Vascular Surgery

Vascular insufficiency is also common among transplant recipients, particularly those with diabetes and/or longstanding hyperlipidemia. When faced with serious peripheral arterial disease, it is sometimes important to favor amputation over distal bypass, particularly among fragile patients with multiple comorbidities. Alternatively, the likelihood of successful ambulation with a prosthesis may be reduced in some patients; in these settings aggressive attempts at limb salvage becomes substantially more important.

When revascularization requires manipulation and/or transient occlusion of distal vessels without ischemia to the allograft, no specific alterations to the usual treatment protocol are necessary. On the other hand, proximal occlusion of arterial inflow to an allograft may result in serious morbidity. The guiding principles include maintenance of transplant perfusion whenever possible. Mannitol is recommended to induce brisk diuresis, as well as for its protective properties as an oxygen free radical scavenger.

When managing aneurysmal disease, we favor aggressive early intervention using established principles of size, growth, etc. When transplant recipients require aortic replacement, outcomes have been excellent. However, the importance of meticulous attention to detail during the perioperative, operative and postoperative period, including optimal maintenance of allograft perfusion cannot be stressed too vigorously.

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