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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2008  |  Volume : 19  |  Issue : 1  |  Page : 26-31
Evaluation of Blood Flow in Allograft Renal Arteries Anastomosed with Two Different Techniques


1 Urology Department, Imam Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
2 Radiology Department, Imam Hospital, Tabriz University of Medical Sciences, Tabriz, Iran

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   Abstract 

Renal artery stenosis in renal transplantation (TRAS) is an avoidable short or long-term surgical complication. The etiology is multifactorial, but faulty anastomosis is a major factor. In our transplant center, we evaluated the incidence of TRAS with the use of two different suturing techniques of the anastomosis site between the allograft renal and iliac arteries in two groups of renal transplant recipients, group A: 14 patients (6 males and 8 females with age 16 to 59 and mean age of 38 years) in whom the allograft arteries were anastomosed with a continuous suture technique, and group B: 14 patients (7 males and 7 females, with age 32 to 61 and mean age of 46.6 years) in whom the allograft arteries were anastomosed with a combined suture technique (continuous and interrupted). Post transplantation, the velocity of blood flow in the renal and iliac arteries at the site of anastomosis was measured by color Doppler ultrasound. The ultrasonographer was blinded to the surgical technique in both study groups. The ratio of the maximum velocity of blood at the site of anastomosis to that in the iliac artery of less than 2.5 was considered as non-significant stenosis, while a ratio of more than 2.5 was considered significant stenosis. In group A there were 9 cases of non-significant stenosis in comparison to 3 cases in group B, while there were no cases of significant stenosis in group A in comparison to 3 cases in group B; the difference was not statistically significant. We conclude that there was no difference in the incidence of stenosis in the compared surgical techniques of anastomosis in our study groups. This suggests that other factors such as gentle handling of tissue, enough spatula, margin reversion, and comparable diameter of the anastomosed vessels may be more important in the prevention of renal allograft stenosis than the type of suture technique.

Keywords: Renal, Allograft, Transplantation, Surgical, Technique, Stenosis

How to cite this article:
Zomorrodi A, Bohluli A, Tarzamany M K. Evaluation of Blood Flow in Allograft Renal Arteries Anastomosed with Two Different Techniques. Saudi J Kidney Dis Transpl 2008;19:26-31

How to cite this URL:
Zomorrodi A, Bohluli A, Tarzamany M K. Evaluation of Blood Flow in Allograft Renal Arteries Anastomosed with Two Different Techniques. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2019 Nov 17];19:26-31. Available from: http://www.sjkdt.org/text.asp?2008/19/1/26/37429

   Introduction Top


Although there are multiple approaches to management of end-stage renal disease (ESRD), kidney transplantation offers the greatest potential for return to near-normal renal function, increased longevity, enhanced quality of life, and lower healthcare costs. [1],[2],[3],[4],[5],[6],[7],[8],[9]

Post surgical vascular complications in renal transplantation are uncommon but important, as they may result in loss of the allograft. The most common of them is renal artery stenosis (TRAS), a potentially treatable com­plication that can occur from months to years after transplantation. [10] Transplant renal artery stenosis can occur secondary to atherosclerosis of the donor artery, suture technique, trauma to either donor or recipient artery during procurement or transplant surgery, and kinking of or damage to the iliac artery during transplantation. TRAS is more common at the site of the anastomosis of the donor artery to the native artery than intimal injury or perforation by cannula. TRAS is more common in cadaver than living kidney trans­plant recipients with new-onset or worsened hypertension. [11]

TRAS is an important cause of hypertension and/or allograft dysfunction. The prevalence of this disorder ranges from 1% to 23%. [10],[11],[12],[13],[14],[15] Hypertension may be due to chronic rejection, cyclosporine toxicity, and steroid use, recurrence of glomerulonephritis, diseased native kidney, or TRAS. [16],[17] Both patient and allograft survival rates are lower in patients with TRAS than in those without it. [16]

It has been suggested that an end-to-side anastomosis is prone to the development of TRAS owing to turbulent blood flow as a result of a hyperacute angle between the donor renal artery and the recipient iliac artery. [18] However, results of several subsequent studies [19],[20],[21],[22] have shown no difference in the prevalence of TRAS between the end-to­side and end-to-end techniques.

TRAS associated with surgical techniques can occur in the early postoperative days. An imperfect suturing technique of the anasto­mosis or kinking of the graft artery may cause early stenosis, which should be corrected by surgery. [23],[24]

We investigated maximum velocity of blood flow in anastomosing site and Iliac artery in two different suture technique and compared to each other.


   Material and Methods Top


Twenty eight consecutive kidney recipients classified in two groups: group A of 14 pa­tients (6males and 8 females with age 16 to 59 with mean age 38 years in whom the renal allografts arteries were anastomosed with continuous suture technique, [Figure - 1] and group B of 14 patients (7 males and 7 females with age range from 32 to 61 and mean age of 46.6 years) in whom we anastomosed the allografts arteries with a combined suture technique (two thirds of the artery diameter with continuous suture and one third with an interrupted one), [Figure - 2].

Post transplantation, the velocity of blood flow in the renal and iliac arteries at the site of anastomosis was measured by color Doppler ultrasound. The ulltrasonographer was blinded to the surgical technique in both study groups. The ratio of the maximum velocity of blood at the site of anastomosis to that in the iliac artery of less than 2.5 was considered as non-significant stenosis, while a ratio of more than 2.5 was considered significant stenosis. [25],[26],[27]


   Results Top


In group A there were 9 cases of non­significant stenosis in comparison to 3 cases in in group B, while there were no cases of significant stenosis in group A in comparison to 3 cases in group B; the difference was not statistically significant, [Table - 1],[Table - 2],[Table - 3].


   Discussion Top


The increased use of noninvasive screening imaging techniques, such as magnetic reso­nance angiography, color Doppler US, and computed tomographic angiography, has led to an apparent increase in the detected cases of TRAS. [28],[29],[30],[31],[32],[33],[34] In a study reported by Wong et al, [16] the prevalence of TRAS was 2.4% before and 12.4% after the introduction of "screening" color Doppler US. CT angio­graphy yields fewer false-positive results than US and is less prone to artifacts due to postoperative clips than MR imaging in the diagnosis of renal artery stenosis. [25],[35]

Stenosis, the most common vascular com­plication of renal transplantation, can occur as early as 2 days or as late as several years after the procedure. The stenosis usually occurs near the anastomosis site and is related to the surgical technique used. Distal stenosis seems to be caused by perfusion alterations, although some authors have suggested that it is a sign of rejection. In our investigation, to detect significant renal artery stenosis we measured the maximum velocity of blood flow at the site anastomosis [25] and the increase of the ratio of maximum velocity at the site of the anastomosis to that in the iliac artery. [26],[27] We did not find any significant difference in the incidence of significant stenosis between both study groups in whom the two different suture techniques were used.

We believe that proper diameter of the anas­tomosed vessels (fish mouth for adaptation to the anatomizing site), careful hemostasis and gentle handling of the vessels such as prevention of kinking and torsion of vessels are more important factors to decrease incidence of surgically induced TRAS than suturing technique.

Percutaneous transluminal angioplasty is accepted as a first line treatment TRAS. [13] Open surgical intervention is often difficult and may cause significant injury to the renal hilar structures and is associated with a 15% graft loss and 5% mortality. [21]

We conclude that there was no difference in the incidence of stenosis in the compared surgical techniques of anastomosis in our study groups. This suggests that other factors such as gentle handling of tissue, enough spatula, margin reversion, and comparable diameter of the anastomosed vessels may be more important in the prevention of renal allograft stenosis than the type of suture technique.

 
   References Top

1.Hansen M. Disorders of renal and urinary function, Pathophysiology: Foundations of Disease and Clinical Intervention. WB Saunders Company: Philadelphia, Pa; 1998.  Back to cited text no. 1    
2.US Renal Data System: Excerpts from the USRDS 2001 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. Am J Kidney Dis 2001;38:S1-S248.  Back to cited text no. 2    
3.Fauci AS, Braunwald C, Isselbacher KJ, et al, eds. Dialysis and Transplantation in the Treatment of Renal Failure (14th ed). McGraw-Hill: New York, NY; 1998.  Back to cited text no. 3    
4.Ray T. Chronic and acute renal failure: Primary care issues. United States Renal Disease System (1999). USRDS 1999 Annual Data Report. Adv Nurse Pract 2000;8:69-73.  Back to cited text no. 4    
5.Hathaway D, Strong M, Ganza M. Post­transplant quality of life expectations. ANNA J 1990;17:433-9.  Back to cited text no. 5  [PUBMED]  
6.Hathaway DK, Hartwig M, Winsett RP, Gaber AO. Quality of life 6-12 months after renal transplant. ANNA J 1992;19:152.  Back to cited text no. 6    
7.Jofre R, Lopez-Gomez JM, Moreno F, Sanz­Guajardo D, Valderrabano F. Changes in quality of life after renal transplantation. Am J Kidney Dis 1998;32:93-100.  Back to cited text no. 7    
8.Perryman JP, Stillerman PU. Kidney trans­plantation. In: Smith SL, ed. Tissue and Organ Transplantation. Mosby Year Book: St. Louis, Mo; 1990;176-209.  Back to cited text no. 8    
9.NIDDK National Kidney and Urologic Diseases Information Clearinghouse. End­stage renal disease: Choosing a treatment that's right for you. 1997. Available from: http://www.niddk.nih.gov/health/kidney/n kudic.htm. (Last accessed on 2002 Aug 30).  Back to cited text no. 9    
10.Fervanza FC, Lafayette RA, Alfrey EJ, Petersen J. Renal artery stenosis in kidney transplants. Am J Kidney Dis 1998;31:142-8.   Back to cited text no. 10    
11.O'Neill CW. Ultrasonography in renal transplantation. Am J Kidney Dis 2002;39:663-78.   Back to cited text no. 11    
12.Faenza A, Spolaore R, Poggioli G, Selleri S, Roversi R, Gozzetti G. Renal artery stenosis after renal transplantation. Kidney Int Suppl 1983;14:S54-9.  Back to cited text no. 12    
13.Lo CY, Cheng IK, Tso WK, Mak KO. Percutaneous transluminal angioplasty for transplant renal artery stenosis. Transplant Proc 1996;28:1468-9.  Back to cited text no. 13  [PUBMED]  
14.Lacombe M. Arterial stenosis complicating renal allotransplantation in man: A study of 38 cases. Ann Surg 1975;181:283-8.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]
15.Becker BN, Odorico JS, Becker YT, et al. Peripheral vascular disease and renal transplant artery stenosis: A reappraisal of transplant renovascular disease. Clin Transplant 1999 ;13:349-55.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]
16.Wong W, Fynn SP, Higgins RM, et al. Transplant renal artery stenosis in 77 patients: Does it have an immunological cause? Transplantation 1996;61:215-9.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]
17.Halimi JM, Al-Najjar A, Buchler M, et al. Transplant renal artery stenosis: Potential role of ischemia/reperfusion injury and long­term outcome following angioplasty. J Urol 1999;161:28-32.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]
18.Morris PJ, Yadav RV, Kincaid-Smith P, et al. Renal artery stenosis in renal transplant­tation. Med J Aust 1971;1:1255-7.  Back to cited text no. 18  [PUBMED]  
19.Greenstein SM, Verstandig A, McLean GK, et al. Percutaneous transluminal angioplasty: The procedure of choice in the hyper­tensive renal allograft recipient with renal artery stenosis. Transplantation 1987;43:29-32.  Back to cited text no. 19  [PUBMED]  
20.Benoit G, Hiesse C, Icard P, et al. Treatment of renal artery stenosis after renal transplan­tation. Transplant Proc 1987;19:3600-1.  Back to cited text no. 20  [PUBMED]  
21.Grossman RA, Dafoe DC, Shoenfeld RB, et al. Percutaneous transluminal angioplasty treatment of renal transplant artery stenosis. Transplantation 1982;34:339-43.  Back to cited text no. 21  [PUBMED]  
22.Munda R, Alexander JW, Miller S, First MR, Fidler JP. Renal allograft artery stenosis. Am J Surg 1977;134:400-3.  Back to cited text no. 22  [PUBMED]  [FULLTEXT]
23.Krumme B, Pisarski P, Blum U, Kirste G, Schollmeyer P. Unusual cause of early graft dysfunction after kidney transplantation. Am J Nephrol 1998;18:237-9.  Back to cited text no. 23  [PUBMED]  [FULLTEXT]
24.Roberts JP, Ascher NL, Fryd DS, et al. Transplant renal artery stenosis. Transplan­tation 1989;48:580-3.  Back to cited text no. 24    
25.Baxter GM, Ireland H, Moss JG, et al. Color Doppler ultrasound in renal transplant artery stenosis: Which Doppler index? Clin Radiol 1995;50:618-22.  Back to cited text no. 25  [PUBMED]  
26.Snider JF, Hunter DW, Moradian GP, Castaneda-Zuniga WR, Letourneau JG. Transplant renal artery stenosis: Evaluation with duplex sonography. Radiology 1989; 172:1027-30.  Back to cited text no. 26  [PUBMED]  [FULLTEXT]
27.Taylor KJ, Morse SS, Rigsby DM, Bia M, Schiff M. Vascular complications in renal allografts: Detection with duplex Doppler US. Radiology 1987;162:31-8.  Back to cited text no. 27    
28.Gray DW. Graft renal artery stenosis in the transplanted kidney. Transplant Rev 1994;8: 15-21.  Back to cited text no. 28    
29.Kuo PC, Petersen J, Semba C, Alfrey EJ, Dafoe DC. CO2 angiography: A technique for vascular imaging in renal allograft dysfunction. Transplantation 1996;61:652-4.  Back to cited text no. 29  [PUBMED]  [FULLTEXT]
30.Luk SH, Chan JH, Kwan TH, Tsui WC, Cheung YK, Yuen MK. Breath-hold 3D gadolinium-enhanced subtraction MRA in the detection of transplant renal artery stenosis. Clin Radiol 1999;54:651-4.  Back to cited text no. 30  [PUBMED]  
31.Mell MW, Alfrey EJ, Rubin GD, Scandling JD, Jeffrey RB, Dafoe DC. Use of spiral computed tomography in the diagnosis of transplant renal artery stenosis. Transplan­tation 1994;57:746-8.  Back to cited text no. 31    
32.Ferreiros J, Mendez R, Jorquera M, et al. Using gadolinium-enhanced three-dimensional MR angiography to assess arterial inflow stenosis after kidney transplantation. AJNR Am J Roentgenol 1999;172:751-7.  Back to cited text no. 32    
33.Loubeyre P, Abidi H, Cahen R, Tran Minh VA. Transplanted renal artery: Detection of stenosis with color Doppler US. Radiology 1997;203:661-5.  Back to cited text no. 33  [PUBMED]  [FULLTEXT]
34.Neimatallah MA, Dong CQ, Schoenberg SO, Cho KJ, Prince MR. Magnetic resonance imaging in renal transplantation. J Magn Reson Imaging 1999;10:357-68.  Back to cited text no. 34    
35.Hofmann LV, Smith PA, Kuszyk BS, Kraus E, Fishman EK. Three-dimensional helical CT angiography in renal transplant recipients: A new problem-solving tool. AJNR Am J Roentgenol 1999;173:1085-9.  Back to cited text no. 35    

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Correspondence Address:
Afshar Zomorrodi
Associate Professor of Urology, Imam Hospital, Tabriz University of Medical Sciences, Tabriz
Iran
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PMID: 18087119

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    Figures

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