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Reconstruction of Multiple Renal Arteries During Simultaneous Pancreas and Kidney Transplantation: A Case Report
Reconstruction of Multiple Renal Arteries During Simultaneous Pancreas and Kidney Transplantation: A Case Report A. Surowiecka-Pastewkaa,b,*, M. Matejak-Górskaa, M. Frączekc,d, and M. Durlika,c a
Department of Gastroenterological Surgery and Transplantation, Central Clinical Hospital of the Ministry of the Interior, Warsaw, Poland; bMossakowski Medical Research Centre, Polish Academy of Sciences Department of Surgical Research and Transplantology, Pawinskiego, Warsaw, Poland; cDiagnostic Radiology Department, Central Clinical Hospital of the Ministry of the Interior, Warsaw, Poland; and dMedical Centre of Postgraduate Education, Warsaw, Poland
ABSTRACT We present a case of a multiple renal artery reconstruction during simultaneous pancreas and kidney transplantation. The kidney graft had 6 renal arteries, the aorta patch was 10 cm long, and there were two renal veins. To perform anastomoses to the left external iliac vessels we had to reconstruct the renal arterial and venal patches. The results of the transplantation were very good. Both grafts had satisfactory function, even though a control computed tomography performed a year after transplantation revealed infarction of a lower renal pole. Anatomical anomalies should not be a contraindication for transplantation, although transplants involving a multiplicity of vessels is a challenge for surgeons and requires both knowledge and microsurgical skills.
M
ULTIPLE RENAL ABNORMALITIES (MRAs) are the most common graft abnormality and are detected in 20e30% of donors [1,2]. MRAs are most often duplicated unilateral arterial systems, but in 10% they can be bilateral [3]. Multiple arterial systems present a higher risk of operative complications, such as bleeding and leaks, but there is no difference in the long-term observation of kidney graft function [1]. At our center, during a simultaneous pancreas and kidney transplantation (SPK), we start the surgery from the pancreas and then transplant the kidney graft into the retroperitoneal space using the same median incision. During surgery, we usually perform 4 arterial and 3 venous anastomoses. In almost all cases, we use the left kidney, as it has a longer renal vein and does not require vascular reconstructions. We perform end-to-side anastomoses between the graft vessels and the recipient’s left external iliac vein and artery. We use the MacKinnon method for uretero-vesical anastomosis, and implement double-J stents only in exceptional situations.
administrated polyclonal antibodies (1.5 mg/kg of body weight daily in 5 doses for a cumulative dose of 6 mg/kg). The donor organs required more anastomoses than in a routine procedure. The kidney graft had 2 renal veins and 6 renal arteries on one 10 cm patch. As a first step, on the back table we reconstructed the pancreas vessels using a routine technique. A Y-graft from the donor’s iliac artery was anastomosed to the graft’s supra mesenteric and splenic arteries. The portal vein was then elongated with a graft from the donor’s common iliac vein. Afterwards, we started preparing the kidney graft. The donor’s aorta patch in the kidney graft was 10 cm and had 6 renal arteries ostia (Fig 1A). We divided the arteries’ patches and performed 5 side-to-side anastomoses, reconstructing the arterial patch (Fig 1B). The result of the reconstruction a was shorter arterial patch. The renal vein reconstructions were done by creating a common trunk (side-to-side anastomosis). The reconstructed vessels were engrafted using a typical method (Fig 1C).
RESULTS
In the reported case, we performed an SPK on 32-year-old male recipient with diabetes diagnosed 25 years ago and who had been receiving renal replacement therapy since 2013 (over 3 years HD). For the induction, we 0041-1345/18 https://doi.org/10.1016/j.transproceed.2018.02.101
2136
*Address correspondence to Agnieszka Surowiecka-Pastewka, MD, PhD, Department of Gastroenterological Surgery and Transplantation, Central Clinical Hospital of the Ministry of the Interior in Warsaw, Woloska 137, 02-507 Warsaw, Poland. Phone: þ48 604 944 236; Fax: þ48 22 508 12 66. E-mail: [email protected] ª 2018 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 50, 2136e2139 (2018)
MRA RECONSTRUCTION IN SPK TRANSPLANTATION
2137
Fig 1. (A) The kidney graft before arterial reconstruction. A long aorta patch with 6 renal arteries visible. (B) The kidney graft during reconstruction. Five side-to side arterial anastomoses were performed. (C) A view after reconstruction and grafting to left external iliac vessels of the recipient.
We used a single median incision and engrafted the pancreas graft first. We performed duodeno-duodenal anastomosis and sutured the graft’s vessels to the right external iliac artery and the left common iliac vein of the recipient. We then transplanted the kidney graft to left external iliac vessels to the retroperitoneal space behind the
left iliac vessels. We used the MacKinnon method for the uretero-vesical anastomosis, without stenting the ureter. The blood loss during the surgery was 400 mL, and the patient required a blood transfusion during the procedure. We did not observe any further surgical complications. The grafts’ function was very good.
2138
In a control ultrasonography the grafted kidney had regular and rich blood supply. Postoperatively, the patient had proper renal and pancreas function. The serum level of creatinine before the SPK was 7.5 mg/dL and 2.09 mg/dL at the discharge. After 1 year of observation, the organs function remained satisfactory. The serum level of creatinine was 1.11. The patient was insulin-independent with positive c-peptide (fasting level 2.3 mg/dL). He continued immunosuppression with corticosteroids, mycophenolate, and tacrolimus. In a control computed tomography all 6 main kidney graft arteries appeared patent (Fig 2A). Small infarctions in the apical segment and at the border of upper and middle segment of the transplanted kidney were visualized, but otherwise no perfusion abnormalities were detected (Fig 2B). In the delayed phase images contrast excretion was appreciated, suggestive of proper graft function.
DISCUSSION
There are only a few articles considering multiple renal arteries in transplantation, but they discuss only kidney
Fig 2. (A) Arterial phase, oblique view of kidney graft demonstrates 2 small areas of infarction in apical segment (red arrow) and at the border of upper and middle segment (white arrow) (otherwise no perfusion abnormalities were detected). (B) MIP reconstruction, excretory phase, axial view of kidney graft depicts contrast in pyelocalyceal system and ureter suggestive of proper excretory function of kidney graft, and the contrast jet (red arrow) indicates the ureterovesical anastomosis.
SUROWIECKA-PASTEWKA, MATEJAK-GÓRSKA, FRĄCZEK ET AL
transplantation; none cover simultaneous pancreas and kidney transplantation. To our knowledge, we have described the first report on MRA reconstruction during the SPK. In our material, almost 10% of transplanted kidneys had two renal arteries. The discussed case was the kidney graft with more than two renal arteries and a single case of multiple renal arteries in the kidney graft used during the SPK at our center. All grafts with multiple arteries were right kidneys from deceased donors and only the kidney used for the SPK was a left kidney. Other studies show that the frequency of MRAs in kidney transplantation reaches 12.8% [2]. MRAs should not be a contraindication for transplantation, even for living donations. According to research, MRAs are present in even 72.4% of grafts coming from living related donors [2]. MRA kidney graft function is comparable to single-artery grafts. There is no significant difference in a long-term observation of level of serum creatinine or mean systolic blood pressure between single and multiple renal grafts [2]. MRAs or duplicated ureters are believed to be associated with higher surgical complication risk. Mazzucchi et al reported the estimated incidence of vascular complications during MRA transplantations was 3.1%: All of these cases were renal vein thrombosis, and no renal artery stenosis or renal artery thrombosis was reported. The authors also reported 4.7% ureteral leakage and 1.6% ureteral stenosis. There were no differences in the frequency of surgical complications between groups with single renal artery and multiple renal arteries [3]. Another interesting article is by Lafranca et al, who reviewed data from living donations in the Netherlands retrospectively. The main difference in kidney transplantation between MRA and single renal arteries was WIT, which was significantly longer in the group with arterial multiplicities [4]. There was no disparity in diuresis or serum creatinine level observed. Multiple renal vessels were not associated with a higher mortality rate among recipients [4,5]. The operation time was also significantly longer for multiple renal arteries [5]. Data coming from small single-center studies do not prove that arterial abnormalities have a negative impact on kidney transplantation results or aggravate operative risk. A metaanalysis from 2016, however, revealed adverse results [6]. Due to this review, MRA grafts were associated with higher complication rates in comparison to single artery grafts (13.8% vs. 11%), particularly vascular complications (10.8% vs. 8.1%). Urological complication rates were also higher in the MRA group (5.5% vs. 5%). One-year graft survival rates were worse for MRAs and delayed graft function was more frequent in the MRA group [6]. An interesting point of the meta-analysis was that many authors tend to conceal methods of arterial reconstruction [6], making it impossible to establish the optimal reconstructive technique. There are few cases of MRAs used for SPKs described in the literature. To our knowledge, this is the first article on multiplicity of renal arteries during pancreas transplantation. The results of our transplantation, however, are promising.
MRA RECONSTRUCTION IN SPK TRANSPLANTATION
CONCLUSIONS
Arterial multiplicity should not be a contraindication for pancreas and kidney transplantation, although it is a technical challenge for the surgeons. MRA cases are associated with longer WIT and longer operation times and vascular and surgical complications are observed more frequently, but longterm results for the grafts with MRAs and single renal arteries are similar. Bearing in mind the disparities between the numbers pancreas and kidney donors and recipients waiting on the lists, MRAs should not disqualify organs from donation. REFERENCES [1] Soliman S, Shokeir AA, Kamal AI, et al. Long-term outcome of grafts with multiple arteries in live-donor renal allotransplantation: analysis of 2100 consecutive patients. Arab J Urol 2011;9:171e7.
2139 [2] Aydin C, Berber I, Altaca G, Yigit B, Titiz I. The outcome of kidney transplants with multiple renal arteries. BMC Surg 2004;4:4. [3] Mazzucchi E, Soaza AA, Nahas WC, Antonopoulos IM, Piovesan AC, Arap A. Surgical complications after renal transplantation in grafts with multiple arteries. Clin Urology 2005;31: 125e30. [4] Lafranca JA, van Bruggen M, Kimenai HJAN, et al. Multiplicity should not be a contra-indication for live kidney donation and transplantation. PLoS One 2016;11:e0153460. [5] Saidi R, Kwai T, Kennealey P, et al. Living donor kidney transplantation with multiple arteries: recent increase in modern era of laparoscopic donor nephrectomy. Arch Surg 2009;144: 472e5. [6] Zorgdrager M, Krikke C, Hofker SH, Leuvenink HGD, Pol RA. Multiple renal arteries in kidney transplantation: a systematic review and meta-analysis. Ann Transplant 2016;21: 469e78.
Department of Gastroenterological Surgery and Transplantation, Central Clinical Hospital of the Ministry of the Interior, Warsaw, Poland; bMossakowski Medical Research Centre, Polish Academy of Sciences Department of Surgical Research and Transplantology, Pawinskiego, Warsaw, Poland; cDiagnostic Radiology Department, Central Clinical Hospital of the Ministry of the Interior, Warsaw, Poland; and dMedical Centre of Postgraduate Education, Warsaw, Poland
ABSTRACT We present a case of a multiple renal artery reconstruction during simultaneous pancreas and kidney transplantation. The kidney graft had 6 renal arteries, the aorta patch was 10 cm long, and there were two renal veins. To perform anastomoses to the left external iliac vessels we had to reconstruct the renal arterial and venal patches. The results of the transplantation were very good. Both grafts had satisfactory function, even though a control computed tomography performed a year after transplantation revealed infarction of a lower renal pole. Anatomical anomalies should not be a contraindication for transplantation, although transplants involving a multiplicity of vessels is a challenge for surgeons and requires both knowledge and microsurgical skills.
M
ULTIPLE RENAL ABNORMALITIES (MRAs) are the most common graft abnormality and are detected in 20e30% of donors [1,2]. MRAs are most often duplicated unilateral arterial systems, but in 10% they can be bilateral [3]. Multiple arterial systems present a higher risk of operative complications, such as bleeding and leaks, but there is no difference in the long-term observation of kidney graft function [1]. At our center, during a simultaneous pancreas and kidney transplantation (SPK), we start the surgery from the pancreas and then transplant the kidney graft into the retroperitoneal space using the same median incision. During surgery, we usually perform 4 arterial and 3 venous anastomoses. In almost all cases, we use the left kidney, as it has a longer renal vein and does not require vascular reconstructions. We perform end-to-side anastomoses between the graft vessels and the recipient’s left external iliac vein and artery. We use the MacKinnon method for uretero-vesical anastomosis, and implement double-J stents only in exceptional situations.
administrated polyclonal antibodies (1.5 mg/kg of body weight daily in 5 doses for a cumulative dose of 6 mg/kg). The donor organs required more anastomoses than in a routine procedure. The kidney graft had 2 renal veins and 6 renal arteries on one 10 cm patch. As a first step, on the back table we reconstructed the pancreas vessels using a routine technique. A Y-graft from the donor’s iliac artery was anastomosed to the graft’s supra mesenteric and splenic arteries. The portal vein was then elongated with a graft from the donor’s common iliac vein. Afterwards, we started preparing the kidney graft. The donor’s aorta patch in the kidney graft was 10 cm and had 6 renal arteries ostia (Fig 1A). We divided the arteries’ patches and performed 5 side-to-side anastomoses, reconstructing the arterial patch (Fig 1B). The result of the reconstruction a was shorter arterial patch. The renal vein reconstructions were done by creating a common trunk (side-to-side anastomosis). The reconstructed vessels were engrafted using a typical method (Fig 1C).
RESULTS
In the reported case, we performed an SPK on 32-year-old male recipient with diabetes diagnosed 25 years ago and who had been receiving renal replacement therapy since 2013 (over 3 years HD). For the induction, we 0041-1345/18 https://doi.org/10.1016/j.transproceed.2018.02.101
2136
*Address correspondence to Agnieszka Surowiecka-Pastewka, MD, PhD, Department of Gastroenterological Surgery and Transplantation, Central Clinical Hospital of the Ministry of the Interior in Warsaw, Woloska 137, 02-507 Warsaw, Poland. Phone: þ48 604 944 236; Fax: þ48 22 508 12 66. E-mail: [email protected] ª 2018 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 50, 2136e2139 (2018)
MRA RECONSTRUCTION IN SPK TRANSPLANTATION
2137
Fig 1. (A) The kidney graft before arterial reconstruction. A long aorta patch with 6 renal arteries visible. (B) The kidney graft during reconstruction. Five side-to side arterial anastomoses were performed. (C) A view after reconstruction and grafting to left external iliac vessels of the recipient.
We used a single median incision and engrafted the pancreas graft first. We performed duodeno-duodenal anastomosis and sutured the graft’s vessels to the right external iliac artery and the left common iliac vein of the recipient. We then transplanted the kidney graft to left external iliac vessels to the retroperitoneal space behind the
left iliac vessels. We used the MacKinnon method for the uretero-vesical anastomosis, without stenting the ureter. The blood loss during the surgery was 400 mL, and the patient required a blood transfusion during the procedure. We did not observe any further surgical complications. The grafts’ function was very good.
2138
In a control ultrasonography the grafted kidney had regular and rich blood supply. Postoperatively, the patient had proper renal and pancreas function. The serum level of creatinine before the SPK was 7.5 mg/dL and 2.09 mg/dL at the discharge. After 1 year of observation, the organs function remained satisfactory. The serum level of creatinine was 1.11. The patient was insulin-independent with positive c-peptide (fasting level 2.3 mg/dL). He continued immunosuppression with corticosteroids, mycophenolate, and tacrolimus. In a control computed tomography all 6 main kidney graft arteries appeared patent (Fig 2A). Small infarctions in the apical segment and at the border of upper and middle segment of the transplanted kidney were visualized, but otherwise no perfusion abnormalities were detected (Fig 2B). In the delayed phase images contrast excretion was appreciated, suggestive of proper graft function.
DISCUSSION
There are only a few articles considering multiple renal arteries in transplantation, but they discuss only kidney
Fig 2. (A) Arterial phase, oblique view of kidney graft demonstrates 2 small areas of infarction in apical segment (red arrow) and at the border of upper and middle segment (white arrow) (otherwise no perfusion abnormalities were detected). (B) MIP reconstruction, excretory phase, axial view of kidney graft depicts contrast in pyelocalyceal system and ureter suggestive of proper excretory function of kidney graft, and the contrast jet (red arrow) indicates the ureterovesical anastomosis.
SUROWIECKA-PASTEWKA, MATEJAK-GÓRSKA, FRĄCZEK ET AL
transplantation; none cover simultaneous pancreas and kidney transplantation. To our knowledge, we have described the first report on MRA reconstruction during the SPK. In our material, almost 10% of transplanted kidneys had two renal arteries. The discussed case was the kidney graft with more than two renal arteries and a single case of multiple renal arteries in the kidney graft used during the SPK at our center. All grafts with multiple arteries were right kidneys from deceased donors and only the kidney used for the SPK was a left kidney. Other studies show that the frequency of MRAs in kidney transplantation reaches 12.8% [2]. MRAs should not be a contraindication for transplantation, even for living donations. According to research, MRAs are present in even 72.4% of grafts coming from living related donors [2]. MRA kidney graft function is comparable to single-artery grafts. There is no significant difference in a long-term observation of level of serum creatinine or mean systolic blood pressure between single and multiple renal grafts [2]. MRAs or duplicated ureters are believed to be associated with higher surgical complication risk. Mazzucchi et al reported the estimated incidence of vascular complications during MRA transplantations was 3.1%: All of these cases were renal vein thrombosis, and no renal artery stenosis or renal artery thrombosis was reported. The authors also reported 4.7% ureteral leakage and 1.6% ureteral stenosis. There were no differences in the frequency of surgical complications between groups with single renal artery and multiple renal arteries [3]. Another interesting article is by Lafranca et al, who reviewed data from living donations in the Netherlands retrospectively. The main difference in kidney transplantation between MRA and single renal arteries was WIT, which was significantly longer in the group with arterial multiplicities [4]. There was no disparity in diuresis or serum creatinine level observed. Multiple renal vessels were not associated with a higher mortality rate among recipients [4,5]. The operation time was also significantly longer for multiple renal arteries [5]. Data coming from small single-center studies do not prove that arterial abnormalities have a negative impact on kidney transplantation results or aggravate operative risk. A metaanalysis from 2016, however, revealed adverse results [6]. Due to this review, MRA grafts were associated with higher complication rates in comparison to single artery grafts (13.8% vs. 11%), particularly vascular complications (10.8% vs. 8.1%). Urological complication rates were also higher in the MRA group (5.5% vs. 5%). One-year graft survival rates were worse for MRAs and delayed graft function was more frequent in the MRA group [6]. An interesting point of the meta-analysis was that many authors tend to conceal methods of arterial reconstruction [6], making it impossible to establish the optimal reconstructive technique. There are few cases of MRAs used for SPKs described in the literature. To our knowledge, this is the first article on multiplicity of renal arteries during pancreas transplantation. The results of our transplantation, however, are promising.
MRA RECONSTRUCTION IN SPK TRANSPLANTATION
CONCLUSIONS
Arterial multiplicity should not be a contraindication for pancreas and kidney transplantation, although it is a technical challenge for the surgeons. MRA cases are associated with longer WIT and longer operation times and vascular and surgical complications are observed more frequently, but longterm results for the grafts with MRAs and single renal arteries are similar. Bearing in mind the disparities between the numbers pancreas and kidney donors and recipients waiting on the lists, MRAs should not disqualify organs from donation. REFERENCES [1] Soliman S, Shokeir AA, Kamal AI, et al. Long-term outcome of grafts with multiple arteries in live-donor renal allotransplantation: analysis of 2100 consecutive patients. Arab J Urol 2011;9:171e7.
2139 [2] Aydin C, Berber I, Altaca G, Yigit B, Titiz I. The outcome of kidney transplants with multiple renal arteries. BMC Surg 2004;4:4. [3] Mazzucchi E, Soaza AA, Nahas WC, Antonopoulos IM, Piovesan AC, Arap A. Surgical complications after renal transplantation in grafts with multiple arteries. Clin Urology 2005;31: 125e30. [4] Lafranca JA, van Bruggen M, Kimenai HJAN, et al. Multiplicity should not be a contra-indication for live kidney donation and transplantation. PLoS One 2016;11:e0153460. [5] Saidi R, Kwai T, Kennealey P, et al. Living donor kidney transplantation with multiple arteries: recent increase in modern era of laparoscopic donor nephrectomy. Arch Surg 2009;144: 472e5. [6] Zorgdrager M, Krikke C, Hofker SH, Leuvenink HGD, Pol RA. Multiple renal arteries in kidney transplantation: a systematic review and meta-analysis. Ann Transplant 2016;21: 469e78.