Restoring Access to Kidney Transplantation: Midterm Outcomes of Pre-Emptive Aortobifemoral Bypass in Candidates with Severe Aortoiliac Disease.

BACKGROUND: Severe aortoiliac calcification and occlusive disease may preclude safe arterial clamping and anastomosis during kidney transplantation (KT), particularly as KT candidates age and accumulate comorbidities such as diabetes and peripheral arterial disease (PAD). Pre-emptive aortobifemoral bypass (ABFB) can restore durable inflow; however, multicenter data describing subsequent transplant access and outcomes stratified by symptom status remain limited.

METHODS: This retrospective multicenter cohort study was conducted across 12 French and 1 Belgian center between 1984 and 2017. Patients undergoing elective ABFB as part of pretransplant vascular assessment prior to (re)listing or waiting-list reactivation were included and stratified as asymptomatic (Rutherford 0-1) or symptomatic (Rutherford 2-5). The primary endpoint was access to KT (proportion transplanted and time from waiting-list reactivation to KT). Secondary endpoints included primary and secondary bypass patency, freedom from reintervention, perioperative major complications, survival, and pre-KT mortality.

RESULTS: A total of 129 patients were included (mean age 57 years; 85% male; 88% on dialysis). Thirty-day and in-hospital mortality was 1.6% (n = 2), and major 30-day complications occurred in 17.8% (n = 23). Median follow-up was 5.4 years. Preoperative imaging demonstrated severe external iliac calcifications in 77.5% of patients (n = 100); 9.3% (n = 12) had complete iliac occlusions. Overall, 55% underwent KT (n = 71). Median time from waiting-list reactivation to KT was 13 months (interquartile range [IQR]: 6-31) and was significantly shorter in asymptomatic PAD (11 months (IQR: 3-22) versus 21 months (IQR: 9-47); P = 0.006). Pre-KT mortality occurred in 9% (n = 11). Primary/secondary bypass patency was 95.8%/100% at 1 year and 90.8%/98.7% at 5 years, without significant differences by symptom status. Overall survival was 94.8% at 1 year and 79.5% at 5 years, favoring asymptomatic patients (1-/5-year 94.4%/92.1% vs. 95.2%/69.1%; log-rank P = 0.04). Secondary vascular procedures were required in 40% of patients.

CONCLUSION: Pre-emptive ABFB enabled KT in over half of high-risk candidates with acceptable early risk and midterm patency. Symptomatic PAD identifies a higher-risk subgroup, supporting early vascular assessment and careful multidisciplinary selection.