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A Novel Technique for Reconstruction of Multiple Renal Arteries in Live Donor Kidney Transplantation: A Case Report and Literature Review
A Novel Technique for Reconstruction of Multiple Renal Arteries in Live Donor Kidney Transplantation: A Case Report and Literature Review B. He and A. Mitchell ABSTRACT Background. Reconstruction for three renal arteries from a living donor becomes a real challenge as the limited material can be used when compared with diseased donors. Therefore, in this report we introduce a novel technique by using the gonadal vein as a Carrel patch for reconstruction with three renal arteries. The other techniques will also be reviewed in this report. Methods. The living donor is a 51-year-old woman with three renal arteries on the left side and one renal artery on the right side, but with early branching 15 mm from the origin. The recipient is her husband, a 56-year-old with end-stage kidney disease secondary to type II diabetes. A left laparoscopic donor nephrectomy was performed successfully. The three renal arteries were anastomosed to the gonadal vein patch in a parallel fashion. Thereafter, the gonadal vein patch was anastomosed to the side of external iliac artery. The renal vein was anastomosed to the side of external iliac vein. Results. The kidney was reperfused rapidly and uniformly. The kidney functioned immediately. Doppler ultrasound and renal nuclear scans revealed that the perfusion of the kidney was normal. The creatinine level was 158 umol/L at day 7 and stable at 140 umol/L during the 2-month follow-up examination. Conclusions. The gonadal vein can be used as a Carrel patch for multiple renal artery reconstruction, in particular, for more than two renal arteries. This technique provides a new approach for the reconstruction of multiple renal arteries in living donor kidney transplantations. ULTIPLE renal arteries are frequently encountered during living donor kidney transplantation procedures. The living donor kidney transplantation, by using the kidney with multiple renal arteries, has an equal outcome in terms of patient and graft survival rates. The technique used for reconstruction of multiple renal arteries is most important for the successful kidney transplantation to prevent long-term vascular complications. The techniques available are very much dependent on the individual surgeons, in particular, when three renal arteries are encountered. The aim of this report is to introduce a novel technique by using gonadal vein as a Carrel patch for reconstruction with three renal arteries. The other techniques for multiple renal artery reconstruction will also be reviewed in this study.
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CASE REPORT The living donor is a 51-year-old female. There was no contraindication for kidney donation during medical work-up. The glomer-
ular filtration rate was 80 mL/min/1.73 m2 on 51Cr ethylenediamenetetraacetic acid and 99mTc dimercaptosuccinic acid nuclear scan with differential kidney function 49% on left side and 51% on right side. The renal artery anatomy was well shown on the computed tomographic angiogram. On left side, there were three renal arteries: the superior renal artery measured 4 mm and rises off the aorta at the level of the superior mesentery artery (SMA). The middle renal artery measures 5 mm and rises 7 mm below the origin of the SMA. The inferior renal artery measures 2 mm and rises off the aorta at the level of the inferior mesentery artery. There was a single renal vein and ureter. On the right side, there was a single renal artery with early branches rising at 15 mm from the origin From the WA Liver and Kidney Transplant Service, Sir Charles Gairdner Hospital, Nedlands, Australia. Address reprint requests to Dr. Bulang He, MB, BS, MS, FRACS, WA Liver and Kidney Transplant Service, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands Western Australia, 6009, Australia. E-mail: [email protected]
Crown Copyright © 2012 Published by Elseiver Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 44, 3055–3058 (2012)
0041-1345/–see front matter http://dx.doi.org/10.1016/j.transproceed.2012.03.054 3055
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HE AND MITCHELL
with a single renal vein and ureter. After thorough discussion in our routine multidisciplinary meeting, donation of the left kidney was determine. The donor nephrectomy was performed routinely by laparoscopic surgery.1 The three renal arteries were preserved, dissected as long as to the aorta, and then divided. The renal vein divided at the level close to the vena cava before the adrenal vein branch. The ureter was dissected with the gonadal vein as a bundle and divided at the level of the iliac vessel.1 The kidney graft was preplaced in the bag and delivered via small incision at the left iliac fossa. The kidney graft was perfused immediately with Ross (Orion, Australia, Ross solution 1 L ⫹ Heparin 10 000 IU) solution through the renal vein (retrograde perfusion).
Surgical Technique The multiple renal arteries were reconstructed using the donor gonadal vein which was retrieved along with the ureter. The gonadal vein was cleaned and opened longitudinally similar to a patch. The renal arteries were anastomosed to the gonadal vein patch using 7/0 Prolene sutures in an interrupted fashion (Figs 1 and 2). The renal arteries were parallel to each other (Figs 1 and 2). The transplant recipient is the donor’s husband, a 56-year-old man with end-stage kidney disease secondary to type II diabetes. His body weight was 88.6 kg and his body mass index was 29. The blood group of donor and recipient is compatible. The cross-match was negative with a 5 HLA mismatch. He underwent peritoneal dialysis for 7 months before the kidney transplantation. The kidney graft is placed at right iliac fossa. The gonadal vein patch was anastomosed to the side of external iliac artery as a Carrel patch using 6/0 prolene sutures (Fig 3). The renal vein was anastomosed to the side of external iliac vein. The kidney graft was reperfused rapidly and uniformly. Urine output was observed on the operating table. The ureteroneocystostomy was performed using 5/0 polydioxanone suture with a ureteric stent placed in situ (Lich-Gregori technique).
Fig 2. The anastomosis was wide open. The renal arteries are paralell to each other.
also been administered a heparin infusion with a subsequent change to oral Clopidogrel according to the cardiologist’s protocol. However, the kidney graft function continuously improved with the Cr level decreasing to 158 umol/L at day 7 posttransplantation and stable at approximately 140 umol/L during the 2-month follow-up examination. The patient’s length of hospital stay was 6 days. The ureteric stent was removed 4 weeks after transplantation. There were no surgical complications. DISCUSSION
On day 1 posttransplantation, the creatinine (Cr) level was down to 437 umol/L from 576 umol/L before transplantation. The kidney graft was well perfused according to Doppler ultrasound and nuclear scans (Figs 4 –7). The patient developed cardiac symptoms during postoperative recovery and required Cardiac Care Unit admission. He has
The living donor kidney transplantation using a graft with multiple renal arteries has an equal outcome in terms of patient and graft survival rates.2–5 The surgical technique for reconstruction of multiple renal arteries has been reviewed by searching PubMed and Embase. The methods for the reconstruction of multiple renal arteries have been described in the literature.6 –9 This technique has not been a problem in deceased donor kidneys because extra materials are usually available from the aortic patch, vena cava, and iliac vessels. In addition, the reconstruction of multiple renal arteries does not increase the risk for renal artery
Fig 1. Three renal arteries were anastomosed to the gonadal vein patch by interrupted 7/0 Prolene stitches.
Fig 3. The gonadal vein patch (similar to the Carrel patch) was anastomosed to side of external iliac artery.
RESULTS
MULTIPLE RENAL ARTERY RECONSTRUCTION
Fig 4. Doppler ultrasound showed normal wave form of the superior renal artery.
thrombosis.10 The technique for reconstruction depends on the situation of the multiple renal arteries. Sometimes additional surgery may be required for obtaining vessel grafts such as the internal iliac atetery with distal branches.11 In general, for two renal arteries, the smalller branch is anastomosed to the side of the main renal artery. The two similar/equal-sized arteries are joined together forming one osteum. Alternatively, the two renal arteries are anastomoed to the individual distal branches of internal iliac artery, respectively. However, that becomes a challenge in reconstruction of the multiple renal arteries from a living donor if there are more than two renal arteries because there is limited material to use for reconstruction. For three renal arteries, the smaller branches are anasmosted to the main renal artery, or the smaller branch is
Fig 5. Doppler ultrasound showed normal wave form of the middle renal artery.
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Fig 6. Doppler ultrasound showed normal wave form of the inferior renal artery.
anastomsed to the side of one major renal artery before the two major renal arteries are joined together forming one osteum. Alternatively, one branch can be anastomoed to the internal iliac artery after other two branches are joined together before being anastomosed to the external iliac artery. The internal iliac artery can be obtained with distal branches for reconstruction.11 However, in an elderly recipient, the internal iliac artery is more often calcified and of poor quality. Therefore, the internal iliac artery is not always readily available for reconstruction. The novel tech-
Fig 7. Renal nuclear scan showed kidney graft was perfused uniformly without evidence of segmental infarction.
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nique presented herein allows multiple renal arteries to be anastomosed on to the gonadal vein patch similar to a Carrel patch that can be anastomosed to the side of external iliac artery. This technique allows the multiple renal arteries to become adequately parallel to each other (Figs 1 and 2) to avoid the risk of kinking. The gonadal vein can be readily removed with the ureter during living donor nephrectomy. This is an invaluable resource during living donor nephrectomy. The gonadal vein has also been used in extension of the renal vein for the right kidney. The gonadal vein can be spiral fashioned to extend the renal vein,12 or it can be used as conduit for end-to-end anastomosis to the renal vein if the gonadal vein size is bigger, in particular for female donors (our experience). We prefer to do bench surgery for multiple renal artery reconstruction whenever possible to avoid prolonged renal artery anastomosis on the table and subsequent acute tubular necrosis. REFERENCES 1. He B, Mitchell A, Delriviere L, et al: Laparoscopic donor nephrectomy. ANZ J Surg 81:159, 2011 2. Kadotani Y, Okamoto M, Akioka K, et al: Management and outcome of living kidney grafts with multiple arteries. Surg Today 35:459, 2005 3. Chabchoub K, Mhiri MN, Bahloul A, et al: Does kidney transplantation with multiple arteries affect graft survival? Transplant Proc 43:3423, 2011
HE AND MITCHELL 4. Tyson MD, Castle EP, Ko EY, et al: Living donor kidney transplantation with multiple renal arteries in the laparoscopic era. Urology 77:1116, 2011 5. Ghazanfar A, Tavakoli A, Zaki MR, et al: The outcomes of living donor renal transplants with multiple renal arteries: a large cohort study with a mean follow-up period of 10 years. Transplant Proc 42:1654, 2010 6. Tzakisl AG, Mazzaferrol V, Pant C-E, et al: Renal artery reconstruction for harvesting injuries in kidney transplantation with particular reference to the use of vascular allografts. Transplant Int 1:80, 1988 7. Dean RH, Meacham PW, Weaver FA: Ex vivo renal artery reconstructions: indications and techniques. J Vasc Surg 4:546, 1986 8. Merkel FK, Straus AK, Anderson O, et al: Microvascular technique for polar artery reconstruction in kidney transplant. Surgery 79:253, 1976 9. Novick AC, Magnusson M, Braun WE: Multiple-artery renal transplantation: emphasis on extracorporeal methods of donor arterial reconstruction. J Urol 122:731, 1979 10. Benedetti E, Troppmann C, Gillingham K, et al: Short- and long-term outcomes of kidney transplants with multiple renal arteries. Ann Surg 221:406, 1995 11. Firmin LC, Johari Y, Nicholson ML: Explantation of the recipient internal iliac artery of bench— surgery during live donor renal transplants with multiple renal arteries. Ann R Coll Surg Engl 92:356, 2010 12. Nghiem DD: Spiral gonadal vein graft extension of right renal vein in living renal transplantation. J Urol 142:1525, 1989
M
CASE REPORT The living donor is a 51-year-old female. There was no contraindication for kidney donation during medical work-up. The glomer-
ular filtration rate was 80 mL/min/1.73 m2 on 51Cr ethylenediamenetetraacetic acid and 99mTc dimercaptosuccinic acid nuclear scan with differential kidney function 49% on left side and 51% on right side. The renal artery anatomy was well shown on the computed tomographic angiogram. On left side, there were three renal arteries: the superior renal artery measured 4 mm and rises off the aorta at the level of the superior mesentery artery (SMA). The middle renal artery measures 5 mm and rises 7 mm below the origin of the SMA. The inferior renal artery measures 2 mm and rises off the aorta at the level of the inferior mesentery artery. There was a single renal vein and ureter. On the right side, there was a single renal artery with early branches rising at 15 mm from the origin From the WA Liver and Kidney Transplant Service, Sir Charles Gairdner Hospital, Nedlands, Australia. Address reprint requests to Dr. Bulang He, MB, BS, MS, FRACS, WA Liver and Kidney Transplant Service, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands Western Australia, 6009, Australia. E-mail: [email protected]
Crown Copyright © 2012 Published by Elseiver Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 44, 3055–3058 (2012)
0041-1345/–see front matter http://dx.doi.org/10.1016/j.transproceed.2012.03.054 3055
3056
HE AND MITCHELL
with a single renal vein and ureter. After thorough discussion in our routine multidisciplinary meeting, donation of the left kidney was determine. The donor nephrectomy was performed routinely by laparoscopic surgery.1 The three renal arteries were preserved, dissected as long as to the aorta, and then divided. The renal vein divided at the level close to the vena cava before the adrenal vein branch. The ureter was dissected with the gonadal vein as a bundle and divided at the level of the iliac vessel.1 The kidney graft was preplaced in the bag and delivered via small incision at the left iliac fossa. The kidney graft was perfused immediately with Ross (Orion, Australia, Ross solution 1 L ⫹ Heparin 10 000 IU) solution through the renal vein (retrograde perfusion).
Surgical Technique The multiple renal arteries were reconstructed using the donor gonadal vein which was retrieved along with the ureter. The gonadal vein was cleaned and opened longitudinally similar to a patch. The renal arteries were anastomosed to the gonadal vein patch using 7/0 Prolene sutures in an interrupted fashion (Figs 1 and 2). The renal arteries were parallel to each other (Figs 1 and 2). The transplant recipient is the donor’s husband, a 56-year-old man with end-stage kidney disease secondary to type II diabetes. His body weight was 88.6 kg and his body mass index was 29. The blood group of donor and recipient is compatible. The cross-match was negative with a 5 HLA mismatch. He underwent peritoneal dialysis for 7 months before the kidney transplantation. The kidney graft is placed at right iliac fossa. The gonadal vein patch was anastomosed to the side of external iliac artery as a Carrel patch using 6/0 prolene sutures (Fig 3). The renal vein was anastomosed to the side of external iliac vein. The kidney graft was reperfused rapidly and uniformly. Urine output was observed on the operating table. The ureteroneocystostomy was performed using 5/0 polydioxanone suture with a ureteric stent placed in situ (Lich-Gregori technique).
Fig 2. The anastomosis was wide open. The renal arteries are paralell to each other.
also been administered a heparin infusion with a subsequent change to oral Clopidogrel according to the cardiologist’s protocol. However, the kidney graft function continuously improved with the Cr level decreasing to 158 umol/L at day 7 posttransplantation and stable at approximately 140 umol/L during the 2-month follow-up examination. The patient’s length of hospital stay was 6 days. The ureteric stent was removed 4 weeks after transplantation. There were no surgical complications. DISCUSSION
On day 1 posttransplantation, the creatinine (Cr) level was down to 437 umol/L from 576 umol/L before transplantation. The kidney graft was well perfused according to Doppler ultrasound and nuclear scans (Figs 4 –7). The patient developed cardiac symptoms during postoperative recovery and required Cardiac Care Unit admission. He has
The living donor kidney transplantation using a graft with multiple renal arteries has an equal outcome in terms of patient and graft survival rates.2–5 The surgical technique for reconstruction of multiple renal arteries has been reviewed by searching PubMed and Embase. The methods for the reconstruction of multiple renal arteries have been described in the literature.6 –9 This technique has not been a problem in deceased donor kidneys because extra materials are usually available from the aortic patch, vena cava, and iliac vessels. In addition, the reconstruction of multiple renal arteries does not increase the risk for renal artery
Fig 1. Three renal arteries were anastomosed to the gonadal vein patch by interrupted 7/0 Prolene stitches.
Fig 3. The gonadal vein patch (similar to the Carrel patch) was anastomosed to side of external iliac artery.
RESULTS
MULTIPLE RENAL ARTERY RECONSTRUCTION
Fig 4. Doppler ultrasound showed normal wave form of the superior renal artery.
thrombosis.10 The technique for reconstruction depends on the situation of the multiple renal arteries. Sometimes additional surgery may be required for obtaining vessel grafts such as the internal iliac atetery with distal branches.11 In general, for two renal arteries, the smalller branch is anastomosed to the side of the main renal artery. The two similar/equal-sized arteries are joined together forming one osteum. Alternatively, the two renal arteries are anastomoed to the individual distal branches of internal iliac artery, respectively. However, that becomes a challenge in reconstruction of the multiple renal arteries from a living donor if there are more than two renal arteries because there is limited material to use for reconstruction. For three renal arteries, the smaller branches are anasmosted to the main renal artery, or the smaller branch is
Fig 5. Doppler ultrasound showed normal wave form of the middle renal artery.
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Fig 6. Doppler ultrasound showed normal wave form of the inferior renal artery.
anastomsed to the side of one major renal artery before the two major renal arteries are joined together forming one osteum. Alternatively, one branch can be anastomoed to the internal iliac artery after other two branches are joined together before being anastomosed to the external iliac artery. The internal iliac artery can be obtained with distal branches for reconstruction.11 However, in an elderly recipient, the internal iliac artery is more often calcified and of poor quality. Therefore, the internal iliac artery is not always readily available for reconstruction. The novel tech-
Fig 7. Renal nuclear scan showed kidney graft was perfused uniformly without evidence of segmental infarction.
3058
nique presented herein allows multiple renal arteries to be anastomosed on to the gonadal vein patch similar to a Carrel patch that can be anastomosed to the side of external iliac artery. This technique allows the multiple renal arteries to become adequately parallel to each other (Figs 1 and 2) to avoid the risk of kinking. The gonadal vein can be readily removed with the ureter during living donor nephrectomy. This is an invaluable resource during living donor nephrectomy. The gonadal vein has also been used in extension of the renal vein for the right kidney. The gonadal vein can be spiral fashioned to extend the renal vein,12 or it can be used as conduit for end-to-end anastomosis to the renal vein if the gonadal vein size is bigger, in particular for female donors (our experience). We prefer to do bench surgery for multiple renal artery reconstruction whenever possible to avoid prolonged renal artery anastomosis on the table and subsequent acute tubular necrosis. REFERENCES 1. He B, Mitchell A, Delriviere L, et al: Laparoscopic donor nephrectomy. ANZ J Surg 81:159, 2011 2. Kadotani Y, Okamoto M, Akioka K, et al: Management and outcome of living kidney grafts with multiple arteries. Surg Today 35:459, 2005 3. Chabchoub K, Mhiri MN, Bahloul A, et al: Does kidney transplantation with multiple arteries affect graft survival? Transplant Proc 43:3423, 2011
HE AND MITCHELL 4. Tyson MD, Castle EP, Ko EY, et al: Living donor kidney transplantation with multiple renal arteries in the laparoscopic era. Urology 77:1116, 2011 5. Ghazanfar A, Tavakoli A, Zaki MR, et al: The outcomes of living donor renal transplants with multiple renal arteries: a large cohort study with a mean follow-up period of 10 years. Transplant Proc 42:1654, 2010 6. Tzakisl AG, Mazzaferrol V, Pant C-E, et al: Renal artery reconstruction for harvesting injuries in kidney transplantation with particular reference to the use of vascular allografts. Transplant Int 1:80, 1988 7. Dean RH, Meacham PW, Weaver FA: Ex vivo renal artery reconstructions: indications and techniques. J Vasc Surg 4:546, 1986 8. Merkel FK, Straus AK, Anderson O, et al: Microvascular technique for polar artery reconstruction in kidney transplant. Surgery 79:253, 1976 9. Novick AC, Magnusson M, Braun WE: Multiple-artery renal transplantation: emphasis on extracorporeal methods of donor arterial reconstruction. J Urol 122:731, 1979 10. Benedetti E, Troppmann C, Gillingham K, et al: Short- and long-term outcomes of kidney transplants with multiple renal arteries. Ann Surg 221:406, 1995 11. Firmin LC, Johari Y, Nicholson ML: Explantation of the recipient internal iliac artery of bench— surgery during live donor renal transplants with multiple renal arteries. Ann R Coll Surg Engl 92:356, 2010 12. Nghiem DD: Spiral gonadal vein graft extension of right renal vein in living renal transplantation. J Urol 142:1525, 1989