*Purpose: Severe iliac atherosclerotic disease can jeopardize the success of, and listing of patients for renal transplantation. Not only does it provide a technical challenge during the surgery itself, but it may lead to a potential steal syndrome in the allograft or ipsilateral limb. Few studies have evaluated the safety and efficacy of performing an endarterectomy in this setting.

*Methods: After institutional review board approval, records of patients receiving renal transplants over a 5-year period from 2013 to 2017 with a minimum of 12-months follow-up were accessed. Patients undergoing simultaneous iliac endarterectomy, and renal transplant were identified, and matched to a non-endarterectomized cohort in a 1:2 fashion using propensity score matching.

*Results: Over the study period, 23 patients underwent endarterectomy during the renal transplantation. The reconstruction of the external iliac artery was performed using bovine pericardial patch in 16 of these patients. The 23 cases were matched to 42 controls, with no significant differences between the endarterectomy patients and their non-endarterectomized matches with regards to age, gender, ethnicity, body mass index, or duration of dialysis, or donor type. There was no significant difference in the quality of the donor organs as estimated from the kidney donor profile index (p=0.88). The ankle-brachial index was significantly lower in the endarterectomized group (p<0.05). Episodes of delayed graft function (26% vs 19%, p=0.54), acute rejection (13% vs 2.4%, p=0.12), graft loss (4.3% vs 7.1%, p=1.0), and 1-year mortality (8.7% vs 7.1%, p=1.0) were similar in endarterectomy and non-endarterectomy patients. Serum creatinine (1.6 vs 1.4, p=0.4) and glomerular filtration rate (50 vs 60, p=0.07) after 12-months were comparable in both groups. There were no incidents of ipsilateral limb loss in the endarterectomized population.

*Conclusions: This is the first matched study of patients undergoing simultaneous endarterectomy and renal transplant. Long-term follow up of limb and graft function is indicated. Our findings demonstrate that the procedure is safe, and technically feasible in this population that would have otherwise been denied access to renal transplant.

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