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。     

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。     

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。     

小儿肾移植的临床研究(附13例报告)

目的：探讨儿童患者肾移植的术式、术后用药以及术后并发症的处理。方法：分析13例儿童患者肾移植的临床资料。结果：13例儿童患者肾移植1年人／肾存活率均为100％，急性排斥反应发生率为38．4％（5／13），肾小管坏死发生率30．7％（4／13），术后发生肾周积液2例，无其它手术并发症。结论：儿童肾移植的术式应根据受者血管情况选择移植肾动脉与髂内动脉端端或端侧吻合，也可与髂外动脉或髂总动脉端侧吻合。免疫抑制剂用量应比成人稍高。     

大鼠肾移植模型四种肾静脉重建术式的比较

目的：探讨不同大鼠移植肾静脉重建术式的效果。方法建立大鼠同种异体肾移植模型，根据移植肾静脉重建方式不同将受体大鼠分为4组：32只实验组大鼠采用内支架法行原位端-端吻合；25只对照组Ⅰ大鼠采用原位端-端吻合；22只对照组Ⅱ大鼠采用Cuff管套扎法吻合；20只对照组Ⅲ大鼠采用受体下腔静脉端-侧吻合。比较各组大鼠移植肾静脉重建手术操作时间和静脉吻合口漏血、静脉血栓形成、静脉吻合口狭窄发生情况。结果实验组供肾静脉分离切取用时最短，为（9．1±0．9） min；对照组Ⅲ用时最长，为（12．1±0．9）min；两组比较差异有统计学意义（P＜0．05）。实验组供肾静脉修整用时为（5．0±0．6）min，短于对照组Ⅱ和对照组Ⅲ，差异均有统计学意义（P均＜0．05）。实验组移植肾静脉重建用时为（6．2±1.5） min，短于对照组Ⅰ和对照组Ⅲ，差异均有统计学意义（P均＜0．05）。实验组术后静脉血栓发生率最低（3．1％），与对照组Ⅱ（27．3％）比较，差异有统计学意义（χ2＝4．77， P＜0．017）；静脉吻合口狭窄发生率最低（3．1％），与对照组Ⅰ（24．0％）比较，差异有统计学意义（χ2＝3．90， P＜0．017）。结论应用内支架法行移植肾静脉原位端-端吻合操作时间短、并发症少，可有效解决大鼠肾移植静脉重建的问题。     

肾移植术中供肾变异血管的处理

为了提高供肾的质量和利用率，对１２８例供肾变异血管的处理进行了总结。１２８例中９９例为双支肾动脉，２２例为３支肾动脉，１例为４支肾动脉。术中采用Ｃａｒｅｌ片与髂外动脉或髂内动脉行端侧吻合，在低温条件下，将变异肾动脉行裤叉端侧或二者兼之的吻合方式修复成单一动脉与髂内动脉吻合，或将变异动脉分别与髂内动脉及其分支吻合等方法处理。一年肾存活率为７３．４３％，与无血管变异供肾移植一年存活率７８．８１％比较无显著性差异。认为，修肾时正确处理供肾变异血管可缩短温缺血时间，保证供肾血供，减少血管并发症和促进肾功能恢复     

肾动脉内套法建立大鼠肾移植模型

目的探索一种操作简单、成功率高的建立大鼠肾移植模型的手术方法。方法选择SD大鼠24只作为供体,Wistar大鼠48只作为受体,采用。肾动脉内套法建立大鼠。肾移植模型。所有受体大鼠均接受左侧原位肾移植,自体右肾切除。受体大鼠动脉重建借助自制动脉套管将受体肾动脉内套人供肾动脉,缝线固定及3点外膜加固行肾动脉重建,受体肾静脉与供体后腔静脉借助自制导管行端一端吻合,尿路改建采用供体输尿管膀胱瓣与受体膀胱吻合。结果研究共实施48例大鼠肾移植术。24只供体大鼠平均手术时间（354±6）min,供肾修整时间（3．9±1．2）rain,供肾热缺血时间（5．7±1．5）s,冷缺血时间（52±6）rain。48只受体大鼠手术时间（39±6）min,动脉吻合时间（6．9±2．5）min,静脉吻合时间（14．2±2．3）min,尿路重建时间（6．6±1．1）min。术后3d内,2只大鼠因血管吻合口出血死亡,2只因移植肾动脉内血栓形成死亡,1只因尿瘘致腹膜炎死亡,其余43只大鼠均获手术成功,成功率89．6％。截至术后14d,共7只受体大鼠存活,所有受体大鼠中位存活时间6d10结论肾动脉内套法操作简单,受体大鼠成功率高,初学者掌握快,易于推广。     

移植肾动脉吻合口狭窄的再手术治疗二例

例1为男性，40岁。因慢性肾小球肾炎、尿毒症接受肾移植术。供肾血管无畸形，动、静脉各一支，动脉直径约5mm，静脉出口直径约15mm。供肾动脉与受者的髂内动脉行端端吻合，供肾静脉与受者的髂外静脉行端侧吻合，受者的髂内动脉直径约6mm。恢复循环后．移植肾迅速红润，张力、色泽良好，1min后即有尿液泌出。但术后尿量少，血尿素氮（BUN）为37．5mmol／L，肌酐（Cr）为1177μmol／L。术后第2d移植肾B型超声波检查提示移植肾图象异常，移植肾内血流速度明显减低，     

肾移植血管吻合技巧

血管吻合技术的好坏直接关系到肾移植手术的成败。提高血管吻合手术技巧的目的,也在于避免肾移植术后常见血管并发症如移植肾血管梗阻、栓塞,移植肾动脉破裂出血,吻合口破裂出血,移植肾动脉瘤,移植肾动脉狭窄等[1]。一、肾移植静脉吻合技巧供肾静脉常与受体髂外静脉端侧吻合,髂外静脉有血栓形成或儿童肾移植患者供肾静脉常与下腔静脉端侧吻合。在静脉吻合之前,须摆好供肾与吻合血管之间的关系,切勿让供肾静脉扭曲。为防止静脉吻合口狭窄,受者静脉切口要足够大,与供肾静脉口径相匹配为原则。左肾静脉一般长度足够,不需延长。右肾静脉相对较短…     

供肾动脉与髂外动脉端侧吻合行肾移植术的临床研究

本文通过对供肾动脉与髂内动脉端端吻合（ＥＥＡ）及与髂外动脉端侧吻合（ＥＳＡ）二种方法的比较，结果显示：ＥＳＡ组非常显著地缩短了手术时间（Ｐ〈０．００１）；ＥＥＡ组动脉吻合口狭窄发生率为７％，显著高于ＥＳＡ组；二组正常功能移植肾血流无显著性差异；ＥＳＡ组多支动脉供肾利用率为９４．４％，显著高于ＥＥＡ组。同时认为ＥＳＡ减少体外多支动脉供肾血管重建手术，缩短冷缺血时间，减少供肾损伤。     

Microvascular reconstructive "bench" surgery for donor kidneys before transplantation: techniques and results

Forty kidneys (10 from live donors) with either multiple renal arteries or damaged vasculature were reconstructed accurately ex vivo with microsurgical techniques before transplantation. The end product in all cases was a kidney requiring a single arterial and venous in situ anastomosis. The warm ischemia time was minimized by this adjunctive "bench" microsurgery. There was no surgical complication relating to the vascular reconstruction. The potential technical and hemodynamic benefits of this surgical approach to kidneys with multiple vessels are discussed. In addition, some kidneys with damaged vasculature can be salvaged for transplantation with microvascular reconstruction.     

供肾血管损伤的外科处理

目的　探讨供肾血管损伤的处理方法 ,为临床提供参考依据。方法　回顾性分析 32例供肾血管损伤同种异体肾移植患者的资料 ,选取 6 0例同期施行肾移植非供肾血管损伤患者作为对照组。供肾血管损伤的修复方法主要包括供肾动脉端端吻合术、并接吻合术、交接吻合术、供 (受 )体髂内血管肾动脉修复术、腹壁下动脉肾动脉吻合术、供肾倒置下极肾动脉髂内动脉吻合术等。结果2 8例为肾动脉损伤 ,4例肾静脉损伤。平均体外修复手术时间 4 2min ,平均温缺血时间 31min。随访 1～ 5 (平均 3 5 )年 ,无患者死亡。供肾血管损伤组和对照组 1年移植肾存活率、术后 1年急性排斥反应、肾功能延迟恢复及血管吻合口狭窄发生率分别为 96 9% ,98 3% (P >0 0 5 ) ;12 5 % ,11 7% (P >0 0 5 ) ;2 1 9% ,18 3% (P >0 0 5 ) ;3 1% ,1 7% (P >0 0 5 )。结论　灵活、恰当地应用不同修复方法和良好的外科操作技术对保证血管损伤供肾的质量、提高利用率有重要作用。     

Gefäßchirurgische Eingriffe bei Nierentransplantationen

Kidney transplantation is the most frequent form of solid organ transplantation. Heterotopic organ implantation in the iliac fossa has become established as the gold standard. A special feature is that there is no upper age limit for both the donor organ and the recipient. Arteriosclerotic vascular alterations of the recipient in particular can make connection of the transplant to the pelvic vessels more difficult or even impossible without appropriate corrective measures. Problems for the donor kidney can also arise due to arteriosclerotic vessels and vascular anomalies. Donor vessels damaged during organ removal represent a further factor, which necessitates expertise in vascular surgery. Aortoiliac vascular stenoses and stenoses in the region of the transplant arteries occurring after renal transplantation can be endovascularly treated with a low risk of ischemia for the transplanted kidney.     

Lymphocele in Kidney Transplantation: A Comparison of Ligation and Non-ligation Technique of Iliac Lymphatic Dissection

BackgroundTo compare the incidence of lymphocele in kidney recipients following 2 lymphatic vessel division techniques: ligation and non-ligation.MethodsRetrospective reviews of the records of 402 patients with end-stage renal disease who underwent kidney transplantation from April 2015 to December 2019 at Siriraj Hospital.ResultsFour hundred two patients were included in the study: 54.9% of the patients were male, and the patient's mean age was 41 years. There were 25.1% and 74.9% that received kidney grafts from living and deceased donors, respectively. The preoperative renal replacement therapies were 83.3% hemodialysis, 12.9% peritoneal dialysis, and 3.7% preemptive transplantation. Two hundred forty-nine patients received lymphatic division with the ligation technique and 153 patients received the non-ligation. Lymphoceles were found in 31 cases (7.7%). Lymphocele occurrence in the ligation group was lower than in the non-ligation group: 5.2% compared to 11.8% (P value = .017). There were 22.6% of lymphoceles that had a spontaneous resolution with no treatment.DiscussionThe ligation of iliac lymphatic vessels during division reduced the incidence of lymphoceles non-ligation.     

Experimental and clinical research on treatment of vascular malformations with retained copper needles

OBJECTIVE: To investigate a simple, safe, and effective surgical approach to treat vascular malformations (VM). METHODS: Tissues of vein, heart, liver, and kidney were obtained and pathologically observed from 30 rabbits whose central veins of the ears were retained with copper needles, and the concentration of Cu in serum was measured. In the clinical research, 3 methods were employed to treat 89 patients with VM: (1) retaining copper needles alone; (2) ligaturing lesions and retaining copper needles; (3) retaining copper needles charged with direct current (DC). RESULTS: After the treatment of retaining copper needles, thrombus, fibrosis, and necrosis of the malformed vein walls gradually increased. The effective rate was 95.5%. CONCLUSION: Treatment with copper needles retained in malformed blood vessels leads to denaturalization, fibrosis, and disappearance of the blood vessel structure, and thus it is an effective way to treat VM.     

肾移植中供肾血管变异的处理

目的提高血管变异的供肾的临床应用价值。方法根据具体情况，将血管变异的供肾进行合并、修整、重建等，使供肾安全、有效的移植给受者。结果78只供肾动脉变异(包括23只供肾静脉变异)经处理后，77只供肾良好。供肾移植后数分钟内有尿排出，2周内肾功能恢复正常，1年后随访无并发症。仅有1例因肾静脉回流障碍，被迫切除移植肾。结论供肾血管变异只要正确处理，移植后可获得良好效果。     

胸廓上口大血管损伤的外科治疗

目的 总结胸廓上口大血管损伤的外科治疗经验。方法 回顾性分析经手术治疗的32例胸廓上口大血管损伤患者的临床资料,其中男性24例,女性8例;年龄2－48岁。致伤原因为锐器伤、钝性或减速伤。损伤血管为颈总动脉、无名动脉、锁骨下动脉以及伴行的静脉。治疗方法为：急诊缝合动脉破口,或加涤纶片修补15例;动脉瘤切除6例;受损血管切除端端吻合5例;以Gore-Tex重建血管3例;大隐静脉移植3例。结果 治愈24例（75％）,死亡7例（21．9％）,1例致残。结论 胸廓上口大血管损伤患者,早期常因失血、脑缺氧或并存的多发伤致死;后期多演变成假性动脉瘤。手术多采用血管破口修复;在体外循环支持下实施假性动脉瘤切除,Gore-Tex人造血管或大隐静脉移植重建血管。     

同种异体原位肾移植初探

同种异体原位肾移植２例，手术经过和术后恢复顺利，至今已随访二年余，移植肾功能正常。因多囊肾，顽固性肾性高血压，慢性肾盂肾炎等需切除自体肾脏时使用摘除受者肾脏的同一切口植入供肾，简化了手术过程。对于第二，三次肾移植，因膀胱病而需行尿流改道者，以及髂血管粥样硬化者，原位肾移植是一种可供选择的方法。     

Adenovirus Disease after Kidney Transplantation: Course of Infection and Outcome in Relation to Blood Viral Load and Immune Recovery

Information on the clinical spectrum and management of adenovirus infection after kidney transplantation is limited. From April 2007 to April 2010, 17 kidney transplant recipients were diagnosed with adenovirus disease. The median time to infection was 5 (range, 2–300) weeks after transplantation. Of the 17 patients, 13 (76.5%) presented early, within 3 months posttransplant, and four (23.5%) presented late, more than 3 months after transplant. Besides urinary tract, involvement of other organs was common (63.6%) among patients with adenovirus viremia. Despite reduction of immunosuppression, six patients subsequently had a rise in the level of blood viral load, mostly within a week after diagnosis. However, only three (27.3%) patients with early infection developed disease progression. Compared to the late infection group, patients with early infection had significantly lower absolute lymphocyte counts at week 1 (p = 0.01) and 3 (p = 0.002) after diagnosis. Four patients received intravenous cidofovir. At 6‐month follow‐up, 10 (90.9%) patients had reversible graft dysfunction. Only one (5.7%) died from bacterial sepsis. Adenovirus disease is a significant complication following kidney transplantation. Early case recognition with reduction of immunosuppression is critical. Serial blood adenovirus viral loads and assessment of lymphocyte recovery are also useful in monitoring the course of infection.     

A vascular surgeon's approach to renal transplantation.

The blood vessels and blood supply are of first importance in organ transplantation, and the use of established vascular surgical principles and techniques can simplify renal grafting and reduce its risks and complications. This paper describes a vascular surgeon's approach to the problems of donor nephrectomy, kidney insertion, and the avoidance and management of complications, based on the surgical experience in the Royal Melbourne Hospital of some 350 transplants.