Use of internal iliac artery as a side-to-end anastomosis in renal transplantation

The internal iliac artery is less commonly used in renal transplantation in comparison to the external iliac artery due to its size and the risk of compromising distal vascular supply to the pelvis. We report a cadaveric renal transplant in which we performed a side-to-end anastomosis using the internal iliac artery. This technique can provide adequate perfusion to the transplant kidney without the associated risks and complications in the patient whose internal iliac artery is of a good diameter and quality.     

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…     

改进的套袖法吻合肾动脉建立大鼠原位肾移植模型

目的 观察改进的套袖法吻合肾动脉用于大鼠肾移植的可行性.方法 选择F344大鼠和Lewis大鼠分别作为肾移植的供、受者.切取供者左侧肾脏时,先剪断输尿管,然后阻断肾动、静脉水平上下的腹主动脉和下腔静脉,靠近下腔静脉剪断左肾静脉根部,经腹主动脉注入含肝素的4℃生理盐水对供肾进行原位灌洗后,靠近腹主动脉剪断肾动脉根部,取出供肾,放入4℃生理盐水中保存.切除受者左侧肾脏时,尽可能长的保留肾动、静脉以利于吻合.供肾植入时,采用改进的套袖法:用显微镊轻轻扩张供肾动脉后,协助显微持针器将针从供肾动脉血管外向血管内穿入,并从血管断端穿出第1针;接着穿入受者肾动脉断端,从受者肾动脉腔内向腔外穿出第2针;然后再从供肾动脉腔内、靠近第1针进针点处向腔外穿出,并与第1针的另外一端打结,此时受者的肾动脉已套入供肾动脉内;将供肾动脉边缘与受者肾动脉外膜固定2针,2针呈180度对角.供、受者的肾静脉及输尿管均行端端吻合.术后5 d内.若受者死亡,则认为手术失败.结泉共行肾移植20次,整个手术耗时70～90 min,供肾热缺血时间为4～9 s,冷缺血时间为30～40 min,肾动脉吻合用时(4.6±0.6)min,肾静脉吻合用时(11.8±1.2)min,输尿管吻合用时(12.2±1.4)min.术后5 d内,受者不明原因死亡1只,存活19只,手术成功率为95%.结论 采用改进的套袖法吻合肾动脉具有便捷、易于掌握、可靠及实用等优点,大鼠肾移植的成功率较高.     

A technique for hepatic artery anastomosis during orthotopic liver transplantation

Hepatic artery thrombosis remains the most common technical complication that causes graft failure following orthotopic liver transplantation. The Hepatic artery anastomosis should be performed using meticulous technique and adequate magnification. We report a very low incidence of Hepatic artery thrombosis (1.3%) utilising a modified microvascular 120° triangulating technique in 150 adult liver transplants.     

Training protocol for feline renal transplantation, using rat vascular anastomosis

Renal transplantation (RTx) has been a potential treatment for renal failure in pet cats. We developed a training protocol for the microsurgical skills required for feline RTx using rat vessels, which are the same size as the feline renal artery and vein. Using interrupted sutures, the transected abdominal aorta was reestablished in an end-to-end fashion. Venous anastomosis was performed with a continuous running suture in an end-to-side fashion between the portal vein and inferior vena cava. In the arterial anastomotic model, technical errors were checked by postoperative hemorrhaging. Those failures in the venous anastomotic model, technical errors were confirmed by the rat's death. Histological examinations of the epithelialization at the anastomotic site were evaluated in both groups. After training, nine cases of feline RTx were performed safely, using an adequate microsurgical technique.     

肾移植术中采用供肾动脉与髂外动脉吻合的体会

对２７例髂内动脉有严重动脉粥样硬化的肾移植受者实施供肾动脉与受者髂外动脉端侧吻合术，术后除有３例患者因环孢素用量过大使移植肾功能恢复略延迟外，其它２４例患者均于术后４天内肾功能恢复正常，且无一例外科并发症。认为该术式可作为髂内动脉情况异常的一种弥补方法，但不宜作为常规术式。     

Renal artery aneurysm at the anastomosis after kidney transplantation

Vascular complications represent serious problems after kidney transplantation. An aneurysm of the transplanted renal artery is an extremely rare but potentially devastating complication that which occurs in fewer than 1% of recipients. It can cause hypertension, functional impairment, and even graft loss. A 49-year-old man was admitted 6 months after his second renal transplantation. Duplex ultrasonography demonstrated an aneurysm at the anastomosis of the transplanted renal artery. The patient has not had any complaints. The function of the graft was stable. A computed tomography scan confirmed the diagnosis. Because of the high risk of rupture we decided upon surgical repair. During the operation, blood flow to the kidney was occluded; the graft was cooled with Euro-Collin’s solution and ice-cold saline. After the resection there was enough usable arterial wall to construct a new anastomosis. The patient had an uneventful postoperative period, the serum creatinine decreased to the preoperative level, and the function of the graft was stable. Renal artery aneurysms represent high-risk complications. We decided on surgical repair, which was performed with simultaneous perfusion and cooling of the graft. There are only a few similar cases in the literature; it was the first operation using this method in our practice. Surgical reconstruction of a renal artery aneurysm, if feasible, is a safe procedure that prevents aneurysm rupture and saves the graft.     

Stenting of the ureterovesical anastomosis in pediatric renal transplantation

From January 1985 to July 1989, 36 children received a renal transplant at our hospital. Their ages ranged from 2 to 18 years. All patients had a standard neoureterocystostomy according to Lich-Grégoir. In the first 18 patients, no transanastomotic stent was placed. In the latter 18, a transanastomotic stent with or without suprapubic bladder drainage was performed. In the nonstented group, six severe urological complications occurred, two of which eventually resulted in loss of the transplant. In the stented group, only one severe urological complication occurred. No kidneys in this group were lost due to urological complications. The number of urinary tract infections in the nonstented group was the same as in the stented group.     

Reversible renal artery stenosis in renal transplantation.

Spontaneous regression of an arterial stenosis in a renal transplant recipient is documented. Implications of this observation and possible pathogenic mechanisms are discussed.     

Sequential anastomosis of accessory renal artery to inferior epigastric artery in the management of multiple arteries in live related renal transplantation: a critical appraisal

In live related renal transplant program, management of multiple renal arteries (MRA) is technically demanding and used to be considered a relative contraindication because of increased risk of vascular and urologic complications. We present a retrospective analysis of the outcome of grafts with MRA and suggest certain guidelines. Of the 680 live related kidney transplantations done, 53 allografts had MRA. Cases were grouped according to the reconstruction technique: group A, MRA reconstructed ex vivo into a single renal artery (n=27); group B, MRA with multiple anastomoses in vivo (n =13); group C, MRA with sequential revascularization using inferior epigastric artery (n=11). We compared serum creatinine, acute tubular necrosis, rejection rates and the rewarm ischemia time between the three groups. Overall patient survival and graft survival were excellent (100 and 96%). Mean serum creatinine at 1 yr did not differ significantly between the three groups. Rewarm ischemia time was significantly less in group C (p<0.01). Incidence of acute tubular necrosis and rejection episodes was also less in group C although the difference was statistically significant only between group C and group B. We conclude that allografts with MRA can be used successfully in a live related renal transplantation program. Bench reconstruction should be done whenever possible. For reconstruction of an accessory vessel, inferior epigastric artery with sequential revascularization is recommended.     

Stenting of the ureterovesical anastomosis in pediatric renal transplantation

Abstract. From January 1985 to July 1989, 36 children received a renal transplant at our hospital. Their ages ranged from 2 to 18 years. All patients had a standard neoureterocystostomy according to Lich-Grégoir. In the first 18 patients, no transanastomotic stent was placed. In the latter 18, a transanastomotic stent with or without suprapubic bladder drainage was performed. In the nonstented group, six severe urological complications occurred, two of which eventually resulted in loss of the transplant. In the stented group, only one severe urological complication occurred. No kidneys in this group were lost due to urological complications. The number of urinary tract infections in the nonstented group was the same as in the stented group.     

Three-legged pair of pants anastomosis: a rare technique for renal transplantation

Because of the shortage of donors, kidneys previously judged to be unsuitable are now accepted for transplantation. Successful engraftment of kidneys with multiple renal arteries is one of the challenges and requires meticulous vascular surgical technique. In one of our case of renal allograft with three renal arteries, we created a single lumen by suturing three arteries together, like a three-legged pair of pants. The end of the single lumen was anastomesed to the side of external iliac artery. There was brisk diuresis on table after transplantation. Postoperatively, the patient had an uneventful course and normal graft function.     

Arterial anastomosis without sutures using ring pin stapler for clinical renal transplantation: comparison with suture anastomosis

PURPOSE: The metal ring pin stapler was initially developed for microvascular surgery and there has been little experience of their use in larger vessels. We determined if the titanium ring pin coupling system could be safely and rapidly applied for arterial reconstruction in clinical renal transplantation. MATERIALS AND METHODS: The donor renal artery was end-to-end anastomosed to the internal iliac artery with titanium ring pin staplers in 36 patients. Anastomotic, clamp and total operative time and vascular problems were compared with those in the control group of sutured anastomosis in 39 transplant recipients. RESULTS: The completion of mechanical anastomosis required half the time of suture anastomosis. Mean clamp time was 17.8 minutes in the nonsuture group and 28.1 minutes in the control group. There was no significant difference in total operative time between the 2 groups. A small anastomotic line leak was noted in each group, which was temporary and self-limited. There were no postoperative anastomotic failures, postoperative bleeding episodes or need to revise the anastomosis (100% patency rate) in the 2 groups. Of the patients 61 were followed for 2 to 5 years. Transplant renal artery stenosis was observed in 1 patient in the nonsuture group but 3 in the control group. CONCLUSIONS: The anastomotic technique with the ring pin system is safe and simple, permitting an expeditious and everting anastomosis with a smooth intima-to-intima junction. Application of this technique may decrease warm ischemia time and the incidence of anastomotic artery stenosis, thus, improving outcomes.     

Renal artery stenosis after renal transplantation

Stenosis of the transplant renal artery was discovered in 113 of 971 (11.6%) renal transplantation patients between three months and five years after transplantation. Diagnosis was reached by angiography performed because of hypertension, with or without impaired renal function. The stenosis was repaired in 63 patients with cure or improvement of hypertension in 35, and improvement of renal function in 12 of 23 patients with impaired renal function. The different types of stenosis were: recipient renal artery stenosis, suture line stenosis, donor artery stenosis (the most common), and multiple stenoses. The causes implicated were: recipient atheroma, faulty suture technique, hemodynamic disorders, trauma, and immunologic mechanisms. As the incidence of this complication is underestimated, routine angiography in all transplant recipients is suggested.     

Renal artery stenosis after renal transplantation

Renal artery stenosis occurred in eight of fifty patients who received a renal transplant during a three year period. The evaluation and management of these cases is summarized. Trauma associated with kidney procurement, preservation, or arterial anastomosis as well as the rejection process itself may ontribute to the development of these lesions. Arteriography may be indicated at an earlier stage in patients who respond poorly to medical treatment of repeated episodes of “rejection”.