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Year : 2022  |  Volume : 16  |  Issue : 3  |  Page : 296-302

Endovascular management of vascular complications in renal allograft - An observational study

1 Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Nephrology, SGPGIMS, Lucknow, Uttar Pradesh, India
3 Department of Radiology, Apollomedics Super Speciality Hospitals, Lucknow, Uttar Pradesh, India

Date of Submission19-Feb-2021
Date of Acceptance24-May-2022
Date of Web Publication30-Sep-2022

Correspondence Address:
Dr. Surya Nandan Prasad
Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna - 801 507, Bihar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijot.ijot_15_21

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Context: Role of endovascular management of vascular complications in renal transplant recipients. Aims: To present our experience in endovascular management of vascular complications in renal transplant recipients with a literature review. Settings and Design: A retrospective observational study. Materials and Methods: This is a retrospective analysis of postrenal transplant recipients referred to our department for the evaluation and endovascular management of vascular complications from January 2010 to December 2014. Cases of transplant renal artery stenosis (TRAS) and common iliac artery (CIA) stenosis were treated with percutaneous transluminal balloon angioplasty with or without stenting. Intraparenchymal pseudoaneurysms, arteriovenous fistula (AVF), and active contrast extravasation cases were managed with coil and/or glue embolization. Treated patients were followed up with serial blood pressure measurements, serum creatinine estimation, and Doppler evaluation in the postprocedure period and at 3-month and 6-month intervals. Results: Among a total of ten patients, there were five TRAS, two intraparenchymal pseudoaneurysms with active contrast extravasation, one AVF, one active renal bleed with peri-graft hematoma, and one right CIA stenosis. Intraparenchymal pseudoaneurysms, AVF, and active extravasations were postbiopsy. All treated patients showed improved renal function, increased hematocrit, improved blood pressure control in the postprocedure period, and follow-up. Conclusions: Vascular complications in renal transplant patients may lead to graft dysfunction, increased morbidity, and even graft loss if left untreated. Endovascular interventions are first-line treatments with excellent short- and long-term outcomes.

Keywords: Balloon angioplasty, embolization, renal graft dysfunction, stent, transplant renal artery stenosis, vascular complications

How to cite this article:
Prasad SN, Singh V, Yachha M, Phadke RV, Bhadauria DS. Endovascular management of vascular complications in renal allograft - An observational study. Indian J Transplant 2022;16:296-302

How to cite this URL:
Prasad SN, Singh V, Yachha M, Phadke RV, Bhadauria DS. Endovascular management of vascular complications in renal allograft - An observational study. Indian J Transplant [serial online] 2022 [cited 2022 Nov 27];16:296-302. Available from: https://www.ijtonline.in/text.asp?2022/16/3/296/357604

  Introduction Top

Renal transplant is considered the treatment of choice in end-stage renal disease (ESRD) because of improved quality of life, survival, and low cost compared to hemodialysis.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] With continued experience and refined surgical techniques, transplant surgeries have become very safe in expert hands. However, renal transplant complications may occur and can be divided into vascular complications and urological complications. Urological complications occur in 4%–8% of patients and include ureteric injury, stricture, urinoma formation, hydronephrosis, bladder outlet obstruction, and urinary tract infection. Vascular complications occur in 3%–15% of patients. Transplant renal artery stenosis (TRAS) is among the most common vascular complications causing graft dysfunction and failure. Other major vascular complications are renal vessel thrombosis, pseudoaneurysm formation, postbiopsy renal bleed, peri-graft hematoma, and intraparenchymal arteriovenous fistula (AVF).[2],[10] Early diagnosis and treatment are necessary, as delay may result in loss of the graft.

Endovascular interventions are the first line of treatment in these cases with excellent immediate and long-term results. However, interventional radiologists should be aware of transplanted allografts' vascular complexity and understand newer surgical skills and interventional techniques guided by images. Endovascular interventions in renal allograft can lead to complications in some patients like major vessel dissection, stent malposition or migration, treatment vessel thrombosis and even renal transplant loss attributable to endovascular intervention.[15],[16],[17],[18] Renal allograft recipients are also at risk of developing contrast-induced nephropathy (CIN) after these procedures. There are limited Indian data on the efficacy and outcome of endovascular management of vascular complications in a renal allograft. Hence, we present our experience in dealing with vascular complications in renal transplant patients with endovascular interventions.

  Materials and Methods Top

This study is a retrospective analysis of post renal transplant recipients (between January 2010 to December 2014), referred to our department of interventional radiology for evaluation and endovascular management of vascular complications. All the transplant kidneys were harvested from live donors.

Protocol for evaluation

The patients were evaluated first with ultrasound (USG), Doppler, and then with magnetic resonance angiography (MRA) if required. Finally, conventional angiography was done with the intent to confirm the diagnosis and treat them with percutaneous transluminal angioplasty (PTA), stenting, or embolization in the same sitting.

Follow-up was done with serial blood pressure measurements, serum creatinine estimation, and Doppler evaluation, first in the immediate postprocedure period, then at 3-month and 6-month intervals.

Management of transplant renal artery stenosis

In TRAS cases, contralateral femoral access was obtained under fluoroscopic guidance, and a 6F guide catheter was placed into the ipsilateral iliac artery. Then, the stenosis was crossed with microwire. Using low profile balloon catheters (2–4 mm × 20 mm), PTA was done, followed by stent placement across the stenosis [Figure 1].
Figure 1: (a) Digital subtraction angiography showing transplant renal artery stenosis at the site of end to end anastomosis of renal artery with right internal iliac artery, (b) balloon angioplasty of stenosis, (c) post balloon angioplasty residual stenosis (arrow) and (d) digital subtraction angiography after stent deployment showing near complete resolution of stenosis

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Management of intraparenchymal pseudoaneurysms/arteriovenous fistula and active contrast extravasation

Through contralateral femoral arterial access, a 5F diagnostic catheter was placed into the ipsilateral iliac artery. Then, graft renal artery and the culprit vessel supplying the pseudoaneurysm/AVF were super selectively cannulated using microwire and microcatheter. Then they were treated with coil and/or glue embolization. In the case of active renal bleed, super-selective microcatheterization of the bleeding segmental artery was done, followed by coil and glue embolization.

Protocol for contrast-induced nephropathy prevention

All the patients undergoing radiological interventions were kept well-hydrated pre-, intra- and post-procedure. The minimum possible dose of contrast was used and unnecessary repeat contrast injections were avoided during the procedure. Dilute (50% with normal saline) iso-osmolar non-ionic iodinated contrast agent was used during the procedure to keep the solute load minimum.

Declaration of patient consent

Patient consent was taken for the procedure, participation in the study and publication of clinical details and images. The patients understand that their personal data will not be revealed and all standard protocols will be followed to conceal their identity.

Ethics statement

Good clinical practice guidelines were followed. As it was a retrospective observational data analysis study, ethics committee approval was not deemed necessary. The study was performed according to the guidelines in Declaration of Helsinki.

Statistical analysis

Data was entered in excel chart and was expressed as mean and percentages.

  Results Top

A total of ten patients were included in the study, with a mean age of 40.6 years (range 21–65 years) [Table 1]. There were five TRAS, two intraparenchymal pseudoaneurysms with active contrast extravasation, one upper polar AVF, one active renal bleed from upper polar segmental artery with peri-graft hematoma, and one atherosclerotic right common iliac artery (CIA) stenosis.
Table 1: Vascular complications in renal allografts and outcome of endovascular management

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TRAS were treated with balloon angioplasty and stent placement across the stenosis except one, who had stenosis close to renal hilum with early branching. In that case, only PTA was performed and stent was not deployed as the stenosis was close to the renal hilum [Figure 2]. In one case of TRAS, there was an extra parenchymal pseudoaneurysm located just proximal to the stenosis. In this case, a stent-graft was used to relieve the stenosis and cover the pseudoaneurysm's neck simultaneously [Figure 3]. One patient had two transplant renal arteries and both of them were showing stenosis. He was treated with angioplasty and stenting of both arteries in one sitting. This patient is doing well even after 6 years of the intervention. One case of CIA stenosis presented with symptoms similar to TRAS and treated with CIA stenting through contralateral femoral arterial access.
Figure 2: (a) Digital subtraction angiography showing transplant renal artery stenosis at renal hilum, (b) stenoses crossed by microwires, (c) balloon angioplasty across stenosis and (d) postballoon angioplasty image showing significant resolution of the hilar stenosis and good intraparenchymal flow

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Figure 3: (a) Digital subtraction angiography showing tight stenosis at renal artery-internal iliac artery anastomotic site and an extra parenchymal pseudoaneurysm (black arrow) proximal to stenosis, (b) stent graft placement (white arrow) across the stenosis, covering neck of the pseudoaneurysm, (c) and (d) postprocedure digital subtraction angiography showing resolution of stenosis and nonfilling of the pseudoaneurysm

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All patients of TRAS showed decrease in serum creatinine, improved blood pressure control, increased urine output post procedure and improved waveform on follow-up Doppler at 3 and 6-months. One patient of TRAS had a history of common femoral vein thrombosis and suffered an injury to the renal artery during transplant surgery. He was treated with balloon angioplasty and stent placement across the stenosis; however, 2 weeks later the patient deteriorated clinically with severe sepsis and died in the early course of illness due to septic shock and subsequent multi-organ failure. One another patient remained dialysis dependent with graft failure at 3 months follow-up, so graft nephrectomy was performed, and brachio-cephalic fistula was made for hemodialysis.

Intraparenchymal pseudoaneurysms/AVF and active extravasations were postbiopsy and managed by angioembolization. Three cases (two intraparenchymal pseudoaneurysms and one active renal bleed from the upper polar segmental artery) were showing active contrast extravasation into peri-renal space following percutaneous biopsy. Postembolization, there was complete occlusion of pseudoaneurysms/AVF and arrest of active contrast extravasation [Figure 4]. Cessation of hematuria increased hemoglobin level, and decreased peri-graft hematoma size were seen following embolization in these cases.
Figure 4: (a) Postbiopsy digital subtraction angiography showing multiple tiny intraparenchymal pseudoaneurysms (black arrow) at upper pole, (b) digital subtraction angiography after super selective cannulation of upper polar segmental artery showing active contrast extravasation (white arrow) into perirenal space, (c) digital subtraction angiography after coiling of feeding artery and (d) postglue embolization digital subtraction angiography showing glue cast (arrow) in medial upper polar region with nonfilling of intraparenchymal pseudoaneurysms

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Two patients were lost to follow-up and the rest six patients (60%) are on regular follow-up and they did not require any further invasive and endovascular treatment. None of our patients developed CIN.

  Discussion Top

Endovascular interventions are the first-line treatment for vascular complications, as they are considered safe, effective, and minimally invasive with excellent follow-up results.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14]

Transplant renal artery stenosis

Renal artery stenosis is the most common vascular complication in renal transplant patients and its incidence has been reported in different series ranging from 1% to 23%.[1],[2],[3],[9],[12],[13] It may occur any time after transplantation but most of the time, it manifests within three months to 2 years of transplant surgery.[1],[2],[3],[6],[9] In our series, we found time to manifest ranges from 10 days to 18 months. Several factors are considered contributory, including erroneous surgical techniques during the harvest of the graft or transplantation, cadaveric transplant, renal vessel trauma, and atherosclerotic vascular disease. End-to-end anastomosis is more prone to developing stenosis than end to side anastomosis.[10],[11] Surgical contributory factors lead to an early presentation like in two of our cases (renal artery injury during graft harvesting and implantation and anastomotic site pseudoaneurysm with stenosis of renal artery), where the presentation was within 10 days to 30 days, and both had an overall poor outcome. Since the transplant patients remain on immunosuppressive therapy, infection with cytomegalovirus is also supposed to play a role in the causation of renal artery stenosis.[1],[6],[11] Atherosclerosis is more common in cases of ESRD and may result in late TRAS. Immunosuppression, on the other hand, may increase the rate of atherosclerotic changes leading to TRAS. Patients present with complaints of accelerated or uncontrolled hypertension, decrease in urine output, and increased serum creatinine. USG with Doppler is the first line of investigation which shows narrowing of renal transplant artery, increased peak systolic velocity with aliasing at the site of stenosis, decreased resistivity index (RI), and tardus-parvus waveform in intraparenchymal arteries.[1],[6],[7] Peak systolic velocity (PSV) >200 cm/second at the site of suspected stenosis, velocity gradient of >2:1 across the narrowed segment and RI <0.5 in intraparenchymal arteries are highly suggestive of renal artery stenosis with a sensitivity of 86%–94% and specificity of 87%-100%.[2],[6],[9],[11],[14] In equivocal or difficult to scan patients, MRA may help in determining the site of the stenosis. Digital subtraction angiography (DSA) is considered the gold standard for diagnosis; however, it exposes the patient to radiation and the allograft to an iodinated contrast agent, which may have nephrotoxic effects with already compromised renal function. The use of carbon dioxide as a contrast agent may protect from the nephrotoxic effect of iodinated contrast; however, it is usually not readily available for use in most of the DSA suits.[1],[4] Hence, it is advisable to go for DSA only if TRAS is strongly suspected with intent to treat the patient by endovascular means in the same sitting.

PTA using balloon catheters with or without stenting is the treatment of choice for this condition.[1],[3],[7],[9],[14] It is not always possible to deploy a stent across the stenosis, especially when the narrowing is close to the hilum or near branches of the renal artery as in one of our cases. This is to avoid ischemic damage to the area supplied by renal artery branches as the stent's deployment across the branching points may compromise the vascularity of the supplied territory. Complications include arterial rupture, dissection, or thrombosis, and overall, their incidence ranges from 2% to 4%.[2] In cases where these complications have occurred, stent or stent-graft placement is imperative to achieve sustained clinical improvement. PTA alone shows very high technical and clinical success rates (85%–93%) in the early postprocedure period to improve or stabilize renal function and improved blood pressure control.[1],[9] There is a high incidence of re-stenosis (16%–62%) after PTA alone in mid and long-term follow-up. In cases where the stent is placed across the stenotic segment, re-stenosis rates (5.5%–29%) are significantly less.[2],[9] Furthermore, in cases where there is the presence of dissection or neointimal hyperplasia, stents afford a better outcome when compared to PTA alone.

Iliac artery stenosis

Peripheral vascular diseases are more common in ESRD cases than in the general population and affect 2% to 3% of patients.[2],[4] In one case series, 1.4% of kidney transplant patients presented with iliac artery stenosis complaints, leading to clinical deterioration needing endovascular intervention.[2] Usually, they present with features suggestive of TRAS; however, in cases of generalized peripheral arterial disease (PAD), other features like limb claudication, cold extremities, and decreased peripheral pulses may be evident on clinical examination.[2],[4] On USG, the renal artery appears normal in caliber; however, on Doppler evaluation, decreased renal artery PSV with monophasic waveform, intrarenal tardus-parvus pattern, and decreased RI is demonstrated. Iliac artery stenotic segment may show increased PSV, increased gradient across the stenosis, and aliasing on Doppler study.[2] DSA is done to confirm the diagnosis and treat the disease in the same sitting. PTA followed by stent placement is the usual acceptable treatment with reasonable patency rates on short-term follow-up. Allograft function improves after stenting of the stenosed iliac artery with decreased serum creatinine and reasonable blood pressure control. Long-term results are not yet known in patients with generalized PAD.[2] However, as we have one follow-up of 7 years and this patient did not require any more intervention, we can say that with limited disease and selected interventions, these patients can have good long-term results.

Extra parenchymal pseudoaneurysm

Pseudoaneurysm formation in renal transplant patients may be intrarenal or extra parenchymal. Extra parenchymal pseudoaneurysms are rare (<1%) and mostly occur at the site of anastomosis of the renal graft artery and iliac artery.[1],[2] A possible explanation for developing these pseudoaneurysms close to anastomosis includes trauma to the arterial wall during suturing, vessel wall ischemic injuries due to damaged vasa vasorum, and infection.[1],[2],[6] Clinically, they may be asymptomatic or sometimes, when large, may compress the transplant renal artery or vein, leading to disturbed renal function. In one of our cases, the pseudoaneurysm was located just proximal to the severely stenosed anastomotic segment, and the patient presented with symptoms suggestive of TRAS. This patient was treated with stent-graft placement across the stenotic arterial segment covering the neck of the pseudoaneurysm. If ruptured, untreated pseudoaneurysms can lead to severe hemorrhage, allograft loss, and even death of the patient.[4],[6],[11] They are usually easily diagnosed on USG as an outpouching of the vessel wall. On Doppler evaluation, they show “to and fro” flow in the region of neck and swirling of blood due to bidirectional flow within the sac of the pseudoaneurysm termed as “Yin-Yang sign.”[4] In doubtful cases, one may confirm the diagnosis on computed tomography (CT) angiography or DSA. These cases may safely be treated with stent-graft placement in the parent artery across the pseudoaneurysm's neck. However, when the landing zone is not of sufficient length, stent-graft deployment may not be possible. Other treatment options include endovascular coiling and percutaneous thrombin injection into the sac under USG guidance.[2] One has to take adequate precautions while injecting thrombin into the pseudoaneurysm sac. It may spill into the parent artery inadvertently and may occlude it, leading to ischemia and graft failure. Balloon-assisted thrombin injection may be considered when the pseudoaneurysm is wide neck or showing high flow. It gives the interventionist sufficient control, which helps avoid complications secondary to an inadvertent spill of the embolizing agent in other arteries. Surgery is difficult and used as a last resort. In symptomatic cases where endovascular treatment has failed, one may have to go eventually for graft nephrectomy as in one of our cases.

Intrarenal pseudoaneurysm and arteriovenous fistula

These are common complications of renal biopsy with an incidence ranging from 1% to 18% in several case series.[1],[2] In renal transplant cases with unexplained deteriorating renal function, one has to perform a renal biopsy to rule out acute rejection as delay in diagnosis may result in allograft loss. Intraparenchymal pseudoaneurysms form when there is an injury to the segmental artery branch during biopsy. When there is simultaneous injury to the artery and adjacent vein, AV fistula forms. They may be asymptomatic or may present with haematuria, increased blood pressure, or graft dysfunction.[11] On USG, pseudoaneurysms appear as simple or complex cystic structures, which show color filling on the Doppler study. AVF appears as a disorganized color flow along intrarenal vasculature.[2],[7],[11] Mostly small AVF are asymptomatic; however, 30% of cases may present with hematuria, increased blood pressure, or graft dysfunction. When large, AVF may present with a significant “steal phenomenon,” resulting in ischemia to the distal renovascular bed due to arteriovenous shunting of blood.[2],[11] Asymptomatic small intrarenal pseudoaneurysms may resolve their own on follow-up. However, they may gradually increase in size and can rupture within renal parenchyma, pelvicalyceal system, or in peri-renal space in several cases. Both AVF and intraparenchymal pseudoaneurysms are treated by endovascular methods with super-selective catheterization of involved vessel and embolization using coils or n-butyl cyanoacrylate (glue). Intrarenal segmental arteries are end arteries, so the pseudoaneurysms arising from their branches need not be trapped, and they are treated with super-selective embolization of the feeder artery branch.[7] The overall technical success rate of the procedure approaches 100%. On follow-up, one-fourth of patients show limited parenchymal infarction of up to 20% of the total renal volume.[2]

Peri-graft hematoma active contrast extravasation

Peri-graft hematoma may be seen in the early postoperative period from the anastomotic site small leak or oozing of blood from the allograft surface.[1] Usually, they are small and do not require active management, but they may compress the graft kidney if enlarged, leading to graft dysfunction.[1] USG-guided evacuation of hematoma needed in those cases. One should take care to avoid infection in peri-graft hematoma, as this may ultimately lead to graft failure needing surgical graft nephrectomy.[1] Active bleed can occur post renal biopsy. Patients present with hematuria, deranged allograft function, decreased hematocrit, and sometimes hypovolemic shock. Treatment is essentially endovascular with super-selective catheterization of the bleeding artery and embolization with coils or glue. Super selective catheterization salvages the maximum possible renal parenchyma.

Contrast induced nephropathy

CIN is defined as increase in serum creatinine by >0.3 mg/dl or >25% from baseline level within 4 days of radiological intervention using contrast.[19] There are several studies in the literature describing CIN in native kidneys after radiological procedures. However, only few studies have described CIN in renal transplant patients undergoing diagnostic/interventional radiological procedures. Hence far, the mechanism of CIN is concerned, several factors are considered responsible including contrast agent-induced vasoconstriction, increased osmotic load in tubular lumen leading to increased interstitial pressure, compression of vasa recta, and decreased GFR.[19],[20] Further, contrast agents may increase blood viscosity and affect red blood cell deformability.[20] All these factors ultimately lead to medullary hypoxemia, production of reactive oxygen species, and renal tubular damage. Renal allografts are more at risk as nephrotoxic immunosuppressive agents are frequently used in these cases. Furthermore, lack of sympathetic innervation in transplant kidneys leads to deranged hemodynamic regulation.[19] Proper hydration is considered protective and has definite role in prevention of CIN. Use of iso-osmolar nonionic iodinated contrast media (in place of high osmolar ionic contrast agents) further decreases the incidence of CIN.[20]


It was a single centre study and the sample size was small.

  Conclusions Top

Vascular complications in renal transplant patients are an important cause of graft dysfunction, leading to increased morbidity and if left untreated, may result in permanent damage and graft loss. Endovascular interventions are the first line of treatment, and most of the time, these vascular complications are managed successfully. When treated timely and adequately with endovascular means, they show excellent short- and long-term results on follow-up.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Dimitroulis D, Bokos J, Zavos G, Nikiteas N, Karidis NP, Katsaronis P, et al. Vascular complications in renal transplantation: A single-center experience in 1367 renal transplantations and review of the literature. Transplant Proc 2009;41:1609-14.  Back to cited text no. 1
Glebova NO, Brooke BS, Desai NM, Lum YW. Endovascular interventions for managing vascular complication of renal transplantation. Semin Vasc Surg 2013;26:205-12.  Back to cited text no. 2
Braga AF, Catto RC, Dalio MB, Tenório EJ, Ribeiro MS, Piccinato CE, et al. Endovascular approach to transplant renal artery stenosis. Ann Transplant 2015;20:698-706.  Back to cited text no. 3
Khaja MS, Matsumoto AH, Saad WE. Complications of transplantation. Part 1: Renal transplants. Cardiovasc Intervent Radiol 2014;37:1137-48.  Back to cited text no. 4
Rana YP, Singh DV, Gupta SK, Pradhan AA, Talwar R, Harkar S, et al. Urological and vascular complications in 720 renal transplantations – Lessons learned. Indian J Transplant 2012;6:73-6.  Back to cited text no. 5
Srivastava A, Kumar J, Sharma S, Abhishek, Ansari MS, Kapoor R. Vascular complication in live related renal transplant: An experience of 1945 cases. Indian J Urol 2013;29:42-7.  Back to cited text no. 6
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Akbar SA, Jafri SZ, Amendola MA, Madrazo BL, Salem R, Bis KG. Complications of renal transplantation. Radiographics 2005;25:1335-56.  Back to cited text no. 7
Osman Y, Shokeir A, Ali-el-Dein B, Tantawy M, Wafa EW, el-Dein AB, et al. Vascular complications after live donor renal transplantation: Study of risk factors and effects on graft and patient survival. J Urol 2003;169:859-62.  Back to cited text no. 8
Patil AB, Ramesh D, Desai SC, Mylarappa P, Guttikonda SH, Puvvada S. Transplant renal artery stenosis: The impact of endovascular management and their outcomes. Indian J Urol 2016;32:288-92.  Back to cited text no. 9
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Ayvazoglu Soy EH, Akdur A, Kirnap M, Boyvat F, Moray G, Haberal M. Vascular complications after renal transplant: A single-center experience. Exp Clin Transplant 2017;15:79-83.  Back to cited text no. 10
Giakoustidis A, Antoniadis N, Giakoustidis D. Vascular complications in kidney transplantation. In: Understanding the Complexities of Kidney Transplantation. London: InTech; 2011.  Back to cited text no. 11
Marini M, Fernandez-Rivera C, Cao I, Gulias D, Alonso A, Lopez-Muñiz A, et al. Treatment of transplant renal artery stenosis by percutaneous transluminal angioplasty and/or stenting: Study in 63 patients in a single institution. Transplant Proc 2011;43:2205-7.  Back to cited text no. 12
Del Pozo M, Martí J, Guirado L, Facundo C, Canal C, de la Torre P, et al. Angioplasty and stent treatment of transplant renal artery stenosis. Nefrologia 2012;32:455-8.  Back to cited text no. 13
Touma J, Costanzo A, Boura B, Alomran F, Combes M. Endovascular management of transplant renal artery stenosis. J Vasc Surg 2014;59:1058-65.  Back to cited text no. 14
Ngo AT, Markar SR, De Lijster MS, Duncan N, Taube D, Hamady MS. A systematic review of outcomes following percutaneous transluminal angioplasty and stenting in the treatment of transplant renal artery stenosis. Cardiovasc Intervent Radiol 2015;38:1573-88.  Back to cited text no. 15
Audard V, Matignon M, Hemery F, Snanoudj R, Desgranges P, Anglade MC, et al. Risk factors and long-term outcome of transplant renal artery stenosis in adult recipients after treatment by percutaneous transluminal angioplasty. Am J Transplant 2006;6:95-9.  Back to cited text no. 16
Willicombe M, Sandhu B, Brookes P, Gedroyc W, Hakim N, Hamady M, et al. Postanastomotic transplant renal artery stenosis: Association with de novo class II donor-specific antibodies. Am J Transplant 2014;14:133-43.  Back to cited text no. 17
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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