| Abstract|| |
The aim of this study is to report our experience in the use of vascular clipping system (VCS) in kidney transplantation (KT), and to discuss its potential clinical benefits for the patients compared with the traditional anastomosis method (suture method). Between October 1985 and December 2000, 350 cases of KT from living related donors (LRD) were performed in the Kidney Transplantation Unit at the Al-Mouassat University Hospital in Damascus, Syria. Between October 1999 and December 2000, 30 cases (21 males and 9 females) of KT were performed using VCS. The mean age of the patients was 32.7 years (14-52). HLA typing showed HLA haploidentical matching in 22 patients and HLA identical matching in eight. Twenty left kidneys and 10 right kidneys were resected from LRD. VCS was used in 22 arterial and 30 venous anastomosis. We used the Vascular Clip Applier/large 2.0-Auto suture Company-Connecticut-USA. Vessel anastomosis was performed end to end between renal and hypogastric arteries and end to side between renal and external iliac vein for all 30 patients. Immunosuppression treatment was with cyclosporine, azathioprine and prednisolone in all patients. The follow-up period was 5-16 months. All the patients were alive at the end of the follow-up period. The other cases of KT (320 patients) were performed by traditional anastomosis method (suture). The time of arterial anastomosis was 12-20 minutes (mean 16) for the suture method versus 7-10 minutes (mean 7.5) for the VCS method The time of venous anastomosis was 15-25 minutes (mean 20) for the suture method versus 7-9 minutes (mean 8.5) for the VCS method. The number of transfused packed red cell units per operation was 1-2 units in the suture method versus 0-1 unit in the VCS method. We observed 17 cases of acute tubular necrosis (ATN) in the 320 cases in whom the suture method was used versus no case in the 30 patients receiving VCS. Vascular anastomosis using VCS shortens the warm ischemia time, reduces packed red cell units transfused and the occurrence of ATN, and thus improves the function of kidney graft.
Keywords: Vascular clipping system, Kidney transplantation, Damascus, Warm ischemia.
|How to cite this article:|
Al-Habash MM, Al-Shaer MB. Use of Vascular Clipping System in Kidney Transplantation in Syria: A Study of 30 Cases. Saudi J Kidney Dis Transpl 2002;13:35-9
|How to cite this URL:|
Al-Habash MM, Al-Shaer MB. Use of Vascular Clipping System in Kidney Transplantation in Syria: A Study of 30 Cases. Saudi J Kidney Dis Transpl [serial online] 2002 [cited 2021 Apr 14];13:35-9. Available from: https://www.sjkdt.org/text.asp?2002/13/1/35/33199
| Introduction|| |
The first kidney transplantation (KT) in Syria was performed in 1978. There are only three kidney transplant centers in Syria and all are located in Damascus. There is no cadaver kidney transplant program till now in our country.
Vascular anastomosis using the nonpenetrating Vascular Clipping System (VCS) in an interrupted fashion, has been described a few years ago. ,, This technique has been proved, in preliminary studies, to be safe in terms of anastomotic bleeding, burst strength and vascular anastomosis patency. It is easy to learn and the time taken to complete the anastomosis is significantly less than that with a running suture. Since its first description, usage of VCS in kidney transplantation has been reported by many centers. , The ability to anastomose blood vessels quickly reduces warm ischemia time and improves outcomes.
VCS is a useful advance in surgical instrumentation that holds significant potential to further improve the already excellent results of solid organ transplantation. This technique has become important in minimizing the warm ischemia time of kidney. The aim of our study is to evaluate the benefits of VCS in kidney transplantation and to discuss other applications of this technique.
| Patients and Methods|| |
Between October 1985 and December 2000, 350 kidney transplantations, all from living related donors (LRD), were performed at the Al-Mouassat University Hospital in Damascus. The age of the patients ranged from 14 to 61 years with a mean of 31.5 years. There Cwere 275 (78.6%) males and 75 (21.4%) females. The follow-up period ranged from 1-183 months. The immunosuppression therapy was conventional (azathioprine (Aza) and prednisone (Pred)) 0 in 71 patients, and triple (cyclosporine (CyA), Aza and Pred) in 279 patients.
Based on selective renal angiography, the donor's left kidney was used in 290 (82.8%) patients, while the right kidney was used in 60 (17.2%). We performed an Lend to side venous anastomosis between the renal vein and the iliac vein in all patients. An end to end anastomosis of the renal artery to the hypogastric artery was used in 336 (96%) patients and an end to side anastomosis of the renal artery to the external iliac artery was used in 14 (4%) patients. A total of 13 donor kidneys had two renal arteries and one had three renal arteries.
Between October 1999 and December 2000, 30 (21 males and 9 females) renal transplants were performed using the VCS technique. The mean age of the patients was 32.7 years. HLA matching was haploidentical in 22 patients and, identical in eight patients. Of the 30 cases, 20 left kidneys and 10 right kidneys were resected from LRD. VCS was used for venous anastomosis in all 30 cases and 22 cases had their arterial anastomosis using this technique. (Vascular Clip Applier/large 2.0Auto suture Company-Connecticut-USA). The anastomoses performed were end to end renal artery-hypogastric artery and end to side renal vein-external iliac vein, for all 30 patients. Immunosuppression treatment was with CyA, Aza and Pred in all patients.
The 30 patients were followed up for 5-18 months. All the patients were alive at the end of the follow-up period. The other transplants (320 patients) were performed by traditional anastomosis methods (running suture). Fifteen of these 320 cases were performed by end to side renal-external iliac arterial anastomosis, the remaining 305 cases were performed by end to end renal artery to hypogastric artery anastomosis.
For each patient in whom the VCS method was used, the time required to perform the anastomosis, the number of packed red cell units transfused intra-operatively and the occurrence of acute tubular necrosis (ATN) were evaluated. We compared these results with the results in the other 320 patients in whom the traditional suture method was used.
| Results|| |
The time of arterial anastomosis was 12- 20 minutes (mean 16) by the suture method versus 7-10 minutes (mean 7.5) by the VCS method. The time of venous anastomosis was 15-25 minutes (mean 20) by the suture method versus 7-9 minutes (mean 8.5) by the VCS method [Table - 1]. The number of transfused packed red cell units was 1-2 units in the suture method versus 0-1 unit in the VCS method. We observed 17 cases of ATN among the 320 cases using the suture method while no cases of ATN were seen in the 30 patients receiving the VCS. Using VCS was not only faster but also easier to performed especially in obese patients and in cases of right donor kidneys (the right renal vein being shorter than the left renal vein).
| Discussion|| |
The use of VCS in LRD kidney transplantation has been demonstrated to be safe, fast and technically easy. Clinical experience has shown that VCS is faster, non-penetrating, less traumatic and achieves better hemostasis and patency. It is of utmost importance in kidney transplantation to perform anastomosis with least difficulty in order to reduce warm ischemia time and thereby improve the outcome, have better hemostasis and achieve better patency. Moreover, in pediatric renal transplantation, non-penetrating interrupted anastomoses are desirable to allow growth with age and avoid anastomotic arterial stenosis. , Many reports have indicated that VCS is faster than suturing by 13-55% in autologous and prosthetic arteriovenous grafts (AV) for dialysis  bile duct,  hepatic artery,  arteriotomy and venotomy  and in renal transplantation [Table - 2]. , In 1999, two published studies compared the damage of vessels in the VCS anastomosis with the suture method. , The first article studied the damage of the arterial saphenous vein anastomoses and the second one studied the damage of the arterial prosthetic graft anastomoses. In both reports, there was clearly less damage in the VCS clipped vessels when compared with the suture method. Also, VCS gives better secondary patency than suturing.  Schild et al, from Miami University, compared 42 VCS patients to 47 suture patients.  The report shows that 50% more access grafts remained open longer when the VCS clip was used instead of suture, with a 90% patency rate by VCS vs. a 60% patency by suture method, after two years. In another report on hemostasis achieved among sutures vs. clipped anastomoses, at the time of clamp removal following an AV Fistula, 41% of VCS cases experienced no bleeding, while only 10% of suture anastomoses experienced no bleeding. ,
There is no need for patients who have undergone VCS to avoid magnetic resonance imaging (MRI) examinations when needed. These non-alloy titanium clips are not displaced by the strong magnetic field like ordinary metal clips, which are known to distort MRI images.  It is usual to screen patients with a scout radiograph prior to an MRI, and these clips are seen quite clearly and may be differentiated easily from metallic objects.  There are many applications and trials for VCS that have been reported [Table - 3]. Also, attention should be paid to some important technical tips and pitfalls [Table - 4],[Table - 5].
| Conclusion|| |
The use of VCS in anastomoses of blood vessels in renal transplantation shortens the time of performing the anastomosis, reduces warm ischemia, achieves more rapid hemostasis, reduces tissue damage of vessels, facilitates surgical procedure and improves significantly the patency rate. This is a useful advance in surgical instrumentation that holds significant potential to further improve the already excellent results of solid organ transplantation.
| References|| |
|1.||Kirsch WM, Zhu YH, Hardesty RA, Chapolini R. A new method for microvascular anastomosis: report of experimental and clinical research. Am Surg 1992;58:722-7. [PUBMED] |
|2.||Kirsch WM, Zhu YH, Gaskill D, Stewart S, Hardesty RA, Lyons TL. Tissue reconstruction with non-penetrating arcuate-legged clips. Potential endoscopic applications. J Reprod Med 1992;37:581-6. |
|3.||Kirsch WM, Zhu YH, Steckel R, et al. Comparative evaluation of sutures and nonpenetrating metal clips for vascular reconstruction. Cardiovasc Surg 1995;26: 136. |
|4.||Mital D, Foster PF, Jensik SC, et al. Renal transplantation without sutures using the vascular clipping system for renal artery and vein anastomosis - a new technique. Transplantation 1996;62:1171-3. [PUBMED] [FULLTEXT]|
|5.||Fung LC, McLorie GA, Khoury AE, Churchill BM. Donor aortic cuff reduces the rate of anastomotic arterial stenosis in pediatric renal transplantation. J Urol 1995; 154:909-13. [PUBMED] [FULLTEXT]|
|6.||Papalois VE, Romagnoli J, Hakim NS. Use of vascular closure staples in vascular access for dialysis, kidney and pancreas transplantation. Int Surg 1998;83:177-80. [PUBMED] |
|7.||Schild AF, Raines J. Preliminary prospective randomized experience with vascular clips in the creation of arteriovenous fistulae for hemodialysis. Am J Surg 1999;178:33-7. [PUBMED] [FULLTEXT]|
|8.||Geevarghese SK, Bradley AL, Atkinson J, et al. Comparison of arcuate-legged clipped versus sutured hepatic artery, portal vein, and bile duct anastomoses. Am Surg 1999;65:311-6. [PUBMED] |
|9.||Golling M, Mehrabi A, Weiss G, Schaffer F, Kraus T, Klar E. [the VCS clipexperimental experiences with a new vascular suture stapling device]. Chirurg 1999;70:206-10. |
|10.||Leppaniemi A, Wherry D, Pikoulis E, et al. Arterial and venous repair with vascular clips: comparison with suture closure. J Vasc Surg 1997;26:24-8. |
|11.||Izzat MB, Yim AP, Ho KC, Yew D, Chow LT. Favorable scanning electron microscopic findings of stapled saphenous veincarotid artery anastomoses. Ann Thorac Surg 1999;67:85-8. [PUBMED] [FULLTEXT]|
|12.||Dal Ponte DB, Berman SS, Patula VB, Kleinert LB, Williams SK. Anastomotic tissue response associated with expanded polytetrafluoroethylene access grafts constructed by using nonpenetrating clips. J Vasc Surg 1999;30:325-33. [PUBMED] [FULLTEXT]|
|13.||McCarty M, Gedroyc WM. Surgical clip artefact mimicking arterial stenosis: a problem with magnetic resonance angiography. Clin Radiol 1993;48:232-5. [PUBMED] |
|14.||Aramendi JI, Otero A, Martinez P. Coronary anastomosis with mechanical sutures: the VCS vascular clips. Initial experience. Hopital de cruces Barcelona, Spain. First virtual congress of cardiology 1999. |
|15.||Nataf P, Hinchliffe P, Manzo S, et al. Facilitated vascular anastomoses: the one- shot device. Ann Thorac Surg 1998;3: 1041-4. |
|16.||Findlay JM, Megyesi JF. Carotid arteriotomy closure using a vascular clip system. Neurosurgery 1998;42:550-4. [PUBMED] [FULLTEXT]|
|17.||Watanabe M, Yu SK, Sawafuji M, et al. Experimental lung transplantation using non-penetrating vascular clips for anastomosis of the pulmonary artery. Thorac Cardiovasc Surg 2000;48:120-2. [PUBMED] |
|18.||Kawamura M, Kase K, Watanabe M, Kobayashi K. Successful angioplasty of the left pulmonary artery using the vascular clip system. Surg Today 2000;30:866-8. [PUBMED] [FULLTEXT]|
|19.||Maxwell KL, McDougall EM, Shalhav AL, et al. Laparoscopic ureteroureterostomy using vascular closure staples in porcine model. J Endourol 1998;12:265-8. [PUBMED] |
|20.||Timonthy J. Evaluation of duraclose clips to close the spinal dura mater. Leeds general infirmary leeds, England, UK 2000. |
Mohammed Mustafa Al-Habash
Department of General Surgery, Renal Transplantation Unit, Al-Mouassat University Hospital, P.O. Box 30129, Damascus
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]