Mini Review
Vascular Reconstruction in Kidney Transplantation
Ashanga Yatawatta*
Department of Surgery, University of Texas, USA
*Corresponding author: Ashanga Yatawatta, Department of Surgery, University of Texas - Medical Branch at Galveston, USA
Published: 07 Mar, 2017
Cite this article as: Yatawatta A. Vascular Reconstruction
in Kidney Transplantation. Clin Surg.
2017; 2: 1357.
Abstract
Kidney transplantation has become the preferred mode of treatment for patient with end stage
renal disease (ESRD) after incorporating into clinical practice in the 1960s. With the rising increase
in ERSD worldwide and higher life expectancy, the need for kidney transplants is rising and the
gap between deceased donors and patients on the waiting list is becoming wider. Living donors
are subjected to less than appreciated risk of morbidity and mortality and have to be considered
carefully. It is of utmost importance to utilize the available donor organs efficiently in deceased
and living donors. One of the limitations has been the complex vascular anatomy of the donor.
Challenging vessels in the recipients are becoming more common with previous surgeries in the
Iliac vessels and open/endovascular interventions for occlusive or aneurysmal disease. This review
addresses the techniques of utilizing less than ideal donor and recipient anatomy to perform vascular
reconstruction.
Keywords: Kidney transplantation; Multiple renal arteries; Arterial reconstruction; Venous reconstruction; Arteriosclerosis; Surgical technique; Anastomosis
Renal Transplantation
ESRD needs renal replacement therapy but the lowest mortality, better quality of life and
better cost efficiency is provided with renal transplantation. This has become the standard of care
for patient with good surgical risks with available organs. Since the first transplant in 1954 and
with further refinements in laparoscopic and robotic methods, the surgical technique has remained
unchanged but immune suppression and better methods of matching continues to evolve [1,2].
In an effort to better utilize donor organs from extremes of age, borderline function, coexisting
infections (hepatitis and HIV) and challenging anatomy, new protocols are being implemented with
increase in the number of organs utilized [3].
Deceased donors
Age is being expanded in donor selection with en-bloc double kidneys from children being used
with good results in adults as well elderly donors with marginal function [4,5]. They pose particular
challenges with size and vessel wall thickness disparities. Severe arteriosclerosis poses challenges in
cannulation for cold perfusion and preparation for pump placement. Aortic cannulation is done
with harvesting of kidneys en bloc with ureters up to bladder, after liver, pancreas and intestines are
harvested. The length of the cava is negotiated with the liver team but usually the length of cava is
sufficient for reconstruction of right renal vein. In the back bench, kidneys are separated carefully
with aorta opened in the midline to look for renal artery ostia. If more than one is noted, they are
taken with a carrel's patch. If multiple arteries are noted wide apart, each is taken with a patch
with reconstruction performed later [6]. A Common ostium is constructed for pump placement to
allow adequate pressure but a minor leak can be tolerated. Veins are left free for the pump. Correct
identification of number of arteries and veins and injuries, if any, are important to note and relayed
to implanting team. In pediatric donors, both kidneys are taken en bloc for implantation and Aorta,
inferior vena cava and bladder are taken in-situ with no back bench preparation [7]. These are
typically not placed on the pump. Gentle handling of tissues, especially intima of arteries is crucial
to avoid thrombosis.
Living donors
Up to 50% of kidneys are donated by living donors in North America and this is on the rise [8].
While less cold ischemia time and better matching with better timing of surgery is an advantage,
the risks involved to an otherwise healthy person are significant by subjecting to a surgery with
a mortality and morbidity not to be taken lightly. Open donor nephrectomy is taken over by
laparoscopic method with better recovery for the donor. Multiple arteries and veins can lead to technical difficulty, especially on right side [9]. In the absence of
carrel's patch and length to spare, living donor reconstruction is
challenging. Left side offers a longer vein, which traditionally has
been favored. However, right side vein can be used although this
is a difficult laparoscopic procedure. Implantation is usually to the
external iliac artery and vein but internal iliac artery or common iliac
can be used as well [10-12]. Pediatric recipients are implanted to the
aorta and inferior vana cava. End to side anastomosis with spatulation
as an option is usually employed. Additional mobilization of the vein
can be achieved with ligation of the internal iliac vein but ligation of
the internal iliac artery for the same purpose in not recommended.
Multiple arteries can be implanted to external or common iliac artery
depending on the length and orientation achieved with other options
being using internal iliac artery or inferior epigastric artery in end to
end manner [15]. Implantation to main renal artery is another option
with smaller branches and if the area of supply is less than 10% or too
small in size, they may be ligated but this is at a small risk of infarction,
infection and renal induced hypertension. Fashioning of carrel's
patches to create a common ostium has to consider the possible
encroachment of lumen, dissection or exposure of sub-endothelial
tissue or kinking or tension on suture line. Proper planning is needed
before committing to re-fashioning at all stages.
Recipient operation
Standard implantation involves external iliac artery and vein
in end to side orientation. In diseased vessels, length discrepancy
and lack of space in retro-peritoneum allows the use of common
iliac or internal iliac as well as Aorta and inferior vena cava in
pediatric patients. In the advent of improved secondary patency with
endovascular intervention this placement may be less important,
especially with previous transplants or pancreas transplants
occupying prime locations. Calcified arteries poses two distinct
problems. Clamping related problems may be amenable to soft clamp
use, fogarty or foley use for control or incorporating a conduit of
donor vessel as inflow, which may then be used for anastomosis to
the artery. Endarterectomy at time of surgery is not widely practiced
since it adds ischemic time and in the absence of expertise and
experience, might lead to complication with limb, pelvis and allograft
ischemia as potential complications. Previously re-vascularized iliac
vessels with open Aorto bifemoral bypass grafts can be safely used
for inflow and even can be used in patient with poor arteries with
TASC D aorto iliac disease at time of transplantation if previously
unknown[16,17]. Aneurysmal disease, even when smaller than
standard treatment criteria, may well be treated with either resection
with primary anastomosis or graft placement may be incorporated
prior to graft anastomoses. Preserving at least one internal iliac
artery in of paramount importance to minimize risk of pelvic, spinal
or colonic ischemia [13,14]. In the event of previous placement of
stent, another inflow site needs to be determined and internal iliac
use has to be considered carefully especially if the stent has essentially
covered the ostium of ipsilateral internal iliac artery, as this will
increase risk of pelvic ischemia. Pediatric kidneys (en bloc) are
implanted with the donor aorta and cava end to side to iliac vessels
the landing zone likely determined by the reach of bladder patch to
the recipient bladder [18]. Special consideration is given to minimize
risk of torsion on kinking as the donor vessels are thin and prone to
kinking. These vessels grow with time and interrupted fine prolene
sutures are used by some to accommodate this and avoid anastomotic
stenosis in the future but with options of angioplasty, this may not be
essential. However, similar to any other type of vascular anastomosis,
meticulous technique is of paramount importance in pediatric donors
and recipients.
Special Situations
Living donors
Presence of renal artery stenosis, fibromuscular dysplasia or
aneurysmal disease is not an absolute contra indication for donation.
Back bench preparation will include careful endarterectomy of the
diseased artery or interposition graft use – usually a saphenous vein
is used but cadaveric or prosthetic grafts are options. Secondary
patency can be maintained with endovascular interventions in
the future. However, careful and meticulous technique cannot be
overemphasized.
Deceased donors
Endarterectomy of a patch is a delicate process. Flow dynamics
are important to minimize potential for dissection. A smooth tapering
point is important and Kunlin type suture to secure the endothelium
might be important.
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