Meticulous use of techniques for reconstruction of multiple renal arteries in live donor kidney transplantation

Troubleshooting Complex Vascular Cases in the Kidney Graft: Multiple Vessels, Aneurysms, and Injuries During Harvesting Procedures

PURPOSE OF THE REVIEW

To update the most relevant literature regarding complex vascular cases in kidney transplant setting involving the graft, especially during the harvesting procedure and back-table preparation from the subsequent implant.

RECENT FINDINGS

Challenging situations affecting the kidney graft such as multiple vessels, renal artery aneurysms, kidney anatomical anomalies, or major injuries do not contraindicate the transplant, but require an exhaustive graft viability assessment and several bench surgery techniques. Graft vessel conditioning in the back-table might include simple anastomosis between them, enlarging with venous patch or reconstruction with donor or synthetic grafts. Compared with conventional transplant, literature reports longer warm ischemia time (40 vs 32 min) and slightly increased rates of delayed graft function (10.3% vs 8.2%) and vascular complications (10.8% vs 8.1%), but similar graft and patient survival. Kidney graft vascular complex cases require exhaustive assessment, meticulous harvesting, good surgical technique in the bench table, and proper surgery in the recipient. Despite its complexity, vascular complex kidney transplant offers comparable outcomes in the long term to conventional population when technically well performed, with slightly increased rates of vascular complications and delayed graft function.

Risk factors for transplant renal artery stenosis after live donor transplantation

Background

Renal transplant surgeons are making increasing use of live donor kidneys with multiple renal arteries. This study aimed to identify independent risk factors for the development of transplant renal artery stenosis (TRAS) in the modern era of complex arterial reconstruction for multiple vessels.

Methods

Multivariable logistic regression analysis with a stepwise variable deletion model was used to identify risk factors for the development of TRAS in a consecutive series of live donor kidney transplants.

Results

Of 506 kidney transplants, 19 (3·8 per cent) had evidence of significant TRAS on CT angiography. Functional TRAS, defined by improvement in BP control or renal function after correction of a stenosis by angioplasty, occurred in 13 of 506 patients (2·6 per cent). Independent risk factors for TRAS were: use of an explanted internal iliac artery graft from the recipient (odds ratio (OR) 4·95; P = 0·020) and total ischaemia time (OR 1·82; P = 0·010). TRAS was associated with a lower 5-year allograft survival rate (79 versus 88·7 per cent; P = 0·020) but only one graft loss was attributed directly to TRAS. The 5-year allograft survival rate after internal iliac artery grafting was 86 per cent.

Conclusion

Although use of an internal iliac artery graft is an independent risk factor for TRAS after live donor kidney transplantation, this technique is still a useful option for complex arterial reconstruction.

Successful Implantation of a Renal Allograft With Quintuple Arteries Retrieved From a Living Donor

In renal transplant, multiple renal arteries in a donor require meticulous vascular reconstruction for successful allograft function in the recipient. Presence of more than 4 renal arteries is usually considered to be a relative contraindication for proceeding with renal donation. We report a living-donor renal transplant procedure where preoperative radiologic imaging of the donor showed 3 left renal arteries. Two additional arteries were identified intraoperatively. All 5 arteries were reconstructed during the back-table procedure, and the allograft was implanted in the recipient. At 3-month follow-up, computed tomographic imaging demonstrated patency of all 5 renal arteries, and the patient had a serum creatinine level of 0.8 mg/dL. Unidentified arteries on preoperative imaging may occasionally require complex reconstruction. A renal allograft with 5 renal arteries is usually a contraindication for renal donation. Here, we describe the first published case of successful kidney transplant after reconstruction of 5 renal arteries in the donor graft.

Cadaveric Study of Mode of Termination of Gonadal Veins: Implications for Procedures Utilizing Terminal Ends of Gonadal Veins as Entry Portals

CONTEXT

The terminal ends of gonadal veins act as an entry portal in gonadal embolization procedures used for treating varicocele in males and pelvic congestion disease in females. Here, we studied the modes of termination of gonadal veins in adult cadavers.

MATERIALS AND METHODS

Thirty-five adult formalin-fixed cadavers (seventy sides) were studied over a period of 4 years. The modes of termination of gonadal veins were observed under the following study variables: (a) number, (b) locale of termination, and (c) termination angle.

RESULTS

Variations in study parameters were observed in eight sides of seven cadavers (seven unilateral and one bilateral). Double veins at termination were observed in six cadavers; anomalous termination was observed in three cadavers. Angle of termination differed from normal in 3 cadavers. In one of these cadavers, the left ovarian vein drained into the left suprarenal vein.

CONCLUSION

Duplication of terminal ends, anomalous drainage site, and varied angles of termination call for caution to ensure the success of procedures, which use terminal ends of gonadal veins as entry portals.