Aim: Renal transplantation usually is performed via extraperitoneal approach and the graft is placed in iliac fossa. However challenging situations can be identified during operation. Here we report the follow up of a 4 year old kidney transplant patient with inferior vena cava occlusion diagnosed during transplant operation.
Case: 4 years old girl, was admitted to our Pediatric Nephrology Department with end stage kidney disaese due to atypical hemolytic uremic syndrome and interstitial nephritis.  We performed kidney transplant from her 47 year old uncle. Her bilateral iliac arterial and venous  doppler ultrasound was normal. During transplantation,  it has ben realized  that her inferior cava was nearly  totally occluded with a chronic  trombus which was unremarked during the preoperative evaluation.  Left kidney graft was  transplanted to right iliac fossa of the child with a standart procedure . Artery of the greft was anastomosed to the right common iliac artery and the renal vein  was anastomosed to the right common iliac vein of the recipient. An uretroneocystostomy was performed without using  a stent. The venous outflow of the greft was seen to be problematic since the colour of the greft turned to be blackish. Than the patient was taken to the Interventional Radiology unite under ongoing  general anesthesia. With using a 5 french guide-wire a cavagram was performed. After the baloon angioplasty, recannalisation of the cava was achived with a 10x80 mm nitinol stent and a perfect venous stream was visualised. After that the patient was taken to the operating room, following bleeding kontrol and replacing a suction drain, standart  wound closure was made. At the first 24 hours she has been followed with a continues heparin infusion, than switched to  low molecular weight heparin. Her postoperative course was un eventfull and she discharged on the  14th day of the operation.  She is on the  6th month of kidney transplant with normal kidney functions.
Conclusion: Detailed preoperative evaluation is needed before kidney transplant. However challenging situations can be identified during operation. Immediate multidisciplinary management of these situations play critical role for the success of the transplant procedure.