Incidence of donor renal fibromuscular dysplasia: does it justify routine angiography?

BACKGROUND: The use of digital subtraction angiography (DSA) versus helical CT angiography (CTA) or MR angiography (MRA) for live renal donor evaluation is still controversial. Although CTA and MRA can detect some proximal moderate to severe arterial changes caused by fibromuscular dysplasia (FMD), mild and distal moderate FMD are not detected well without angiography. METHODS: This is a retrospective chart review of all potential, normotensive live renal donors at our center from July 1995 to June 2001. One hundred fifty-nine patients completed the donor evaluation process and underwent DSA. RESULTS: Seven cases of FMD, an incidence of 4.4%, were discovered. These patients were eliminated from donation. The distribution of renal vessels for our 159 patients was single arteries bilaterally, 64.8%; single left with multiple right, 16.4%; double left with single right, 9.4%; and multiple bilateral arteries, 9.4%. Three of the seven FMD patients had bilateral disease. Two of the seven (28.6%) FMD patients have subsequently required antihypertensive medications, with one requiring angioplasty of a progressive FMD stenotic lesion. CONCLUSIONS: We are concerned that CTA or MRA may overlook mild cases of DSA-detectable FMD. All seven FMD patients had single left renal arteries and would have undergone left donor nephrectomy. This would have resulted in their remaining right native kidneys having mild to moderate FMD in six of seven patients and in four donor kidneys having mild to moderate FMD. The need for antihypertensive medications in two of these seven potential donors within 4 years of their evaluation supports previous literature reports.     

Preoperative evaluation of living kidney donors using multirow detector computed tomography: comparison with digital subtraction angiography and intraoperative findings

To assess the accuracy of multirow detector computed tomography (MDCT) for the evaluation of renal anatomy for preoperative donor assessment in living related kidney transplantation. MDCT-scans (4- and 16-slice-CT) of 51 consecutive living kidney donors (age, 51.6 +/- 9.7 years; range, 28-68 years) were analysed by three blinded observers and compared with digital subtraction angiography (DSA) and surgery. Contrast-enhanced MDCT was performed with 1 mm slice thickness reconstruction interval during arterial and venous phases. Supernumerary renal arteries, veins, early branching of vessels and abnormalities of the ureters were documented. The overall accuracy of computed tomography angiography (CTA) for detection and classification of surgically relevant arterial variants was 97% (99/102). The interpretation of 16-channel MDCT images was correct in all cases (accuracy, 100%), while the four-channel CTA had three incorrect results regarding the differentiation of early branching vessels from double renal arteries (accuracy, 93%). The overall accuracy of DSA was 91%. Renal vein abnormalities were correctly diagnosed with MDCT in 100% compared with 89% correct findings with DSA. There were three kidneys with incomplete ureter duplication, detected both with MDCT and DSA. MDCT demonstrated superior accuracy compared with non-selective DSA for the preoperative assessment of renal anatomy in living kidney donors; and for the distinction of supernumerary arteries versus early branching patterns, 16-channel CTA data were better than those of the four-channel system.     

Renal Vascular and Ureteral Anatomic Variations in 1859 Potential Living Renal Donors

BackgroundRenal vascular and ureteral anomalies detected by preoperative computed tomography angiography (CTA) are important for determining the side of the donor nephrectomy and the optimal surgical technique. In the present study, we aimed to examine the renal vascular and ureteral variations in living kidney donor candidates.MethodsA retrospective analysis was made of 1859 patients who were examined in our clinic as donor nephrectomy candidates between November 2008 and December 2019. Renal CTA images were acquired using a 64-channel multidetector computed tomography scanner, and renal vascular and ureteral variations were evaluated.ResultsThe prevalence rates of multiple renal arteries on the right and left sides were 18.3% and 22.6%, respectively. The prevalence rates of early branching of the renal arteries, in turn, were 6.3% on the right side and 6.5% on the left side. The overall rate of renal artery variations on both the right and left sides was significantly higher in male individuals than in female individuals (P < .001). Multiple renal veins rates were 28.2% and 2.3% on the right and left sides, respectively, and the short renal veins rates on the right and left sides were 10.1% and 4.35%, respectively. Among the 941 cases undergoing donor nephrectomy, the procedure was completed by laparoscopy in 815 and by conversion from laparoscopic to open surgery in 36. The rate of vascular variations was higher in the conversion to open surgery group than in the laparoscopy group (P = .015).ConclusionsCareful preoperative assessments of donor renal vascular and ureteral anatomy and variations in CTA are essential for successful and safe renal transplant.     

Multi-detector row CT scanner angiography in the evaluation of living kidney donors

Renal vascular anomalies are frequent and are not usually problematic, especially when they have been identified and localised with preoperative imaging; computed tomography angiography is a fast and minimally invasive procedure that may afford accurate visualisation of arterial and venous anatomy. We report on our experience with the utilisation of multi-detector row angiography in the preoperative evaluation of living kidney donors. Nineteen living kidney donors underwent multidetector row scan angiography with 3D post-processing. The subjects were 12 male and 7 female donors with a mean age of 60 years. Renal vascular anomalies were identified in 52.6% of donors. A total of 10 supernumerary arteries were identified. Surgical correlation was available for 19 kidneys (17 left and 2 right). The donated kidneys were selected on the basis of CT scan and renal function. CT scan identified all 29 arteries including 10 double right or left arteries (100% specificity and sensitivity). Dual multi-phase multi-detector row CT angiography is a minimally invasive and highly accurate method for preoperative evaluation of renal donors. It affords comprehensive depiction of the arterial and venous anatomy of the kidney, which is particularly critical for planning and performing the donor nephrectomy, especially via a laparoscopic approach.     

Utility of 16-multidetector CT angiography in the preoperative evaluation of vascular and ureteral anatomy of donor nephrectomy

ObjectiveTo evaluate the accuracy of 16-section multi-detector row computed tomography (MDCT) angiography in the preoperative evaluation of renal transplant donors in comparison with intra-operative findings.Patients and methodsIn this prospective study 89 consecutive renal donors (69 men and 20 women) underwent 16-MDCT angiography followed by open surgical donor nephrectomy from January 2008 to March 2010. We reported the number and origin of renal arteries and the presence of early branching arteries. Renal venous anatomy was evaluated for the presence of major and minor venous anomalies. The renal calyces and ureters were assessed with delayed excretory phase images. On a 3D workstation, images were evaluated by the radiologist and the urologist. These CT angiography results were compared with surgical findings.ResultsThe mean age of the donors was 31 years. Open donor nephrectomy was performed on the left in 52 and on the right in 37 subjects. At surgery, accessory renal arteries were found in 14 kidneys (double arteries to 13 kidneys and triple arteries to one kidney). CT and surgical findings agreed in 92% of subjects. Seven small accessory renal arteries in seven donors were missed by radiology reviewers. Early branching of the renal arteries was shown in 5 arteries, and CT matched surgical findings in 88 cases (99%). Renal vein anomalies were present in six subjects, three of them were missed with the preoperative CT. The major shortcoming of MDCT angiography was noted in identifying minor venous anatomy. The presence of discrepancies between pre-operative MDCT and the findings at surgery did not affect the clinical outcome of transplantation, except in one case where intra-operative surgical distress was noted due to failure in identifying multiple major renal veins.Conclusions16-MDCT angiography is a good modality in the pre-operative evaluation of live renal donors. However, it provides suboptimal information on renal vascular anatomy, particularly complex venous patterns. Surgeons should not rely fully on pre-operative CT angiography while performing donor nephrectomy.     

多层螺旋CT在活体肾移植供者术前评估中的作用

目的 探讨多层螺旋CT(MELt)在活体肾移植供者术前评估中的作用.方法 对104名活体供肾者术前肾脏MDCT检查的资料进行回顾性分析.均采用64层螺旋CT检查,对双肾进行非增强扫描,注射造影剂后分别行动脉、静脉和排泄期增强扫描,扫描范围从膈顶到耻骨联合.扫描完后重建MDCT图像.根据MDCT图像,记录供者肾脏、输尿管、肾动脉及肾静脉的解剖结构和变异情况,并以供肾切取术中被证实的情况作为标准,对比分析术前MDCT检查对供肾的评估作用.结果 104名供者成功完成MDCT检查,肾脏和输尿管异常者8例.除外1例蹄铁型肾,副肾动脉和肾动脉过早分支的发生率分别为27.2%(28/103)和12.6%(13/103),有双肾静脉者3例,左肾静脉位于腹主动脉之后者3例.共有93名供者成功接受供肾切取术,术中证实,术侧供肾和输尿管异常与术前MDCT检查结果一致;术侧副肾动脉的检出率为80%.直径大于1 mm的副肾动脉和肾动脉过早分支术前均被MDCF检出;肾静脉均与术前MDCT检查结果一致.结论 活体供肾切取前采用MDCT检查能准确显示肾脏的解剖结构和血管变异情况,对供者选择及手术方案的制定具有重要意义.     

How Safe and Effective Is Routine Left Hand-Assisted Laparoscopic Donor Nephrectomy With Multiple Renal Arteries? A High-Volume,Single-Center Experience

BackgroundWe investigated the safety and effectiveness of routine harvest of the left kidney for renal transplantation regardless of the presence of multiple renal arteries to obtain the longer renal vein.Patients and MethodsBetween February 2000 and July 2008, 325 patients underwent left hand-assisted laparoscopic living donor nephrectomy. The true renal arterial anatomy as evaluated intraoperatively was compared with the renal arterial anatomy by computed tomography (CT). We compared the results for the patients with a single renal artery (group I) with the patients with multiple renal arteries (group II) in terms of the donor and recipient outcomes.ResultsMultiple renal arteries in left kidney were identified in 86 patients (26.5%). Thirty-seven CTs (11.4%) were in discord with the renal arterial anatomy evaluated intraoperatively. There was no difference in age, gender, body mass index, estimated blood loss, complication rate, or length of hospital stay between the 2 groups in the donor. Although the warm ischemic time and the operation time were significantly longer in group II (P = .008 and .001), overall graft survival was similar between the groups.ConclusionRoutine harvest of the left kidney can be performed safely and effectively for the donor and recipient, even in the presence of multiple renal arteries.     

Multidetector CT angiography in living donor renal transplantation: accuracy and discrepancies in right venous anatomy

Kulkarni S, Emre S, Arvelakis A, Asch W, Bia M, Formica R, Israel G. Multidetector CT angiography in living donor renal transplantation: accuracy and discrepancies in right venous anatomy.
Clin Transplant 2011: 25: 77–82. © 2010 John Wiley & Sons A/S. Abstract: Multidetector computed tomography (MDCT) angiography is a reliable technique for assessing pre‐operative renal anatomy in living kidney donors. The method has largely evolved into protocols that eliminate dedicated venous phase and instead utilize a combined arterial/venous phase to delineate arterial and venous anatomy simultaneously. Despite adoption of this protocol, there has been no study to assess its accuracy. To assess whether or not MDCT angiography compares favorably to intra‐operative findings, 102 donors underwent MDCT angiography without a dedicated venous phase with surgical interpretation of renal anatomy. Anatomical variants included multiple arteries (12%), multiple veins (7%), early arterial bifurcation (13%), late venous confluence (5%), circumaortic renal veins (5%), retroaortic vein (1%), and ureteral duplication (2%). The sensitivity and specificity of multiple arterial anomalies were 100% and 97%, respectively. The sensitivity and specificity of multiple venous anomalies were 92% and 98%, respectively. The most common discrepancy was noted exclusively in the interpretation of right venous anatomy as it pertained to the renal vein/vena cava confluence (3%). MDCT angiography using a combined arterial/venous contrast‐enhanced phase provides suitable depiction of renal donor anatomy. Careful consideration should be given when planning a right donor nephrectomy whether the radiographic interpretation is suggestive of a late confluence.     

活体供肾术前评估中16层螺旋CT的价值

目的：评价16层螺旋CT三维重建在活体供肾血管、肾实质、泌尿系统评估中的实际应用价值.方法：回顾2004年以来41例活体肾移植供体临床资料,术前均行16层螺旋CT扫描,采集肾动脉期、静脉期以及排泄期的影像数据,采用MIP、VR、MPR和CRP等三维图像后处理技术,评估供体肾动脉、肾静脉、泌尿集合系统和肾实质情况,与术中所见相对照.结果：41例供肾动脉显示,34例双肾单支动脉供血,其中2例左肾动脉、3例右肾动脉分支较早;4例右肾见一支副肾动脉,3例左肾见一支副肾动脉;术中证实有1例右副肾动脉,1例左肾动脉早期分支未能在影像中显示清楚,准确率95.1%.41例供肾静脉显示,37例双肾静脉为单支,4例右侧双支肾静脉;术中证实5例右侧双支肾静脉未能在影像中显示,准确率87.8%;泌尿集合系统显影满意,1例左侧双肾盂双输尿管畸形.结论：16层螺旋CT三维重建能准确显示供体肾脏血管、泌尿集合系统、肾实质解剖及可能的病理情况,给临床肾移植术前评估提供有价值的帮助,可作为供体术前检查的首选方法.     

A prospective analysis of the accuracy and cost-effectiveness of digital subtraction angiography for living-related renal donor evaluation

From 1982 to 1984, we conducted a prospective study to evaluate the usefulness of i.v. renal digital subtraction angiography (DSA) for living-related donor (LRD) evaluation. Twenty-eight LRDs were evaluated with the traditional approach of intravenous pyelography (IVP) and standard catheter arteriography (SCA) (group 1). During the same period, 33 LRDs underwent renal DSA and IVP from a single i.v. contrast injection (group 2). If renal arterial imaging with DSA was considered satisfactory, no further radiographic studies were done (group 2-A, n = 23). If renal arterial imaging with DSA was not satisfactory, SCA was then obtained (group 2-B, n = 10). DSA alone accurately defined the number and location of renal arteries in 21 of 23 patients from group 2-A, and in 5 of 10 patients from group 2-B. The major limitation of DSA was in patients with multiple renal arteries; accurate imaging was obtained in only 7 of these 13 patients (54%). In group 2 overall, preoperative renal imaging was not accurate in 2 of 33 patients (6%); in both cases, an unsuspected polar artery was found at nephrectomy. The mean cost per patient of all radiographic renal imaging studies was $953.00 for group 2 and $1721.00 for group 1. These data suggest that the approach of preferentially evaluating LRDs with DSA-IVP, and obtaining SCA only if DSA yields poor visualization, is more cost-effective but not as accurate as the traditional policy of obtaining SCA and IVP in all cases.     

Selection Criteria for Kidney Laterality in Retroperitoneoscopic Living Donor Nephrectomy and the Usefulness of Pretransplant Intervention

Objectives

To evaluate the selection criteria for kidney laterality and the usefulness of pretransplant intervention in living donor nephrectomy.

Gadolinium-enhanced three-dimensional magnetic resonance angiography versus conventional digital subtraction angiography: which modality is superior in evaluating living kidney donors?

This study evaluates the correlation of magnetic resonance angiography (MRA) and digital subtraction angiography (DSA) with the operative vessel findings in living kidney donors. The intraoperative vessel findings of 52 living renal donors were compared with the preoperative diagnoses of each imaging technique. Sixty-seven arteries were found during explantation. Forty kidneys showed a single arterial blood supply, and 12 kidneys showed a multiple arterial blood supply. No advantage of either imaging method was found for arterial imaging. There were 55 veins identified during organ harvesting. MRA could not determine the venous system in one donor (1.9%) and failed to detect one small pole vein in another. DSA did not yield a venous diagnosis in seven patients (13.5%) and yielded misdiagnoses in four patients. The correct diagnosis of renal donor veins differed significantly in favor of MRA (kappa 0.79 vs. 0.45; P=0.008). MRA is superior to DSA in assessing the renal vasculature in living kidney donors.     

锥束CT在动脉栓塞治疗大咯血中的应用

目的探讨急诊经动脉栓塞术中应用锥束CT判定DSA疑似责任动脉是否为大咯血责任动脉的价值。方法回顾性分析接受动脉栓塞治疗的31例大咯血患者的资料。急诊栓塞术中对DSA疑似责任血管行锥束CT成像,根据锥束CT图像判断其是否为肺内靶病灶的供血动脉,从而判定其是否为大咯血责任血管。对经锥束CT判定的责任血管及锥束CT难以确定的疑似责任血管进行栓塞,对经锥束CT判定的非责任血管不予栓塞。结果 31例均于急诊动脉栓塞治疗后24 h内停止咯血。37条动脉为DSA疑似责任动脉;其中29例(29/31,93.55%)患者34条(34/37,91.89%)疑似责任动脉经术中锥束CT可明确鉴定其是否为大咯血责任动脉,包括责任动脉11条(11/37,29.73%)、非责任动脉23条(23/37,62.16%),另2例(2/31,6.45%)患者3条(3/37,8.11%)DSA疑似责任动脉经术中锥束CT仍未明确判定其是否为大咯血责任动脉。结论大咯血急诊经动脉栓塞术中应用锥束CT有助于准确判定DSA疑似责任动脉是否为真正的责任动脉。     

Should the indications for laparascopic live donor nephrectomy of the right kidney be the same as for the open procedure? Anomalous left renal vasculature is not a contraindiction to laparoscopic left donor nephrectomy

BACKGROUND: The left kidney is preferred for live donation. In open live donor nephrectomy, the right kidney is selected if the left kidney has multiple renal arteries or anomalous venous drainage. With laparoscopic live donor nephrectomy (LLDN), there is reluctance to procure the right kidney because of the more difficult exposure and further shortening of the right renal vein (RRV) after a stapled transection. An experience with LLDN is reviewed to determine whether the right kidney should be procured laparoscopically. METHODS: From February 1995 to November 1999, 227 patients underwent live donor renal transplants with allografts procured by LLDN. The results of these transplants were analyzed. RESULTS: Of the 227 kidneys transplanted, 17 (7.5%) were right kidneys. In the early experience, three (37.5%) of the eight right renal allografts developed venous thrombosis, two of which had duplicated RRV. Based on these initially unacceptable results, donor evaluation and LLDN techniques were modified. Spiral computerized tomography (CT) replaced conventional angiography to define better the venous anatomy. LLDN was modified in one of three ways: (1) changing the stapler port placement such that the RRV was transected in a plane parallel to the inferior vena cava, (2) relocation of the incision for open division of RRV, or (3) lengthening of the donor RRV with a panel graft constructed of recipient greater saphenous vein. Finally, the recipient operation enjoined complete mobilization of the left iliac vein with transposition lateral to the iliac artery. With these modifications, there were no vascular complications with the subsequent nine right renal allografts (P<0.05). Of the left kidneys transplanted, 31 had multiple renal arteries, 14 had retroaortic or circumaortic veins, 4 had both multiple arteries and venous anomalies, and 1 had a duplicated IVC draining the left renal vein. There were no vascular complications with left renal allografts that had multiple arteries or venous anomalies. CONCLUSIONS: LLDN of the left kidney is technically easier. Left kidneys with multiple arteries or anomalous venous drainage are not problematic. The right kidney can be procured with LLDN; however, a rational approach to preoperative angiographic imaging, donor operation, and recipient operation is crucial.     

活体肾移植供肾动脉解剖学特点及其处理的临床体会

目的 总结活体肾移植供者肾动脉解剖学特点及多支动脉供肾的手术处理方式.方法 分析我中心142例活体肾移植供者术前数字减影血管造影和CT血管成像的供肾动脉解剖结果.用6种不同方式对多支动脉供肾进行显微技术处理,比较供肾多支动脉受者(n=31)与供肾单支动脉受者(n=111)术后早期的临床疗效.结果 30.99%的供者存在肾脏多支动脉,两侧肾脏相似(左肾22.54%,右肾22.13%),在一侧存在时,对侧也存在的概率分别为56.25%和60.00%.左肾动脉主干稍粗(P=0.001)且主干上第1个分支距腹主动脉距离稍近(P=0.004).多支动脉组受者手术时间和供肾冷、热缺血时间延长,但在术中出血量、移植肾功能延迟恢复、急性排斥反应及移植肾彩超弓形动脉流速等方面与单支动脉组差异并无统计学意义.在术后7 d、1个月、3个月3个观察点2组受者血清肌酐和肌酐清除率相似,重复测量的方差分析还表明供肾是否为多支动脉对术后早期肾功能的变化趋势并无影响.结论 充分了解活体供肾的动脉解剖并采用正确的处理方式是保证移植效果的重要因素.     

Variations in arterial supply to the lower lumbar spine

Purpose

Several papers examined the vascular anatomy of the lumbosacral region using cadavers with angiography. However, few reports used CT angiography, and discussion on variations of fourth lumbar, fifth lumbar, and lumbar branch of iliolumbar arteries were limited. To clarify the vascular variations around the lower lumbar spine including the lumbosacral region, particularly at the posterior elements, we performed anatomical analysis using computed tomography (CT).

Methods

Extra-osseous arteries surrounding the lumbar spine including the lumbosacral region were evaluated by two orthopedic surgeons independently, using 323 consecutive abdominal contrast-enhanced multi-planner CT scans that were taken for surgical plans in colon cancer patients. Subjects were 204 men and 119 women, whose ages ranged from 15 to 89 years (mean 66.5).

Results

Each segmental artery was visible at the L1–4 spinal levels, running from the vertebra through the lamina in 91.0 % on the right side, in 90.7 % on the left side, while it was visible in 4.6 % on the right side, in 8.7 % on the left side at the L5 level. The extra-osseous arterial supply to the L5 lamina was basically provided by two vessels on each side. One was mostly derived from the L4 segmental artery (right: 92.6 %; left: 92.0 %) that was distributed around the superior articular process, the other was derived from the iliolumbar artery (right: 62.9 %; left: 55.7 %) that was distributed around the inferior articular process through the lamina. There were mainly four combination patterns of those arteries. These combinations, which had been considered as regular patterns in textbooks, were observed in approximately 50 % (right: 55.7 %; left: 48.6 %) of patients.

Conclusion

Various distributions of arteries around the lower spine were identified.

     

Impact of Hepatic Artery Variations and Reconstructions on the Outcome of Orthotopic Liver Transplantation

Background

Donor variational arteries often require complex reconstruction.

Methods

We analysed the incidence of different variations, types of arterial reconstructions and their impact on post-operative results from 409 patients undergoing liver transplantation at Karolinska Institute between 2007 and 2015.

Results

A total of 292 (71.4%) liver grafts had a standard hepatic artery (SHA), and 117 (28.6%) showed hepatic artery variants (HAV). 58% of HAV needed reconstruction. The main variations were variant left hepatic artery (45.3%) from the gastric artery; variant right hepatic artery (38.5%); and a triple combination of variant right and left hepatic artery and the proper hepatic artery from the common hepatic artery (12.8%); other 3.4%. Patients/graft survival and arterial complications were not different between SHA and HAV. Incidence of biliary stricture was numerically higher in left hepatic artery variants (p = 0.058) and in variants where no arterial reconstruction was performed (p = 0.001). Operation and arterial warm ischaemia time were longer in the HAV group. The need for intraoperative re-reconstruction was higher in the HAV group (p = 0.04). Intraoperative bleeding was larger after back-table reconstruction than with intraoperative reconstruction (p = 0.04).

Conclusion

No overall differences were found between the HAV and the SHA groups. Occurrence of a variant left hepatic artery and HAV with no reconstruction seems to increase the risk of biliary strictures.

     

Imaging of hepatic arterial anatomy for depicting vascular variations in living related liver transplant donor candidates with multidetector computed tomography: comparison with conventional angiography

AIMS: The aim of this study was to evaluate liver arteries to depict variations by using multidetector computed tomography (CT) in donor candidates for living related liver transplantation. METHODS: Computed tomographic hepatic angiography was carried out using a multidetector 16-row CT scanner (Sensation 16; Siemens) in 48 candidates between April 2003 and August 2004. Multidetector CT was performed after intravenous injection of 150 mL of contrast material at a rate of 4 mL/s. Arterial phase images were acquired after contrast injection. Afterward, maximum intensity projections and volume-rendered images were produced from the axial image data. Twenty-eight of these patients underwent conventional catheter angiography. RESULTS: Excellent arterial opacification was shown on multidetector CT scans in all patients; arteries up to tertiary branches were identified with CT. Of 28 patients who had both multidetector CT angiography and conventional angiography, only a branch of hepatic artery originating from superior mesenteric artery that supplied the posterior segment of the right lobe was not identified on multidetector CT angiography. In 27 donors, hepatic arterial anatomy depicted at multidetector CT angiography was identical to that at conventional angiography. We identified hepatic vascular variants in 22 of 48 patients with multidetector CT. The most common arterial variant was an accessory hepatic artery arising from the left gastric artery. CONCLUSIONS: Preoperative imaging evaluation of hepatic vascular anatomy is crucial for surgical planning in living related transplant donors. Multidetector CT is useful to depict hepatic arterial anatomy with high accuracy.     

Anastomosis of accessory arteries via microsurgical technique in renal transplantation

Purpose

For many years there has been reluctance to use kidneys having multiple arteries of <2 mm diameter, especially where they supply the lower pole. The usage of these kidneys has increased using microsurgical anastomosis techniques. We reviewed the anastomotic techniques among renal transplantations with multiple arteries.

Materials and Methods

Between January 2008 and August 2010, we examined the perfusion of 605 live donor kidneys bearing multiple arteries at 1 week and after 3 months using Doppler ultrasonography and magnetic resonance imaging (MRI) angiography. In addition, we reviewed vascular and urinary complications. The diameters of the arteries were measured using multi-slice computerized tomographic (CT) angiography.

Results

Multiple arteries were detected in 49 (8.1%) kidneys, including 14 from the right and 35 left: namely, 45 with double and 4 with 3 arteries. In 26 patients an end-to-side microsurgical anastomosis was performed using the accessory artery; 23 organs underwent other techniques. The average diameter of all arteries was 3.89 ± 1.38 mm (thinnest, 1.2; widest, 8 mm). The average diameter of the main arteries was 5.12 ± 1.16 mm (thinnest, 3; widest, 8 mm) and the accessory arteries 2.81 ± 0.69 mm (thinnest, 1.2; widest, 3.8 mm). In patients with microsurgical techniques the average diameters of all arteries and accessory arteries were 3.7 ± 1.6 mm and 2.6 ± 0.69 mm, respectively. In those undergoing techniques other than microsurgery, the average diameters of all arteries and accessory arteries were 4.11 ± 1.34 mm and 3.1 ± 0.43 mm, respectively. The average diameters of the arteries in both groups were significantly different (P < .001). Kidney perfusion was intact upon ultrasonographic and MRI angiography of all patients. In 1 subject with a microsurgical technique used, anastomostic dehiscence with bleeding was observed after removal of the arterial clamps. Also in this group, 1 patient experienced a ureteral stricture beyond postoperative month one.

Conclusion

Microsurgery is a reliable technique for kidneys with thin accessory renal arteries.