Orthotopic renal homotransplantation in a patient with thrombosis of the inferior vena cava

Kidney Transplantation Using Gonadal Vein for Venous Anastomosis in Patients With Iliac Vein Thrombosis or Stenosis: A Series of Cases

BACKGROUND

Kidney transplantation is the treatment of choice for patients with end-stage renal disease. The standard surgery uses the recipient's iliac vessels for vascular anastomosis. Thrombosis and/or stenosis of the iliac vein, which are possible complications of multiple vascular access points for dialysis, can be detected intraoperatively, constituting a surgical challenge. An infrequently reported option is the use of the gonadal vein.

OBJECTIVES

This study aims to evaluate the outcomes of venous anastomosis in the gonadal vein in patients with iliac vein thrombosis and/or stenosis submitted to kidney transplantation.

METHODS

We reviewed the records of five adult recipients with iliac vein thrombosis and/or stenosis detected intraoperatively during emergency kidney transplantation with deceased donor due to vascular access failure from February 2013 to December 2014. Antithrombotic prophylaxis was not performed. We evaluated the postoperative complications, length of stay, early graft echo-Doppler, and renal function during the first year postoperatively.

RESULTS

Delayed graft function occurred in three cases. Two patients developed postoperative infection requiring antibiotics. One patient required reoperation due to post-renal biopsy complications. The mean length of stay was 31.2 days and the mean serum creatinine levels at discharge, at 6 months, and at 12 months postoperatively were 1.42 mg/dL, 0.86 mg/dL, and 0.82 mg/dL, respectively. All patients had normal ultrasonography. There were no losses of graft or deaths during follow-up.

CONCLUSION

Venous anastomosis using the gonadal vein in kidney transplantation for patients with iliac vein thrombosis and/or stenosis showed good clinical and surgical results, showing this method to be a viable alternative to venous drainage in these complex patients.

Renal transplantation to the ovarian vein: a case report

Renal failure patients with absent or thrombosed inferior vena cava (IVC) and iliac veins are considered technically unsuitable for transplantation. Occasional cases have been reported in literature of transplant using inferior and superior mesenteric veins. We describe a case in which kidney was transplanted on to an ovarian vein in a young patient who had thrombosed IVC and iliac veins and was previously declared unsuitable for transplantation.

[Orthotopic renal transplant: our experience]

Orthotopic renal transplant (ORT) is useful in cases of severe atherosclerosis, heterotopic bilateral transplant, unsuitable pelvic vessels and in aortic thrombosis, but it is not available in all the institutions and it is only realized of exceptional form.

AIM

To review the indication, surgical technique and outcome of the ORT at our hospital.

MATERIAL AND METHODS

The studied included five cases between January 1990 and December 2005. We analyzed several variables: demographic characteristics, characteristics of the donor, ischemia times, evolution of renal function and morbi-mortality associated.

RESULTS

Left ORT was performed in three men and two women. Mean patient age was 52+/-5 years, all the patients received kidneys from cadaveric donors. Mean creatinine and urea one month postoperative were 2.2+/-0.72 mg/dl and 103+/-17.2 mg/dl and at 6 months postoperative were 1.8+/-0.59 mg/dl and 78+/-14 mg/dl respectively. Immediately all patients received prophylaxis with low molecular weight heparin but it was indicated antiaggregation to two patients when they left the hospital, anticoagulation to two patients and to one of them was decided to anticoagulation nor antiagregation for history of bled digestive. A patient died for bleeding episode at level of the renal graft six months after the transplant, she was in treatment with dicumarinics, they were indicated by venous deep thrombosis in right leg. The survival a year is 80 % of the graft and the patient. Only two patients returned to hospital later, one of them for presenting an episode of diverticulitis and the other one for renal obstructive failure that needed laying of catheter pig-tail. Four patients presented stenosis of renal native vassels detected in control magnetic nuclear resonance, not symptomatic. There are two patients who take more than three years transplanted with renal stable function (creatinina 1.3 mg/dl and 1.4 mg/dl respectively).

CONCLUSION

ORT is an excellent option in patients with co-morbidity increased for atherosclerosis and that cannot be placed in the iliac fossaes.

Right renal vein elongation with the inferior vena cava for cadaveric kidney transplants: an old neglected surgical approach

INTRODUCTION

Short right renal vein is a frequent and well-known technical inconvenience that is commonly observed during transplantation of the right kidney. We present our experience with the elongation of short cadaveric right renal veins using the contiguous vena cava during cadaveric renal transplants.

METHODS

We performed 34 kidney transplantations with a short right renal vein requiring elongation using the inferior vena cava, to make the venous anastomosis technically feasible. The elongated right renal vein was anastomosed end to side to the external iliac vein in 24 patients, to the common iliac vein in 8 patients and to the inferior vena cava in 2 patients. The right renal artery with an aortic patch was implanted end to side in 33 patients, and end to end without aortic patch to the internal iliac artery in one patient.

RESULTS

In all cases, the vascular anastomoses were easily performed in the recipient and no thrombosis was observed.

CONCLUSION

Elongation of a short right renal vein with the inferior vena cava is a feasible mean to overcome technical problems that may compromise the results of cadaveric renal transplantation.

Alternative Grafting Technique for Patients Unsuited to Heterotopic Transplantation due to Diseased Pelvic Conditions

INTRODUCTION

An alternative technique for kidney transplantation is presented for patients in whom the use of pelvic vessels is precluded.

PATIENTS AND METHODS

Of 482 cases of kidney or pancreas-kidney transplants, 4 were unsuited to heterotopic grafting, 1 due to multiple operations in the fossae and the 3 others due to extensive vascular occlusive disease. The patients were studied preoperatively by magnetic resonance angiography, which revealed extensive occlusive disease of the distal aorta and/or iliac vessels.

RESULTS

The patients received kidneys from living related donors as a third or second transplant opportunity in the orthotopic position (2 cases). Gross dissection of the aorta revealed a thickened wall, impeding direct anastomoses between the recipient's arteries and the donated organ. After a termino-lateral Dacron graft to the aorta, all cases were stented for uretero-uretero anastomosis. Recovery with respect to the renal graft was uneventful for all cases.

CONCLUSIONS

Alternative direct grafting from the aorta represents a viable and easy way to perform kidney transplants in patients unsuited to the heterotopic approach.

Renal transplantation in patients with complete obstruction of the inferior vena cava

We describe 2 patients with end-stage renal disease who had complete obstruction of the inferior vena cava and were successfully treated with renal transplantation in the usual iliac fossa position. One patient is doing well, with normal renal function more than 20 years after transplantation; the other patient was lost to follow-up after 3 months. Despite some technical difficulties, these patients apparently do well provided that an adequate collateral circulation bypassing the obstruction is confirmed by venography, and the patients receive anticoagulant therapy indefinitely.

Orthotopic renal transplant and results in 139 consecutive cases

Although a commonly performed technique, heterotopic renal transplantation may be a cause of late graft failure owing to ureteral stenosis, urinary fistula and vesicoureteral reflux secondary to the immune response. The new retroperitoneal lumbar approach to the splenic vessels has allowed the orthotopic technique to be developed using the splenic artery or aorta, the renal vein and a pyelo-pyelic anastomosis. In this manner the renal graft is located in an anatomical position that is well protected, and with the recipient urinary tract the normal physiology is preserved with comparatively low complication and mortality rates. A third transplant attempt also is simplified. This method is the only alternative in some cases. Transplant ureter pathology symptoms are not observed. The results of 139 consecutive cases are presented.