Surgical Endarterectomy for Suprarenal Iliac Artery Stenosis in Renal Allograft Recipient Mauro Ferrari, MD, Gianluca Bonanomi, MD, Fabio Vistoli, MD, Carlo Moretto, MD, Mario Carmellini, MD, and Franco Mosca, MD, Pisa, Italy Aortoiliac surgery performed in renal transplant recipients carries the risk of inducing a pro- longed period of ischemia that can threaten organ survival. Recently, endovascular techniques have been increasingly applied but the rate of complications and recurrences remains signifi- cant. We report the case of a kidney heterotopic allotransplant recipient who presented with a history of new-onset arterial hypertension, right lower limb claudication, and allograft dysfunction related to a long, eccentric, and ulcerated plaque causing hemodynamic stenosis of suprarenal iliac artery that was successfully managed with surgical endarterectomy. Despite new advances in less invasive procedures such as transluminal angioplasty and stent implantation, surgical endarterectomy of suprarenal iliac artery may be safely performed in selected heterotopic kidney transplant recipients. It allows for complete removal of the plaque, with better long-term results, and does not preclude subsequent endovascular or surgical procedures; therefore it should be considered a therapeutic option in this clinical setting. Late post-transplant kidney dysfunction associated with arterial hypertension may be due to acute or chronic rejection, immunosuppressive therapy, re- current renal disease, and vascular complications. 1 Among vascular complications the most frequent are anastomotic or donor renal artery stenoses with an incidence of 12%, while suprarenal iliac artery stenoses are relatively rare. 2,3 CASE REPORT A 52-year-old man who had undergone a right iliac fossa cadaveric renal transplant 12 years previously presented at our institution with a history of right lower limb clau- dication after 50 meters, new-onset arterial hypertension, and rising serum creatinine levels over the last 2 months. The patient suffered from end-stage renal failure of un- known origin and had started hemodialysis 4 years before transplantation became available. Immunosuppression was maintained with cyclosporine (175 mg daily) and prednisone (5 mg daily). One year after transplantation, at another institution, the patient underwent surgical re- intervention for correction of an arterial anastomotic ste- nosis that was responsible for progressive organ failure and arterial hypertension. Afterwards, the patient recov- ered well, renal function and blood pressure returned to normal, and the clinical course was unremarkable until coming to our attention with the current symptoms. The patient used to be a heavy smoker (30 cigarettes/day). On admission his blood pressure was 180/90 mmHg, despite anti-hypertensive therapy (amlodipine 20 mg daily), his heart rate was 68 beats/min, and on physical examination he had an absent right femoral pulse and a right ankle/brachial index (ABI) of 0.55. Serum creati- nine was 2.6 mg/dL and serum urea 90 mg/dL. Color duplex scan showed the presence of hemodynamic ste- nosis (80%) of the right common iliac artery due to a long, eccentric, and ulcerated atherosclerotic plaque; the end-to-end anastomosis between the donor renal artery and the recipient right hypogastric artery was patent (Fig. 1). Digital subtraction angiography confirmed the pres- Division of General and Vascular Surgery, University of Pisa, Pisa, Italy. Correspondence to: M. Ferrari, MD, Division of General and Vas- cular Surgery, University of Pisa, Via Paradisa, 2, Cisanello, 56124 Pisa, Italy Ann Vasc Surg 2001; 15: 571-574 DOI: 10.1007/s10016-001-0007-x © Annals of Vascular Surgery Inc. Published online: August 23, 2001 571