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Comparative study of helical CT scan angiography, conventional arteriography, and intraoperative findings for the evaluation of living renal transplant donors
Comparative Study of Helical CT Scan Angiography, Conventional Arteriography, and Intraoperative Findings for the Evaluation of Living Renal Transplant Donors M.A. Manu, M. Harza, R. Manu, S. Georgescu, M. Lesaru, H. Toma, and I. Sinescu
O
NE OF the most important data that must be known before transplantation surgery is the donor kidney vascular anatomy. Conventional renal angiography (CA) and digital angiocinematography represent the most common and well-known methods of preoperative evaluation of donor renal vascular anatomy. CA evaluates the anatomy of renal vessels, main arteries and their primary branches, sinus anatomy, intrarenal arterial branches, veins, and urography. CA can also prove variants of common vascular anatomy such as aberrant and accessory vessels, early branches, and multiple codominant arteries, which occur in one-third of cases. CA shows pathologic conditions of renal artery such as stenosis and aneurysm. In the last few years, helical computer tomography scan angiography (HCTSA) has been introduced as a new method for the evaluation of donor renal vascular anatomy. The method is less invasive, can be done ambulatory. We assessed whether HCTSA could be a substitute for or an addition to CA for the evaluation of living kidney donors. PATIENTS AND METHODS We introduced the HCTSA as a routine evaluation method of donor vascular anatomy in June, 1999. All kidney donors (32 patients) underwent CA and HCTSA. Findings obtained by HCTSA were compared with those of CA (64 renal units) and with those of surgery (32 operated kidneys). We defined the criteria to judge the visualization of renal vessels: well visualized (WV), poorly visualized (PV), and not visualized (NV). WV means that the anatomy of the vessels, their origin, length, and direction, their branches, and normal or abnormal conditions could be clearly, sharply, and definitely identified. PV means that all the aspects mentioned above could be identified, but not sharply and clearly.
NV means that aspects of vascular anatomy were not proved by CA and/or HCTSA but they were discovered by another method or during surgery. The goal of the study was to evaluate by both methods the main renal arteries, the main branches of the renal arteries, the intrarenal branches, the aberrant arteries, and early branches (less than 2 cm from aorta), and pathologic conditions (stenosis and aneurysm). Thirty-two patients entered the study, and 64 kidneys were evaluated by CA and HCTSA. In 32 cases we could compare the preoperative aspects with those obtained by surgery. Sixty-seven main arteries were proved; in 3 cases two codominant arteries were discovered. In 8 cases aberrant vessels or early branches were shown. They were studied together cause of their common influence for the harvesting act. Two cases of simple renal artery stenosis and one case of aneurysm were solved by bench surgery.
RESULTS
The main renal arteries were WV by HCTSA in 58 ⫾ 3 of 67 cases (90.6%). Three cases, representing the codominant arteries, were WV as well. In 6 cases (9.4%), the main arteries were PV by HCTSA, and no case was NV. The main arteries were WV by CA in 56 ⫾ 3 of 67 cases
From the Department of Urology and Kidney Transplantation, Fundeni Clinical Institute (M.A.M., M.H., R.M., S.G., M.L., I.S.), Bucharest, Romania and the Kidney Center, Tokyo Women’s Medical University (H.T.), Tokyo, Japan. Address reprint requests to Marcian Antonio Manu, MD, Department of Urology and Kidney Transplantation, Fundeni Clinical Institute, Fundeni street No. 258, Bucharest, Romania. E-mail: [email protected].
Table 1. Well-Visualized, Poorly Visualized, and Nonvisualized Aspects of Renal Artery WV
Main artery Main branches Intrarenal branches Aberrant vessels and early branches Stenosis (n) Aneurysm (n)
PV
NV
HCTSA
CA
HCTSA
CA
HCTSA
CA
90.6% 78.1% 0% 62.5% 1 0
87.5% 87.5% 100% 50% 1 0
9.4% 18.7% 0% 25% 1 0
12.5% 10.9% 0% 37.5% 1 0
0% 3.2% 100% 12.5% 0 1
0% 1.5% 0% 12.5% 0 1
Abbreviations: WV, well visualized; PV, poorly visualized; NV, nonvisualized; HCTSA, helical CT scan angiography; CA, conventional arteriography.
0041-1345/01/$–see front matter PII S0041-1345(00)02776-7
© 2001 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
2028
Transplantation Proceedings, 33, 2028–2029 (2001)
COMPARATIVE STUDY
(87.5%), PV in 8 cases (12.5%), and no case were NV (Table 1). The main branches were WV by HCTSA in 50 of 67 (78.1%) cases, PV in 12 (18.7%) cases, and 2 (3.2%) cases were NV. CA showed WV the main branches in 56 of 67 (87.5%) cases, PV in 7 (10.9%) cases, and 1 case (1.5%) was NV (Table 1). The intrarenal branches were WV by CA in all cases (100%). HCTSA could not prove the intrarenal branches. The aberrant vessels and early branches were WV by HCTSA in five of eight (62.5%) cases, PV in two (25%) cases, and NV in one case (12.5%). CA showed the abnormal anatomy in four of eight (50%) cases, PV in three (37.5%) cases, and one case was NV (12.5%). One case of renal artery stenosis was WV by HCTSA and one was PV. One case was WV and the other case was PV by CA. One case of renal artery aneurysm was not proved by both preoperative methods; it was discovered during surgery (Table 1). For the 32 operated cases, a comparison of findings shown by both methods with those obtained by surgery, proved a sensitivity of 96.5% for HCTSA and 95.4% for CA. DISCUSSION
In 30% to 32% of cases, renal vascular anatomy abnormalities occur. These aspects must be known prior to donor nephrectomy. If the anatomy of the blood supply is well proved by any of these methods, a proper surgery can be done. In our study both methods proved the main arteries and the codominant main arteries in all the cases (WV ⫹ PV ⫽ 100%). HCTSA showed better than CA the main arteries (90.6% WV vs 87.5% WV). The codominant arteries were WV in all the cases by both methods. The main branches were better shown by CA (87.5% WV vs 78.1%). In two cases (HCTSA) versus one case (CA), the main branches
2029
were NV. CA is a proper method to prove the intrarenal branches anatomy, including segmental, small branches, and their abnormalities, because HCTSA is “blind” inside the kidney. Both methods evaluated the pathologic conditions (stenosis and aneurysm) in the same way. For the last one, surgery surprised us because CA and HCTS had not proved the abnormality. As a conclusion of the study, the visualization of renal vascular anatomy using CA and HCTSA is quite similar, with a small advantage of HCTSA for the evaluation of the main arteries, aberrant vessels, and early branches, which represent the clue of the living donor nephrectomy. HCTSA is less invasive than CA, and in our department it is less expensive as well. HCTSA could be a suitable replacement of CA for the evaluation of extrarenal vascular anatomy, but not for intrarenal aspects. Both methods have limits—they complement each other. Because HCTSA can be performed ambulatory, we propose it be the first choice for evaluation of kidney donor vascular anatomy. REFERENCES 1. Manu M, Tanabe K, Tokumoto T, et al: Transplant Proc 31:2883, 1999 2. Galanski M, Prokop M, Chavan A, et al: Radiology 189:185, 1993 3. Spring DB, Salvatierra O Jr, Palubinskas AJ, et al: Radiology 133:45, 1979 4. Dachman AH, Newmark JM, Mitchell MT, et al: Am J Roentgenol 171:193, 1998 5. Tsuda K, Murakami T, Kim T, et al: J Comput Assist Tomogr 22:186, 1998 6. Plat JF, Ellis JH, Korobkin M, et al: Am J Roentgenol 169:1325, 1997 7. AJR Am J Roengenol 168:1569, 1997 8. Platt JF, Ellis JK, Leichyman AB: Radiology 198:419, 1996 9. Harrison LH, Flye MW, Seigler HF: Ann Surg 188:83, 1978 10. Mell MW, Alfrey EJ, Rubin GD, et al: Transplantation 57:746, 1994
O
NE OF the most important data that must be known before transplantation surgery is the donor kidney vascular anatomy. Conventional renal angiography (CA) and digital angiocinematography represent the most common and well-known methods of preoperative evaluation of donor renal vascular anatomy. CA evaluates the anatomy of renal vessels, main arteries and their primary branches, sinus anatomy, intrarenal arterial branches, veins, and urography. CA can also prove variants of common vascular anatomy such as aberrant and accessory vessels, early branches, and multiple codominant arteries, which occur in one-third of cases. CA shows pathologic conditions of renal artery such as stenosis and aneurysm. In the last few years, helical computer tomography scan angiography (HCTSA) has been introduced as a new method for the evaluation of donor renal vascular anatomy. The method is less invasive, can be done ambulatory. We assessed whether HCTSA could be a substitute for or an addition to CA for the evaluation of living kidney donors. PATIENTS AND METHODS We introduced the HCTSA as a routine evaluation method of donor vascular anatomy in June, 1999. All kidney donors (32 patients) underwent CA and HCTSA. Findings obtained by HCTSA were compared with those of CA (64 renal units) and with those of surgery (32 operated kidneys). We defined the criteria to judge the visualization of renal vessels: well visualized (WV), poorly visualized (PV), and not visualized (NV). WV means that the anatomy of the vessels, their origin, length, and direction, their branches, and normal or abnormal conditions could be clearly, sharply, and definitely identified. PV means that all the aspects mentioned above could be identified, but not sharply and clearly.
NV means that aspects of vascular anatomy were not proved by CA and/or HCTSA but they were discovered by another method or during surgery. The goal of the study was to evaluate by both methods the main renal arteries, the main branches of the renal arteries, the intrarenal branches, the aberrant arteries, and early branches (less than 2 cm from aorta), and pathologic conditions (stenosis and aneurysm). Thirty-two patients entered the study, and 64 kidneys were evaluated by CA and HCTSA. In 32 cases we could compare the preoperative aspects with those obtained by surgery. Sixty-seven main arteries were proved; in 3 cases two codominant arteries were discovered. In 8 cases aberrant vessels or early branches were shown. They were studied together cause of their common influence for the harvesting act. Two cases of simple renal artery stenosis and one case of aneurysm were solved by bench surgery.
RESULTS
The main renal arteries were WV by HCTSA in 58 ⫾ 3 of 67 cases (90.6%). Three cases, representing the codominant arteries, were WV as well. In 6 cases (9.4%), the main arteries were PV by HCTSA, and no case was NV. The main arteries were WV by CA in 56 ⫾ 3 of 67 cases
From the Department of Urology and Kidney Transplantation, Fundeni Clinical Institute (M.A.M., M.H., R.M., S.G., M.L., I.S.), Bucharest, Romania and the Kidney Center, Tokyo Women’s Medical University (H.T.), Tokyo, Japan. Address reprint requests to Marcian Antonio Manu, MD, Department of Urology and Kidney Transplantation, Fundeni Clinical Institute, Fundeni street No. 258, Bucharest, Romania. E-mail: [email protected].
Table 1. Well-Visualized, Poorly Visualized, and Nonvisualized Aspects of Renal Artery WV
Main artery Main branches Intrarenal branches Aberrant vessels and early branches Stenosis (n) Aneurysm (n)
PV
NV
HCTSA
CA
HCTSA
CA
HCTSA
CA
90.6% 78.1% 0% 62.5% 1 0
87.5% 87.5% 100% 50% 1 0
9.4% 18.7% 0% 25% 1 0
12.5% 10.9% 0% 37.5% 1 0
0% 3.2% 100% 12.5% 0 1
0% 1.5% 0% 12.5% 0 1
Abbreviations: WV, well visualized; PV, poorly visualized; NV, nonvisualized; HCTSA, helical CT scan angiography; CA, conventional arteriography.
0041-1345/01/$–see front matter PII S0041-1345(00)02776-7
© 2001 by Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
2028
Transplantation Proceedings, 33, 2028–2029 (2001)
COMPARATIVE STUDY
(87.5%), PV in 8 cases (12.5%), and no case were NV (Table 1). The main branches were WV by HCTSA in 50 of 67 (78.1%) cases, PV in 12 (18.7%) cases, and 2 (3.2%) cases were NV. CA showed WV the main branches in 56 of 67 (87.5%) cases, PV in 7 (10.9%) cases, and 1 case (1.5%) was NV (Table 1). The intrarenal branches were WV by CA in all cases (100%). HCTSA could not prove the intrarenal branches. The aberrant vessels and early branches were WV by HCTSA in five of eight (62.5%) cases, PV in two (25%) cases, and NV in one case (12.5%). CA showed the abnormal anatomy in four of eight (50%) cases, PV in three (37.5%) cases, and one case was NV (12.5%). One case of renal artery stenosis was WV by HCTSA and one was PV. One case was WV and the other case was PV by CA. One case of renal artery aneurysm was not proved by both preoperative methods; it was discovered during surgery (Table 1). For the 32 operated cases, a comparison of findings shown by both methods with those obtained by surgery, proved a sensitivity of 96.5% for HCTSA and 95.4% for CA. DISCUSSION
In 30% to 32% of cases, renal vascular anatomy abnormalities occur. These aspects must be known prior to donor nephrectomy. If the anatomy of the blood supply is well proved by any of these methods, a proper surgery can be done. In our study both methods proved the main arteries and the codominant main arteries in all the cases (WV ⫹ PV ⫽ 100%). HCTSA showed better than CA the main arteries (90.6% WV vs 87.5% WV). The codominant arteries were WV in all the cases by both methods. The main branches were better shown by CA (87.5% WV vs 78.1%). In two cases (HCTSA) versus one case (CA), the main branches
2029
were NV. CA is a proper method to prove the intrarenal branches anatomy, including segmental, small branches, and their abnormalities, because HCTSA is “blind” inside the kidney. Both methods evaluated the pathologic conditions (stenosis and aneurysm) in the same way. For the last one, surgery surprised us because CA and HCTS had not proved the abnormality. As a conclusion of the study, the visualization of renal vascular anatomy using CA and HCTSA is quite similar, with a small advantage of HCTSA for the evaluation of the main arteries, aberrant vessels, and early branches, which represent the clue of the living donor nephrectomy. HCTSA is less invasive than CA, and in our department it is less expensive as well. HCTSA could be a suitable replacement of CA for the evaluation of extrarenal vascular anatomy, but not for intrarenal aspects. Both methods have limits—they complement each other. Because HCTSA can be performed ambulatory, we propose it be the first choice for evaluation of kidney donor vascular anatomy. REFERENCES 1. Manu M, Tanabe K, Tokumoto T, et al: Transplant Proc 31:2883, 1999 2. Galanski M, Prokop M, Chavan A, et al: Radiology 189:185, 1993 3. Spring DB, Salvatierra O Jr, Palubinskas AJ, et al: Radiology 133:45, 1979 4. Dachman AH, Newmark JM, Mitchell MT, et al: Am J Roentgenol 171:193, 1998 5. Tsuda K, Murakami T, Kim T, et al: J Comput Assist Tomogr 22:186, 1998 6. Plat JF, Ellis JH, Korobkin M, et al: Am J Roentgenol 169:1325, 1997 7. AJR Am J Roengenol 168:1569, 1997 8. Platt JF, Ellis JK, Leichyman AB: Radiology 198:419, 1996 9. Harrison LH, Flye MW, Seigler HF: Ann Surg 188:83, 1978 10. Mell MW, Alfrey EJ, Rubin GD, et al: Transplantation 57:746, 1994