've only seen 2 cases of graft used for kidney transplant. First was an aorto-femoral graft followed by an elective LRT, the second an emergency ilio-femoral graft for iliac artery dissection 24 hours after a CRT followed by re-implantation of the renal artery. In both cases the artery was connected to the Gore-Tex graft using 6-0 polypropylene running suture. The LRT worked well. The deceased donor kidney didn't work and after 1 week thromboses requiring subsequent transplant nephrectomy. Cannot make any recommendations from this but things shows that prosthetic graft can be used with acceptable results, and probably the second kidney was lost do to ischemic injury related with iliac artery dissection and delayed revascularization.

The group from Bologna (Italy) reported the first use of Gortex arterial conduit for liver transplant in Transplantation (January 27, 1998) issue: http://www.centerspan.org/pubs/transplantation/1998/0127/tr029800288o.pdf

Although some isolated successful results have been reported, these are sporadic and infrequent. Prosthetic grafts are used only when no other option available.

personally have experience of goretex in one case of kidney tx. Dr Lee's group in Asan uses it often for v5 v8 and dual lobes. they reportedly have no problems

I have gone out of my way to avoid a prosthetic like PTFE in kidney or pancreas transplantation, not because I am worried about infection, but because of the risk of thrombosis. This is particularly concerning in the early post-op period, where the presence of ATN will increase intrarenal pressure, resulting in increases of resistive index, sluggish flow, and other thrombogenic events. I would usually use autologous (recipient) vein if needed and available (e.g., saphenous). I have used cadaver vein conduit on one occasion with good results. There are concerns about intermediate term stricture with cadaver vein, but this is possibly (my hypothesis) the result of rejection of the vein graft when it is used for preipheral bypasses, and since the transplant patients are immunosuppressed, it might be less of a concern in this setting.

In one situation I had to perform Aorto-Femoral arterial prosthetic bypass. Then I anastomosed Donor Renal Transplant Artery to the prothetic arterial bypass. This patient 's distal aorta and iliac felt like a lead pipe / egg shell. Patient did very well. However, I agree about what has been said re avoid prosthetics in transplant setting if possible.

Dear Debora

Please contact Professor Malekzadeh who is top expert.

Eghbal

It might be suggested that vascular allografts be used cautiously due to the risk of sensitisation and/ or rejection. This has been reported by Lopez-Cepero et al 'Sensitization of renal transplant candidates by cryopreserved cadaveric venous or arterial allografts', and we have our own experience of de novo DSA and rejection of a donor Y-graft in a pancreas transplant patient where the Y-graft came from a different donor to the pancreas.

Thanks everyone for your contributions. This has been very useful exercise to get a feel for what is happening internationally.

I have done kidney transplant renal artery anastomoses into synthetic grafts, but have not used one constructed at the time of transplantation. A punch arteriotomy (conduitotomy?) is, I think, important to prevent coaptation if hypotension ensues.

We used in two cases omniflow biosynthetic prothesis as an aorto-hepatic procedure in LTX after severe infection of the hepatic ligament with bleeding and arrosion of the hepatic anastomosis. One case went well, in the other case the ongoing infection destroyed even the collagen prothesis. We would never use a synthtic graft in liver tx because of the danger of infection with an open bile duct.