糖尿病髂动脉硬化患者肾移植术51例报告

目的探讨糖尿病髂动脉硬化患者的肾移植手术特点。方法51例糖尿病合并髂动脉硬化的肾移植受者共行肾移植术54例次。其中肾动脉与髂外动脉直接端侧吻合13例次；切除硬化内膜，肾动脉与髂总／髂外动脉端侧吻合19例次；切除硬化内膜，肾动脉与髂内动脉钛环钉法端端吻合22例次。结果发生移植肾血流灌注不足致移植肾原发性无功能3例次，发生移植肾功能延迟恢复9例次（17．6％），其余42例次移植肾功能恢复良好。围手术期死亡2例（均为心跳骤停）。随访11—70个月，1年人／肾存活率为89．8％／87．8％，3年存活率为84．4％／81．3％。结论糖尿病髂动脉硬化患者移植肾动脉吻合困难，为保证移植肾有充足的血流灌注，应根据患者的不同情况选择吻合血管，并行硬化动脉内膜切除术。合并冠心病的患者肾移植术前应先行心肌再血管化手术。     

肾移植中供受者血管变异的处理

在肾移植中,常会遇到供受者动脉病变及多支血管变异,如处理不当,常导致移植肾失败或肾功能不全.本院共施行肾移植350例,其中受者髂内动脉严重粥样斑块硬化、管腔接近闭塞者30例,供肾多支动脉变异36例,供肾动脉与髂内动脉管径悬殊较大8例,均作了合理的处理.术后移植肾血供良好,1年后随访,吻合血管通畅,肾功能正常,现将其处理经验介绍如下.1 处理方法1.1 髂内动脉严重粥样斑块硬化的处理髂内动脉管腔很小,接近闭塞.这种髂内动脉如与肾动脉吻合,开放血流后移植肾常供血不足,肾色虽鲜艳,但充盈张力差,术后常发生急性肾衰及无尿,导致肾移植失败.对此,我们有沉痛的失败教训.后来我们对25例粥样斑块硬化患者采取髂内动脉斑块切除,然后与肾动脉作端端吻合,开放血流后移植肾充盈张力良好.对5例斑块不能切除者,采取肾动脉与髂外动脉端侧吻合,同样取得良好效果.术后随访1年,肾功能正常,肾动脉无血管杂音,B超、彩色多普勒血流图、肾动脉造影(部分患者)未发现异常变化.     

移植肾动脉瘤五例报告

目的 探讨移植肾动脉瘤(RAA)的病因、诊断及治疗. 方法 1998年8月至2004年12月共行同种异体肾移植手术1251例,发生RAA 5例(0.4%).5例均为男性,平均年龄43岁,移植肾血管吻合方式均为移植肾动脉一髂内动脉端端吻合.患者主要临床表现为进行性肾功能减退,突发少尿或无尿,顽固性高血压及肾区疼痛,均经彩色多普勒超声、数字减影血管造影检查确诊为动脉瘤,动脉瘤大小1.8 cm×2.0 cm×2.0 cm～4.0 cm×4.0 cm×5.0 cm. 结果 移植肾动脉吻合口动脉瘤2例,1例发现动脉瘤后1个月内移植肾功能丧失,行移植肾切除术,术后规律透析治疗,随访1年后行二次肾移植;1例移植肾失功后1周内行对侧髂窝二次肾移植手术,保留原移植肾,术后随访2年肾功能正常.RAA合并近端移植肾动脉狭窄2例,1例行吻合口球囊扩张并放置支架后,以弹簧螺圈栓塞动脉瘤,术后随访1年肾功能稳定;1例行移植肾切除、二次.肾移植术,术后随访3年肾功能正常.吻合口髂内动脉侧粥样硬化斑块导致髂内动脉狭窄、移植肾动脉侧动脉瘤1例,行移植肾切除术,术后2 d因脑干栓塞死亡. 结论 移植肾动脉-髂内动脉端端吻合易诱发血管并发症,RAA治疗应谨慎采用开放手术切除,可选择近期行二次肾移植和血管内介入治疗.     

肾移植后血管并发症的诊治体会

目的探讨。肾移植术后血管并发症的特点和诊治方法。方法回顾34例术后并发血管疾病的。肾移植患者临床资料，对其发病特点和诊治方法进行分析总结。结果34例患者中，并发移植肾动脉梗阻13例，移植肾动脉出血8例，动脉吻合口破裂7例，移植肾静脉梗阻4例，髂外动脉瘤和髂外静脉栓塞各1例。21例经彩色多普勒血流显像（CDFI）作出诊断，其中10例进一步行磁共振血管成像（MRA）明确诊断。5例移植。肾动脉狭窄患者中，3例放置血管内支架扩张后肾功能恢复良好，分别随访8、10、14个月，血肌酐维持在115～135μmol／L；1例将与髂内动脉端端吻合的移植。肾动脉改为与髂外动脉端侧吻合，术后至今1个月，血肌酐降至正常水平；1例MRA显示不完全狭窄，给予保守治疗，至今观察21d，血肌酐持续降低。3例静脉梗阻患者经手术解除梗阻，其中1例死于心力衰竭，另2例随访13、36个月，肾功能恢复良好。1例髂外静脉栓塞患者术后死于移植肾破裂。其余患者均切除移植肾。结论。肾移植术后的血管并发症进展迅速，应根据具体情况及时采取相应治疗手段，处理不及时往往导致移植肾功能丧失，因此早期诊断非常重要，CDFI可作为首选筛查手段。     

选择髂内或髂外动脉吻合对移植肾的影响

目的 探讨肾移植动脉重建选择髂外或髂内动脉时移植肾血流参数、肾脏功能和血管并发症的差异。方法 135例初次肾移植患者随机分为2组，2组患者平均年龄、HLA错配数目、淋巴细胞毒试验、冷／热缺血时间差异均无统计学意义（P〉0．05），术后免疫抑制剂应用方案相同。应用髂外动脉端侧吻合66例，髂内动脉端端吻合69例。随访3个月，比较2组患者肾脏功能、彩色多普勒肾脏血流参数和血管并发症发生率。结果 髂内动脉、髂外动脉组2组患者术后3个月时肾功能监测指标（Cr：118．41 vs123．68μmol／L），移植肾主肾动脉、段动脉、大叶间动脉血流及阻力指数差异无统计学意义（P〉0．05）。结论 肾移植动脉重建选择髂内外动脉对移植肾功能及血液流变学无明显影响，动脉选择应根据患者具体情况决定。     

肾移植术后髂内动脉自体移植治疗感染性髂外动脉出血(附一例报告及文献复习)

目的 探讨肾移植术后感染性髂外动脉吻合口出血的处理。方法 报告1例髂内动脉自体移植治疗感染性髂外动脉吻合口大出血病例，结合文献复习讨论。患者，男，25岁。肾移植术后第22、24、38天3次出现感染性移植。肾动脉髂外动脉吻合口大出血，出血量分别达800、2500、3800ml。经输血、及时手术探查，两次吻合口缝合修补效果不佳，第3次手术切除移植肾，并将感染病变严重的髂外动脉段切除，髂外动脉缺损长约2cm，以3cm长的髂内动脉段移植修复。结果 修复后髂外动脉血流通畅，患侧下肢血供良好，患者恢复血液透析，等待再次移植。结论 感染性移植肾动脉髂外动脉吻合口出血为肾移植术后严重并发症，单纯修补常难以奏效，髂内动脉自体移植修补缺损合理可行，操作简易，效果较好。     

马蹄形供肾肾移植术二例报告

20 0 1年 4月我们利用一个马蹄形供肾为 2例尿毒症患者行肾移植术 ,现报告如下。例 1,男 ,4 3岁。 1987年因慢性肾小球肾炎、尿毒症行第 1次肾移植术 ,1999年因移植肾慢性排斥恢复腹膜透析。 2 0 0 1年 4月 2 0日行第 2次肾移植术 ,术前群体反应抗体 (PRA) 14 .3%。术中将马蹄形肾从峡部分开后 ,右侧供肾动脉与受者髂内动脉端端吻合 ,供肾下极异位动脉与受者腹壁下动脉端端吻合 ,供肾静脉与受者髂外静脉端侧吻合 ,供肾输尿管与受者膀胱隧道式吻合。术后尿量约 5 0 0 0ml/d ,术后第 6天肾功能恢复正常。目前患者肾功能良好 ,作者单位 :5 10…     

探讨肾动脉多支畸形的供肾在体外血管重建中的方式及在肾移植中的应用

目的探讨。肾动脉多支畸形的供。肾在体外血管重建中的方式及其在肾移植中的应用。方法对5例肾动脉多支畸形供肾的修整采取截取受者同侧髂内动脉的方法，依据供肾动脉的分支数而保留髂内动脉的分支数；在体外将供肾动脉各分支与髂内动脉大分支的开口进行端端吻合，然后将髂内动脉主干与受者髂外动脉行端侧吻合。将肾动脉重建后的供肾应用于双侧肾动脉瘤患者的自体肾移植术1例、亲属活体供肾肾移植术3例和尸体肾移植术1例。结果术后5例受者均未发生外科并发症。1例术后发生短暂的急性。肾小管坏死，但48h后进人多尿期，肾功能恢复顺利。术后随访10-36个月，受者移植。肾功能全部正常，肾动脉及分支未发生血栓或闭塞。结论采用受者的髂内动脉体外重建供。肾动脉的方法，可有效修复肾动脉3支以上以及。肾动脉过短的供肾，是一种安全可行的血管重建的方法，血管并发症较低，可有效应用于肾移植。     

基于人工血管置换术治疗肾移植术中髂外动脉夹层的临床效果研究

目的探究通过人工血管置换术治疗肾移植术中髂外动脉夹层的临床效果。方法选取2015年1月至2021年5月西安交通大学第一附属医院肾移植科应用人工血管置换术治疗肾移植术中髂外动脉夹层4例, 男性3例, 女性1例, 年龄28～55岁。4例肾移植受者均为术中突发髂外动脉夹层, 拆除血管缝合线发现动脉内膜剥脱堵塞髂外动脉3例, 堵塞移植肾动脉1例, 使用膨体聚四氟乙烯(ePTFE)制成的人工血管, 行髂外动脉的人工血管置换术。4例受者移植肾行二次灌注, 改与髂内动脉吻合。结果 1例受者术后1周肾功血肌酐恢复正常, 2例发生移植肾功能延迟恢复, 1例发生移植肾功能延迟合并急性排斥反应, 给予血液透析治疗, 术后2～3周血肌酐恢复正常。随访时间0.5～5.0年, 移植肾功能稳定, 术侧下肢血供及皮温正常, 活动有力自如。结论肾移植术中髂外动脉血管夹层发生率不高, 但病情进展迅速且凶险, 如不及时处理后果严重, 通过人工血管置换术治疗肾移植术中髂外动脉夹层可取得比较满意的临床效果。     

糖尿病肾病患者行肾移植术的临床分析

目的:探讨糖尿病肾病患者行肾移植术的临床特点.方法:回顾性分析了151例糖尿病肾病患者肾移植术的临床资料.结果:62.9%的患者有髂动脉硬化或钙化.术后移植肾功能延迟恢复发生率为16.7%,显著高于非糖尿病患者(16.7% vs 8.5%,P＜0.01).围手术期死亡3例(2例猝死,1例急性心肌梗死).人/肾1年存活率为95.2%/92.7%,3年存活率为84.8%/78.8%.受者死亡的主要原因是心血管并发症.结论:糖尿病肾病终末期肾衰竭患者肾移植术后的近期人/肾存活率良好,主要困难在于冠状动脉和髂动脉硬化,术前应做好冠心病的筛查和外周动脉硬化病变的评估.冠心病患者应在肾移植术前行心肌血管重建术.     

Reconstruction of a Transplant Recipient’s External Iliac Artery Using Donor’s Inferior Vena Cava in Renal Transplantation: 2 Case Reports

Iliac atherosclerosis is common in renal transplant recipients. In severe cases, it affects intraoperative renal arterial anastomosis and increases the risk of postanastomosis complications. At present, safe and efficient vascular replacement methods are relatively limited. In the 2 renal transplant cases at our center, described here, the donors’ iliac arteries were unavailable. We therefore attempted to replace the recipients’ diseased external iliac artery with the donors’ inferior vena cava and then performed an end-to-side grafting with the attachment in arterial reconstruction. One patient received a single kidney transplantation, while the other received a dual kidney transplantation. Antiplatelet/anticoagulation drug application was avoided, and both patients were observed for more than 6 months. Stable renal graft function was achieved without any vascular complications. During this study, all procedures were in compliance with the Helsinki Congress and the Declaration of Istanbul. For end-stage renal disease patients with severe iliac atherosclerosis who are waiting for kidney transplantation, a donor’s vena cava graft could potentially be a promising replacement option to restore external iliac artery patency and reconstruct renal blood flow, without the necessity of harvesting a recipient’s autologous vessels or looking for costly artificial ones.     

Upside-Down Kidney Transplantation in a Recipient with Severe Arteriosclerosis: A Case Report

Recently, the number of patients with significant arteriosclerosis has been increasing owing to the aging of kidney transplant patients, an increase in the number of patients with kidney failure with diabetes as the primary disease, and an increase in the number of patients undergoing long-term dialysis. Severe atherosclerosis in kidney transplant recipients makes it difficult to determine the site of vascular anastomosis and increases the technical difficulty of the surgical procedure. This study presents a case of upside-down kidney transplantation in a recipient with severe arteriosclerosis.The patient was a 58-year-old male with diabetic nephropathy. He received an ABO-compatible living donor kidney transplant from his wife. Preoperative computed tomography revealed a mild calcification of the external iliac artery. However, during surgery, more than half of the external iliac artery was found to be calcified, making vascular anastomosis difficult.The peripheral side of the external iliac artery showed mild atherosclerosis. Therefore, the vessel could be anastomosed to the peripheral side of the external iliac artery by turning the kidney graft upside-down for use as the anastomosis site. The postoperative course was uneventful, and the kidney function was good at the last follow-up.Upside-down kidney transplantation is safe in patients with severe arteriosclerosis.     

再次肾移植对尿毒症患者性功能的影响

目的:探讨再次肾移植对尿毒症患者性功能的影响。方法:对接受2次肾移植和同期双肾移植的30例患者术后的性功能状态进行问卷调查及阴茎血流多普勒超声检查。2次移植选用髂外动脉与供肾动脉吻合者9例(A组);一侧选用髂内动脉另一侧选用髂外动脉吻合者11例(B组);均选用髂内动脉与供肾动脉吻合者10例(C组),其中包括同期行双肾移植的1例患者。结果:术后半年恢复正常性生活者,A组8例;B组7例;C组5例。C组患者的阴茎海绵体动脉收缩期最大血流速度明显低于A及B组。结论:2次肾移植均选用髂内动脉与供肾动脉吻合,对患者的性生活有影响;但通过侧支循环代偿一段时间后,一部分患者仍可有满意的性生活。     

Simultaneous PTFE reconstruction of the external iliac artery with kidney transplantation

Four cases of simultaneous reconstruction of the external iliac artery with PTFE (polytetrafluoroethylene) during kidney transplantation are described. The procedure facilitated renal artery anastomosis in these cases where direct anastomosis to the external artery was deemed precarious because of marked atherosclerosis. All the kidneys functioned immediately, and there were no infectious or other complications encountered relative to PTFE placement. It is suggested that simultaneous iliac artery reconstruction with PTFE be considered when the renal artery anastomosis is complicated by severe iliac atherosclerosis.     

Kidney transplantation in diabetic recipients with iliac atherosclerosis: arterial anastomosis with Nakayama's ring pin stapler after endarterectomy

Objectives: To report our experience of arterial anastomosis with Nakayama's ring pin staplers (titanium staplers) after an endarterectomy in kidney transplantation of diabetic recipients with iliac atherosclerosis. Methods: In a series of 2126 kidney transplantations carried out between January 1998 and December 2008, 62 recipients received an endarterectomy during transplantation before renal arterial anastomoses as a result of severe iliac atherosclerosis. The renal arteries were anatomosed to hypogastric arteries through titanium staplers in 32 patients (group 1), or to external/common iliac arteries with conventional suturing in 30 patients (group 2). Perioperative outcomes of the two groups have been compared. Results: The mean artery anastomosis time in group 1 was considerably shorter than in the group 2 (6.4 min vs 17.3 min, P < 0.001). Group 1 showed a lower rate of delayed graft function (4.8% vs 27.5%, P = 0.004). No difference in Kaplan–Meier patient survival rate was found between group 1 and group 2 after follow up of 67 ± 28 months (P = 0.58). Graft survival rate (patient deaths included) was higher in group 1 than in group 2 (P = 0.04). Conclusions: Arterial anastomosis with a titanium stapler is more rapid than conventional suture. It can diminish the rate of delayed graft function and improve the graft survival rate in diabetic recipients with severe iliac atherosclerosis.     

14例亲属活体供肾动脉变异的血管重建

目的 探讨亲属活体供肾动脉变异的血管重建方法.方法 在104例亲属活体供肾移植中,有14例供肾动脉变异.供肾动脉变异的分类和血管重建方法分别为:(1)单支动脉较早分支型2例,取肾时分支受损,分别用受者髂内动脉及其分支、腹壁下动脉离体重建受损动脉.(2)双支动脉型10例,4例用受者髂内动脉及其分支离体重建血管,3例用受者腹壁下动脉与较细分支于体内吻合,1例较短肾动脉与较长肾动脉端侧吻合,1例较细副.肾动脉与主肾动脉端侧吻合,1例双支分别与髂外动脉端侧吻合.(3)3支动脉型2例,1例用受者髂内动脉及分支离体重建血管,1例结扎细小分支后,将较细的副肾动脉与主肾动脉端侧吻合.14例血管重建后,分别将供肾动脉较粗支和/或髂内动脉主干端与受者髂外动脉端侧吻合.结果 术后各支动脉血流通畅,移植.肾血液供应丰富、均匀.12例肾功能早期恢复正常,其中1例术后第14天发生急性排斥反应.1例术后即发生急性排斥反应;1例血肌酐下降缓慢.随访至2008年7月,除1例动脉粥样硬化较重的受者(三支动脉)下极动脉栓塞,血肌酐升高并稳定在170μmol/L外,其余患者动脉血流通畅,血液供应丰富、均匀.结论 供肾动脉变异时,利用所得供肾动脉的自身条件重建血管,或用受者髂内动脉及分支或腹壁下动脉重建血管,可获得较好的移植肾功能.受者动脉粥样硬化较重,同时有较细肾动脉支做重建吻合时,应注意该支动脉发生栓塞的可能.     

The long-term outcomes of transplantation of kidneys with multiple renal arteries

Kidneys with multiple renal arteries are increasingly procured for transplantation. To compare the outcomes of kidney transplantation using allografts with multiple arteries, we studied long-term graft function and survival according to their number of arterial anastomoses during an 18-year period from July 1, 1990, through December 31, 2008, in which only the recipient's external iliac artery or internal iliac artery was used for anastomosis (n = 1186). The recipients were divided into four groups: group I, single renal artery with single anastomosis (n = 890, 75.0%); group Il, multiple renal arteries, single anastomosis (n = 26, 2.2%); group Ill, multiple renal arteries, multiple anastomoses (n = 236, 19.9%); and group IV, polar artery ligation (n = 34, 2.9%). We compared the following variables patient and graft survivals; mean creatinine levels at 1 and 6 months, as well as 1-, 3-, and 5-years posttransplant; the number of acute rejection episodes, and the rates of vascular and urologic complications. The creatinine values and incidences of acute rejection episodes did not differ significantly (P = 0.399 and P = 0.990, respectively). There were no significant differences among the four groups in graft survival (P = 0.951), patient survival (P = 0.751), incidence of vascular (P = 0.999) or urologic complications (P = 0.371). The four groups were subdivided according to the recipient arterial anastomosis to the main graft renal artery. The subdivided groups showed no significant differences in graft or patient survival, or complications rates. The results indicated that multiplicity of renal arteries in kidney transplantation did not adversely affect allograft or patient survival compared with single renal artery transplantation. Moreover, the type of the arterial anastomosis (main renal artery end-to-end anastomosed to internal iliac artery or end-to-side anastomosed to external iliac artery appeared to not affect graft or patient survival or the incidence of vascular or urologic complications.     

Arterial reconstruction with donor iliac vessels during pancreas transplantation: an intraoperative approach to arterial injury or inadequate flow

BACKGROUND: Outcome of pancreas transplantation (PTX) has improved because of use of novel immunosuppression and advances in surgical technique. It is not uncommon for severe atherosclerosis in patients with type 1 insulin-dependent diabetes mellitus or the presence of a previously transplanted organ to limit the options for vascular anastomosis. Herein we report the novel application of donor iliac arterial interposition grafts for arterial reconstruction in patients with severe iliac artery arteriosclerosis, and/or previous transplant who develop an arterial injury or stenosis during surgery. METHODS: In five patients undergoing PTX, the external iliac artery was severely atherosclerotic and/or occupied by a previous vascular anastomosis. In four of the five patients, an arterial intimal dissection became apparent. The external iliac artery was excised and reconstructed with donor iliac artery interposition graft (end-to-end anastomosis). Pancreas or kidney was engrafted onto this arterial interposition graft (end-to-side anastomosis). RESULTS: There was no operative morbidity related to this surgical approach. All grafts functioned well after transplantation. Distal lower extremities have no evidence of vascular insufficiency with mean follow-up of 26 months (7-45 months). CONCLUSION: This surgical technique is an acceptable option during PTX for the patient with severe iliac artery arteriosclerosis with intraoperative intimal dissection or stenosis, or perhaps those with challenging arterial access.     

External Iliac Artery Dissection During Renal Transplantation: A Case Report and Literature Review

Iliac artery dissection in the setting of renal transplant is a rare but potentially catastrophic event that may result in loss of kidney and lower extremity perfusion. We report a right external iliac artery dissection in a 45-year-old man with end-stage renal disease, diabetes, and hypertension who underwent a renal transplant at our institution. An external iliac artery dissection was diagnosed intraoperatively after completion of the arterial anastomosis given the mottled appearance of the kidney and loss of Doppler signal. The dissection was repaired via open endarterectomy, intimal tacking, bovine patching, and re-anastomosis of the kidney to a proximal site on the external iliac artery. To date, 23 cases of transplant-related iliac artery dissection have been described in the literature. Predisposing risk factors include atherosclerosis and hypertension combined with trauma from vascular clamps or suturing. There is a slight male predominance. Only one group utilized an open endarterectomy approach similar to ours, whereas others used synthetic vascular grafts (12 of 23), endovascular stents (4 of 23), donor iliac artery grafts (4 of 23), or saphenous vein grafts (2 of 23). In the absence of long-term outcomes data, the optimal repair mechanism is yet to be established.