Year : 2008 | Volume
: 19 | Issue : 4 | Page : 554--558
Renal Transplantation Using Live Donors with Vascular Anomalies: A Salvageable Surgical Challenge
Pratap Bahadur Singh1, Neeraj K Goyal1, Abhay Kumar1, Udai Shankar Dwivedi1, Sameer Trivedi1, DK Singh2, Jai Prakash3,
1 Department of Urology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
2 Department of Anesthesia, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
3 Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
Pratap Bahadur Singh
Department of Urology, Banaras Hindu University, Institute of Medical Sciences, Varanasi 221 005
Renal transplantation is an established mode of management for patients with endstage renal disease (ESRD). In India, majority of the patients with ESRD depend upon live donors for renal transplantation and renal vascular anomalies are commonly seen in these potential donors. We present our experience in renal transplantation using donors with vascular anomalies. During the period between 2001 and 2004, we performed 36 live related donor renal transplantations. All study patients had only one donor each, with compatible blood group. Ten of the donors had vascular anomalies. Three had bilateral double arteries, one had double left and single right renal artery, one had bilateral triple arteries, one had triple arteries on left and double arteries on right side, of which one had early branching, two had bilateral early branching of arteries, and two other cases had double renal veins. Open donor nephrectomy was performed in all the cases. End-to-side anastomosis with external iliac vein and artery of the recipient was performed by the parachuting technique. Eight kidneys had immediate diuresis after transplantation. In two kidneys, diuresis started 2-3 hours after administration of 120 mg of furosemide. All patients had serum creatinine ranging between 0.9 and 1.8 mg/dl by the 10th post-operative day. Follow-up of these cases have varied from one month to two years. In the current scenario, multiple arteries in the donor are no longer considered relative contraindications for renal transplantation. With good surgical skill and experience in bench surgery, all such donors can be accepted. Use of external iliac artery for anastomosis with the technique of parachuting makes the procedure easy and safe.
|How to cite this article:|
Singh PB, Goyal NK, Kumar A, Dwivedi US, Trivedi S, Singh D K, Prakash J. Renal Transplantation Using Live Donors with Vascular Anomalies: A Salvageable Surgical Challenge.Saudi J Kidney Dis Transpl 2008;19:554-558
|How to cite this URL:|
Singh PB, Goyal NK, Kumar A, Dwivedi US, Trivedi S, Singh D K, Prakash J. Renal Transplantation Using Live Donors with Vascular Anomalies: A Salvageable Surgical Challenge. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2021 Jan 17 ];19:554-558
Available from: https://www.sjkdt.org/text.asp?2008/19/4/554/41313
Renal transplantation is an established mode of management for patients with end-stage renal disease (ESRD). In India, majority of patients with ESRD depend upon live donors for renal transplantation because cadaveric transplant program is still in its infancy. Renal vascular anomalies in the potential donors are common problems. It is much easier to handle such anomalies in cadaveric transplants because of availability of Carrel patch but in live donor transplantation, single artery and vein in the donor is preferred. In view of the limited donor pool, it becomes difficult to reject donors with multiple vessels. In our center, we have performed 36 renal transplants between 2001 and 2004. Of these 36, we came across 10 cases with vascular anomaly. The present study is aimed at highlighting the procedures performed and outcome of these transplants.
Materials and Methods
During last two and half years, between 2001 and 2004, we performed 36 live related renal transplantations in our center. The donor pool included mother, sister, wife, brother or father. All recipients had only one donor each with compatible blood group. Donor and recipient were evaluated as per standard protocol. Renal vascular assessment was done by spiral computerized tomography. First priority was for donor with single renal artery preferably in the left kidney. Ten of the donors had vascular anomalies. Three had bilateral double arteries, one had double left and single right renal artery, one had bilateral triple arteries, one had triple arteries on left and double arteries on right side, of which one had early branching, two had bilateral early branching of arteries, and two cases had double renal veins. No donor was refused on account of anomalous vessels because there was no other donor available. In eight cases in which the anomalies were bilateral, the left kidney was retrieved. One case had double artery on the left and single artery on the right side. In this case, the left kidney with double artery was preferred for retrieval because the right kidney had GFR of 60% and it was felt that it should be left to the donor. In the donor with three arteries to the left kidney and two to the right, the right kidney was preferred for retrieval.
Open donor nephrectomy was performed as per standard procedure. Good diuresis was ensured before retrieval. Two patients had renal artery spasm, which was treated by administration of papaverine, and retrieval was performed after good diuresis was re-established. The following procedures were performed during transplantation. The principal author always prefers end-to-side anastomosis with external iliac vein and artery
Kidneys with early branching: Two patients had double artery with a short common stump. All precautions were taken during retrieval and meticulous dissection was done up to its origin. In both cases, a two mm stump could be saved and end-to-side anastomosis was performed with the external iliac artery.Kidneys with double arteries: Two kidneys had two major arteries of equal sizes. In one case, reconstruction was done as conjoined anastomosis to make a common ostium which was anastomosed end-to-side to the external iliac artery. In the other two cases, two separate multiple anastomosis were performed end-to-side with the external iliac artery. The total duration of vascular anastomosis did not exceed 45 minutes. Two kidneys had one major artery and another thin lower polar artery. In these two cases, sequential multilple anastomosis was performed by first anastomosing the major artery after which the clamps were released to perfuse the kidney. Subsequently, the lower polar artery was anastomosed end-to-side with the external iliac artery.Kidney with three arteries: One kidney had three arteries. One artery was small in length while the other two were equal in length. Bench surgery was performed to do end-to-side anastomosis of smaller artery to large artery [Figure 1]. Subsequently two separate anastomoses were performed with the external iliac artery.Kidneys with double renal veins: One kidney had one major vein and another comparatively small sized vein. The smaller vein was ligated and the major vein was used for anastomosis. One kidney had two small veins of equal size and in this, bench surgery was performed to make a common ostium, which was used for anastomosis
In all cases, the transplanted kidneys got adequately perfused immediately after releasing the clamps. Eight kidneys had immediate diuresis on the table; in two patients, the kidneys did not diurese immediately. In these cases, furosemide infusion at the rate of 120 mg/hr was commenced following which these two kidneys also began diuresing. All patients had uneventful recovery except one who had uncontrolled hypertension which could be controlled by using intravenous nitroglycerine (NTG). All patients received triple drug regimen (cyclosporin, azathioprine and prednisolone) for immunosuppression. Colour doppler performed on the fourth post-operative day revealed good perfusion of kidneys with resistive index varying from 0.62 to 0.75 [Figure 2]. All patients had serum creatinine ranging between 0.9 and 1.8 mg/dl by the 10th post-operative day. Follow-up of these cases has varied from one month to two years. One patient with double artery who had multiple anastomosis died after two months with functioning graft due to cardiac complications. All the other patients are doing well with a mean serum creatinine of 1.6mg/dl at last followup.
In India, the renal transplant program depends upon live related donors because cadaveric program is still in its infancy. The joint family concept is also vanishing resulting in limited donor pool involving mainly mother, wife and occasionally, father. Brothers and sisters are also donors where joint families exist. The ground reality is that usually one of the members belonging to same blood group agrees for organ donation without any other choice resulting in single precious donor.
The reported incidence of multiple renal arteries varies between 18-30%.  We started renal transplant program about three years back after the principal author had his training in renal transplantation at Cardiff in the UK. During a period of two and half years, we have performed 36 live related renal transplants. Of these 36 cases, we came across 10 kidneys with anomalous vessels (27.77%) and we could not reject any donor on this technical issue because for that particular patient, there was no other alternative.
Various techniques of reconstruction have been described  but we always prefer to use external iliac artery for end-to-side anastomosis. It has distinct advantage over the internal iliac artery in such cases, because spatulated end-to-side anastomosis of even a small vessel has less risk of stenosis. Endto-end anastomosis with internal iliac artery not only increases the chance of stenosis but also makes subsequent percutaneous transluminal angioplasty more difficult as compared to external iliac artery.  Many surgeons use inferior epigastric artery  or branches of the internal iliac artery. In such procedures, dissection is quite cumbersome and small end-to-end anastomosis may increase chances of vascular or urological complications.
The technique of parachuting in end-toside anastomosis of smaller vessels is a perfect one with very less chance of anastomosis related complications. With this technique, two separate anastomoses with the external iliac artery together with venous anastomosis never allow warm ischemia time to go beyond 40 to 45 minutes. When arteries were located close to one another, we performed conjoined anastomosis to create a common ostium for single end-toside anastomosis; otherwise, we would have preferred multiple end-to-side anastomosis. In cases of small polar artery, we have gone for sequential multiple anastomosis. After anastomosing the major artery, clamps were released and subsequently the polar artery was anastomosed. There may be an increased incidence of acute tubular necrosis in the segment supplied by the polar artery in sequential anastomosis as compared to when clamps were released after completing both anastomoses.  However, we did not encounter any such problems. Sequential anastomosis is now an established technique for accessory small caliber artery. ,
In cases with three arteries, bench end-toside anastomosis of small artery to large artery followed by two separate anastomoses subsequently is a good and established option as we have done in one of our cases. Multiple veins are never a problem in transplantation. One good size vein is sufficient and the other may be ligated; however, if the two veins are of small caliber, conjoined anastomosis should be done as we have done in one of our cases.
Even in the early phase of transplant program in our center, we used donors with anomalous renal vessels for transplantation and did not find any difference in either immediate or delayed graft function. In the current scenario, multiple arteries in the donor, are no longer considered a relative contraindication. , With good surgical skill and experience in bench surgery, all donors can be accepted. Use of external iliac artery for anastomosis using the technique of parachuting makes the procedure easy and safe.
Miss Rozanne H. Lord Clinical Director Renal Transplantation & Consultant transplant Surgeon Royal Free Hospital London, excellent teacher and surgeon for giving maximum opportunity to learn renal transplantation in Cardiff and to my dedicated team for excellent out come.
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