Transplant Vascular Complications
Because the graft is end-arterial, vascular complications are graft-threatening: early renal artery or vein thrombosis causes sudden anuria and is a surgical emergency, while late transplant renal artery stenosis causes hypertension and a creeping creatinine and is treated by angioplasty.
The big picture
The graft is perfused by a single artery anastomosed to the iliac artery, with no collateral supply. Early vascular complications — renal artery thrombosis and renal vein thrombosis — typically occur in the first days and cause sudden loss of urine output and graft function; both are surgical emergencies, and thrombosis usually results in graft loss unless treated within a very short window. Late, transplant renal artery stenosis (TRAS) develops over months and presents as worsening hypertension, a rising creatinine (especially after ACE inhibitor/ARB), and sometimes a bruit; it is the commonest vascular complication and is treated by angioplasty ± stenting.
End-arterial graft: early thrombosis (sudden anuria) is a surgical emergency; late artery stenosis (hypertension, creatinine rise after ACEi/ARB) is treated by angioplasty.
Red flags
Arterial/venous thrombosis — urgent Doppler and emergency exploration; salvage window is short.
Suspect transplant renal artery stenosis — confirm with angiography, treat with angioplasty.
Consider AV fistula/pseudoaneurysm — angiography ± embolisation.
Diagnostic algorithm
Each step answers one question. Tap to expand.
Treatment ladder
Act emergently for thrombosis (the end-arterial graft has no collaterals) and treat stenosis with angioplasty; manage pseudoaneurysm/AVF by embolisation.
Complications
- Graft loss (thrombosis), uncontrolled hypertension and renal impairment (TRAS), bleeding (pseudoaneurysm/AVF)
- Angioplasty: restenosis, vessel injury
- Surgery: graft loss, bleeding
- Meticulous vascular technique; prompt recognition of early anuria; careful ACEi/ARB use in suspected TRAS
- Emergency exploration for thrombosis; angioplasty for stenosis; embolisation for AVF/pseudoaneurysm
If treatment fails
If perfusion is not restored or hypertension persists, ask: is the graft already infarcted (thrombosis), or is the stenosis recurrent/refractory to angioplasty?
Memory hooks
Graft is end-arterial — no collaterals.
Early sudden anuria = thrombosis = emergency.
Late HTN + creatinine rise (esp. after ACEi/ARB) = TRAS.
TRAS → angioplasty; AVF/pseudoaneurysm → embolise.
Board traps
Early sudden anuria → graft thrombosis (emergency), not rejection.
Creatinine rise after ACEi/ARB → TRAS.
Treating TRAS surgically first-line instead of angioplasty.
Clinical cases
Eight months after transplant, a recipient develops worsening hypertension and a graft bruit; the creatinine rises sharply soon after an ACE inhibitor is started.
What is the likely diagnosis and treatment?