Home About us Current issue Back issues Submission Instructions Advertise Contact Login   

Search Article 
Advanced search 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 201 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 

Table of Contents   
Year : 2015  |  Volume : 26  |  Issue : 5  |  Page : 1009-1012
Renal artery anastomosis to internal or external iliac artery in kidney transplant patients

1 Kidney Transplantation Unit, Faculty of Medicine, Damascus University, Damascus, Syria
2 Department of Surgery, Faculty of Medicine, Damascus University, Damascus, Syria

Click here for correspondence address and email

Date of Web Publication7-Sep-2015

How to cite this article:
Daowd R, Al Ahmad A. Renal artery anastomosis to internal or external iliac artery in kidney transplant patients. Saudi J Kidney Dis Transpl 2015;26:1009-12

How to cite this URL:
Daowd R, Al Ahmad A. Renal artery anastomosis to internal or external iliac artery in kidney transplant patients. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2020 Jun 4];26:1009-12. Available from: http://www.sjkdt.org/text.asp?2015/26/5/1009/164593
To the Editor

Most transplant centers report that the results of kidney transplantation at present are much better when compared with previous decades. [1],[2],[3],[4],[5] This improvement is due to improvements in instruments of surgery and developments in the immunosuppressive regimen. [4] The improvement in the survival rates may also be attributed to refinement in the technical quality of the surgery. Usually, two techniques of renal artery anastomosis are used in kidney transplant patients, namely end-to-end and end-toside anastomosis. The aim of our study is to compare the outcomes of kidney transplantation using these two different techniques. We could not find much data in the literature regarding this. Many centers prefer to perform end-to-side anastomosis in kidney transplant patients receiving grafts from both live and deceased donors. The trend in our center is also to perform end-to-side renal artery anastomosis.

All male patients of end-stage renal failure (ESRD) scheduled to be transplanted in our center in 2009 were included in the study. There were no exclusion criteria. Seventy-six patients were divided into two groups: the first group (Monday group, 35 patients) underwent an end-to-end renal artery anastomosis to the internal iliac artery (where all patients were eligible for this type of anastomosis and there was no underlying atherosclerotic disease of the internal iliac artery in the recipient) and the second group (Tuesday group, 41 patients) underwent end to-side renal artery anastomosis to the external or common iliac arteries. All the transplant operations were performed by the same team. Arterial anastomosis was performed using 6-0 non-absorbable running sutures.

We evaluated surgical and clinical complications as well as graft and patient survival. Erectile dysfunction (ED) was evaluated preand one year post-operatively. We did not use an international scoring system like the International Index of Erectile Function (IIEF); instead, we used three degrees for evaluation of the potency: weak, moderate and good, as described by the patients themselves. All patients were evaluated during the hospitalization period, then every month for three months, and every two months afterwards. We performed Doppler ultrasonography for all patients one week after transplantation, then as and when necessary, and one-year post-operatively.

The mean age of the kidney transplant patients was 48.5 ± 1.8 and 53.3 ± 1.6 years in group 1 and group 2, respectively (P = 0.06). The duration of warm ischemia time, cold ischemia time, arterial anastomosis duration, venous anastomosis duration and primary hospitallization period were similar in the two groups [Table 1]. Surgical and clinical complications were also similar in both groups [Table 2]. We evaluated the peak systolic velocity and resistive index by means of Doppler ultrasonography, which was performed routinely for all patients one week post-operatively and after one year, and whenever indicated during the follow-up period [Table 3]. Analysis of creatinine clearance in the early post-operative period and one year after transplantation showed no differences between the two groups [Table 4]. During the first post-operative year, there were nine deaths (11.8%): four in group 1 (two due to sepsis and two as a result of pulmonary embolism) and five in group 2 (four due to sepsis and one secondary to cardiopulmonary failure). Eleven graft losses were seen, seven in group 1 (20%) and four in group 2 (9%). The one-year graft and patient survival rates were 63.5% and 79.3% in group 1 and 68.7% and 76.4% in group 2, respectively (P = 0.25 and P = 0.86, respectively). ED was the only difference between the two groups, 25 patients in the first group (71.4%) developed de novo ED, whereas it was found only in eight patients in the second group (19.5%) (P = 0.01).
Table 1: Recorded time periods during the transplantation surgery.

Click here to view
Table 2: Surgical and clinical complications in the two groups.

Click here to view
Table 3: Doppler ultrasonography results in the two groups after 1 year.

Click here to view
Table 4: Creatinine clearance in the two groups.

Click here to view

Many factors in the kidney transplantation field have improved, such as immunosuppression protocols, antibiotics, understanding the immunology of transplantation and development of better surgical tools. [5],[6],[7],[8] What is the best technique regarding renal artery anastomosis, end-to-end to the internal iliac artery or end-to-side to the external or common iliac arteries, is controversial even now. Many centers prefer the old and standard technique using end-to-end anastomosis to the internal iliac artery, [9] because dealing with complications such as post-operative renal artery stenosis is more difficult with the end-to-side anastomosis due to the angle of anastomosis, although there is a higher likelihood of development of "Steal phenomenon," which could cause weakness in renal flow during intense physical exercises. [10],[11],[12],[13],[14] In our study, there were no significant differences in surgical or clinical complications between the two groups, with the exception of ED, which was more frequent post-operatively in patients of group 1 who underwent the end-to-end renal artery anas-tomosis technique to the internal iliac artery. In theory, the reduction in blood supply to the pudendal artery arising from the internal iliac, even in the absence of associated vascular problem, slightly decreases the blood flow to the penis however without negatively affecting the potency. [15],[16],[17],[18],[19],[20] Anyway, the defenders of our preference for end-to-side renal artery anastomosis assure that this technique should be followed in "second transplant," in which we already used the ipsilateral external iliac artery. [4],[21],[22],[23],[24],[25]

To conclude, this study shows that the results of both techniques are similar, with one exception regarding the post-operative development of ED, which was higher among patients with end-to-end anastomosis to the internal iliac artery. Both techniques had comparable surgical and clinical complications, without differences in graft and patient survival. However, we feel that a larger, double-blinded, randomized, prospective study needs to be performed in the future, which can better answer the main question: "Which is the best technique?" In the mean-time, we recommend performing end-to-side renal artery anastomosis, and the end-to-end technique should only be performed in cases where the external iliac artery is not usable for anastomosis.

   References Top

van Roijen JH, Kirkels WJ, Zietse R, Roodnat JI, Weimar W, Ijzermans JN. Long-term graft survival after urological complications of 695 kidney transplantations. J Urol 2001;165(6 Pt 1):1884-7.  Back to cited text no. 1
Hernández D, Rufino M, Armas S, et al. Retrospective analysis of surgical complications following cadaveric kidney transplantation in the modern transplant era. Nephrol Dial Transplant 2006;21:2908-15.  Back to cited text no. 2
Allen RD. Vascular complications after renal transplantation. In: Morris PJ (ed). Kidney Transplantation, Principles and Practice. 6 th ed. Saunders Elsevier; Philadelphia, USA, 2008:450-3.  Back to cited text no. 3
Matheus WE, Reis LO, Ferreira U, et al. Kidney transplant anastomosis: Internal or external iliac artery? Urol J 2009;6:260-6.  Back to cited text no. 4
Ali-El-Dein B, Osman Y, Shokeir AA, Shehab El-Dein AB, Sheashaa H, Ghoneim MA. Multiple arteries in live donor renal transplantation: Surgical aspects and outcomes. J Urol 2003;169:2013-7.  Back to cited text no. 5
Simmons RG, Abress L. Quality-of-life issues for end-stage renal disease patients. Am J Kidney Dis 1990;15:201-8.  Back to cited text no. 6
Goel MC, LaPerna L, Whitelaw S, Modlin CS, Flechner SM, Goldfarb DA. Current management of transplant renal artery stenosis: Clinical utility of duplex Doppler ultrasonography. Urology 2005;66:59-64.  Back to cited text no. 7
Bitker MO, Benoit G. Surgical aspects of kidney transplantation in France in 1997. Eur Urol 1998;34:1-5.  Back to cited text no. 8
Moon I, Kim Y, Park J, Kim S, Koh Y. Various vascular procedures in kidney transplantations. Transplant Proc 1998;30:3006.  Back to cited text no. 9
Schnuelle P, Lorenz D, Trede M, Van Der Woude FJ. Impact of renal cadaveric transplantation on survival in end-stage renal failure: Evidence for reduced mortality risk compared with hemodialysis during long-term follow-up. J Am Soc Nephrol 1998;9:2135-41.  Back to cited text no. 10
Akbar SA, Jafri SZ, Amendola MA, Madrazo BL, Salem R, Bis KG. Complications of renal transplantation. Radiographics 2005;25:1335-56.  Back to cited text no. 11
Audard V, Matignon M, Hemery F, et al. Risk factors and long-term outcome of transplant renal artery stenosis in adult recipients after treatment by percutaneous transluminal angioplasty. Am J Transplant 2006;6:95-9.  Back to cited text no. 12
Baxter GM. Imaging in renal transplantation. Ultrasound Q 2003;19:123-38.  Back to cited text no. 13
Barry JM. Current status of renal transplanttation. Patient evaluations and outcomes. Urol Clin North Am 2001;28:677-86.  Back to cited text no. 14
Moore FD. Transplantation - A perspective. Transplant Proc 1980;12:539-50.  Back to cited text no. 15
Carrel A, Guthrie CC. Anastomosis of blood vessels by the patching method and transplantation of the kidney. Yale J Biol Med 2001;74:243-7.  Back to cited text no. 16
Sutherland RS, Spees EK, Jones JW, Fink DW. Renal artery stenosis after renal transplantation: The impact of the hypogastric artery anastomosis. J Urol 1993;149:980-5.  Back to cited text no. 17
Ersöz S, Anadol E, Aydintug S, Bumin C, Erkek B, Ates K. Anastomotic artery stenosis in living related kidney transplantation: The impact of anastomotic technique. Transplant Proc 1996;28:2331-2.  Back to cited text no. 18
Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The international index of erectile function (IIEF): A multidimensional scale for assessment of erectile dysfunction. Urology 1997;49:822-30.  Back to cited text no. 19
Abdel-Hamid IA, Eraky I, Fouda MA, Mansour OE. Role of penile vascular insufficiency in erectile dysfunction in renal transplant recipients. Int J Impot Res 2002;14:32-7.  Back to cited text no. 20
Voiculescu A, Schmitz M, Hollenbeck M, et al. Management of arterial stenosis affecting kidney graft perfusion: A single-centre study in 53 patients. Am J Transplant 2005;5:1731-8.  Back to cited text no. 21
Garovic VD, Textor SC. Renovascular hypertension and ischemic nephropathy. Circulation 2005;112:1362-74.  Back to cited text no. 22
Irish A. Hypercoagulability in renal transplant recipients. Identifying patients at risk of renal allograft thrombosis and evaluating strategies for prevention. Am J Cardiovasc Drugs 2004;4:139-49.  Back to cited text no. 23
Morris PJ, Knechtle SJ, Richard DM. Kidney Transplantation Principles and Practice, Vascular Complications after Kidney Transplantation. 6 th ed. Saunders Elsevier; Philadelphia, USA, 2008:439-61.  Back to cited text no. 24
Efrasio P, Parada B, Moreira P, et al. Surgical complications in 2000 renal transplants. Transplantation 2011;43:142-4.  Back to cited text no. 25

Correspondence Address:
Dr. Rateb Daowd
Kidney Transplantation Unit, Faculty of Medicine, Damascus University, Damascus
Login to access the Email id

DOI: 10.4103/1319-2442.164593

PMID: 26354580

Rights and Permissions


  [Table 1], [Table 2], [Table 3], [Table 4]


    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  

    Article Tables

 Article Access Statistics
    PDF Downloaded357    
    Comments [Add]    

Recommend this journal