Successful use of the dilated right spermatic cord vein for renal transplantation in a patient with congenital hypoplasia of the inferior vena cava

A 29-year-old man was admitted to our department with renal failure secondary to glomerulonephritis. No history of deep venous thromboses was reported, and no iliac vessel abnormality was evident on routine ultrasound (B-mode) examination before the operation. Transplantation of his mother's left kidney revealed occlusion of his common iliac vein and distal inferior vena cava (IVC). The right spermatic cord vein was noted to be dilated and suitable for venous drainage of the allograft, which was accomplished by an end-to-side anastomosis between the renal vein and the right spermatic cord vein. The allograft showed immediate function; serum creatinine was decreased to a normal value at 5 days after surgery. After the operation, a vascular spiral computerized tomographic 3-dimensional reconstruction showed absence of the infrarenal IVC with the right spermatic cord vein draining into the end of IVC. Physical examination revealed a right-side varicocele with dilated epigastric vein. The donor kidney slower normal values upon routine follow-up at 2 years after the operation.     

Renal transplantation with venous drainage through the superior mesenteric vein in cases of thrombosis of the inferior vena cava

Renal transplantation usually is performed by placing the graft in the iliac fossa, anastomosing the renal vein to the iliac vein or, when this is not possible, to the vena cava. When vascular complications occur, particularly on the venous side, the position of the graft may have to be changed. This report describes orthotopic renal grafts and positioning of the organ with anastomosis to the splenic vessels. Venous drainage was established directly into the mesenteric-portal territory, with two cases to the portal vein and one to the inferior mesenteric vein. A new technique for the venous drainage of the renal graft is shown. We have used this model in two cases of infrarenal inferior vena cava thrombosis. The kidney was located in a retroperitoneal position, with venous drainage to the superior mesenteric vein through an orifice in the posterior peritoneum.     

Nontraditional sites for vascular anastomoses to enable kidney transplantation in patients with major systemic venous thromboses

Successful renal transplantation requires low‐pressure venous drainage to permit adequate outflow from the allograft. We report here a series of three patients in whom the inferior vena cava as well as bilateral iliac veins were thrombosed, making it necessary to explore less traditional vessels for venous drainage of the renal allograft. We utilized the splanchnic vasculature in two cases and the native left renal vein in another. The resulting atypical intra‐abdominal locations of these allografts also presented difficulties for arterial anastomoses and for urinary drainage. Arterial conduits were utilized in two cases to facilitate anastomosis to the common iliac artery or the aorta, and in the third case, the splenic artery was used for arterial inflow. A traditional ureterocystostomy was technically feasible for only one patient. In another, ureteroureterostomy to the native ureter was performed, and in the third case, the creation of an ileal conduit was necessary. All three patients had antibodies to human leukocyte antigens and two required desensitization. All three kidneys had immediate graft function and continued to function at 1 year post‐transplant. With a combination of planning, creativity, and persistence, patients with IVC thrombosis can enjoy the benefits of renal transplantation.     

Portal venous drainage for cadaveric renal transplantation

The iliac vessels are the standard site for vascular connections for kidney transplantation. Unusual circumstances may render the iliac vessels unusable. We report a case in which a cadaveric renal allograft was successfully transplanted despite an absence of normal venous anatomy, using the inferior mesenteric vein for revascularization.     

Variability of venous anatomy of rat testis: application to experimental testicular surgery.

The venous drainage of the testis of the laboratory rat was observed in 31 animals. The right testicular (internal spermatic) vein drained directly into the right common iliac vein in 77.4%, and into the inferior vena cava in 22.6% of the animals. The left testicular vein drained into the left common iliac vein in all animals, but in 90.3% there was also an accessory branch of the testicular vein draining into the left renal vein. These observations suggest that in the rat the exact anatomy of the venous drainage of each testis should be identified prior to undertaking any surgical procedure on the testis where the venous vasculature plays a major role such as testicular transplantation or the creation of an experimental varicocele.     

Orthotopic renal homotransplantation in a patient with thrombosis of the inferior vena cava

Complete thrombosis of the infrarenal vena cava and the entire iliac venous system is a unique circumstance in a candidate for renal allotransplantation. This condition was created in a patient by the previous use of an inferior vena caval clip. The patient received a kidney transplant in the orthotopic intra-abdominal position, using his own renal vein for renovenous anastomosis. The usual method of urinary drainage was also modified. This approach to transplantation should be considered in the presence of partial clotting or occlusion in the distal vena cava or iliac venous system.     

Successful renal transplantation in high-risk small children with a completely thrombosed inferior vena cava

BACKGROUND: Inferior vena cava (IVC) thrombosis is generally a contraindication to renal transplantation in small children because of the technical difficulty and limitations in allograft venous outflow drainage that risk graft thrombosis. METHODS: The records of six consecutive children (9.9-27.4 kg) with end-stage renal disease and thrombosed IVCs were reviewed. Small deceased donor renal allografts were utilized in all cases where immediate posttransplant venous renal outflow would theoretically not exceed the drainage capacity of the iliac or adjacent pelvic collateral veins. RESULTS: There is 100% patient survival with two patients returning to dialysis at seven and three years posttransplantation. There were no surgical complications or delayed graft function. Postoperatively, progressive renal vein and simultaneous iliac venous enlargement was observed in five of six recipients concomitant with renal allograft enlargement. In these patients, maximum renal volume achieved was between 152 and 275 ml and last recorded Schwartz glomerular filtration rates ranged from 67 to 118 ml/min. The sixth allograft had an early, severe rejection episode that limited renal growth and attainment of good renal function. All patients demonstrated resumption of growth rates commensurate with age but without significant catch-up growth. CONCLUSION: A small deceased donor kidney can provide freedom from dialysis and better quality of life for small children with IVC thrombosis during an age when dialysis treatment is difficult and the complications of the thrombosed IVC may compromise life. Good renal function was attained in patients without rejection episodes. In those with rejection, our approach allowed for patient growth during allograft function, providing a bridge for a repeat transplant.     

Successful renal transplantation in the right iliac fossa 2 years after serious deep venous thrombosis in a patient with systemic lupus erythematosus

Deep venous thrombosis (DVT) possibly occurs in the perioperative period, and induces serious complications such as a pulmonary embolism. On the other hand, allograft renal vein thrombosis leads to a high incidence of graft loss. We experienced a case in which a serious DVT occurred prior to renal transplantation; however, a successful renal transplantation in the right iliac fossa was performed after 2 years of anticoagulant therapy. It is suggested that the external iliac vein even after suffering from DVT can be anastomosed to an allograft vein successfully, when enough blood fl ow or a lower venous pressure is confirmed. However, one should be aware of the risk factors and the adequate management of thrombosis in renal transplantation because of the serious complications of DVT and the poor prognosis of allograft vein thrombosis.     

Interpostion vein graft in living donor liver transplantation

In adult-to-adult living donor liver transplantation (LDLT), right lobe grafts without a middle hepatic vein can cause hepatic congestion and disturbance of venous drainage. To solve this problem, various types of interposition vein graft have been used. OBJECTIVES: We used various types of interposition vein grafts for drainage of the paramedian portion of the right lobe in living donor liver transplantation. METHODS: From June 1996 to June 2003, 37 of 176 patients (128 adults, 48 pediatric) who underwent LDLT received vein grafts for drainage of segments V, VIII, or the inferior portion of the right lobe. RESULTS: In 36 adult cases the reconstruction included the inferior mesenteric vein of the donor (n = 14); cadaveric iliac vein stored at cold (4 degrees C) temperature (n = 5); cryopreserved (-180 degrees C) cadaveric iliac vein (n = 10); cryopreserved cadaveric iliac artery (n = 1 case); donor ovarian vein (n = 1); recipient umbilical vein (n = 3); recipient saphenous vein (n = 1); recipient left portal vein (n = 1); recipient left hepatic vein (n = 1). In a pediatric case with malignant hemangioendothelioma that encased and compressed the inferior vena cava, we used an interposition vein graft to replace the inferior vena cava. CONCLUSION: Various types of interposition vein grafts can be used in living donor liver transplantation. Cryopreserved cadaveric iliac vein and artery are useful to solve these drainage problems.     

Salvage of renal allograft function and lower extremity venous patency with thrombolytic therapy: Case report and review of the literature

Five months after a cadaveric renal transplant a 69-year-old man was admitted with caval, iliac, and renal allograft vein thrombosis that occurred in the setting of a previously placed caval filter. The patient's urine output and renal function deteriorated rapidly. Thrombolytic therapy with urokinase was begun, and lysis of the thrombus occurred in 72 hours. The patient's renal function returned to baseline, and the transplant was salvaged. Moreover lower extremity venous patency and valvular function were maintained. We report the case and review the literature on thrombolytic therapy for renal allograft vein and lower extremity deep venous thrombosis. (J VASC SURG 1995;21:691-6.)     

Venous anomalies encountered in aortoiliac surgery

Reconstructive procedures of the aortoiliac system are extremely common. Aside from ruptured aneurysms, most severe intraoperative hemorrhage is due to venous injuries. The ability to recognize and manage venous anomalies is essential. This article presents a review of major venous anomalies including (1) transposition of the inferior vena cava, (2) double vena cava, (3) retroaortic left renal vein, (4) circumaortic renal collar, and (5) preaortic iliac venous confluence. Embryologic development, operative recognition, and techniques of operative management are discussed. A case report is presented in which an anomaly similar to a preaortic iliac confluence was discovered during aortic reconstruction for a ruptured abdominal aortic aneurysm. This case differs from previously reported cases of preaortic iliac confluence in that the right common iliac vein persisted in its course anterior to the right common iliac artery.     

一种新型大鼠门腔静脉转位模型的建立

目的探讨一种新型大鼠门腔静脉转位模型建立的可行性。方法大鼠40只,采用袖套法建立同种异体血管门腔静脉转位模型。于左肾静脉末端安装一袖套,将左肾静脉与门静脉残端借袖套连接,贴近左肾静脉上方结扎并剪断下腔静脉,将下腔静脉借同种异体血管及袖套与肠系膜上静脉连接。另取10只大鼠切除左肾后作为对照组。观察术后大鼠的体重、生化指标、核磁共振及其肝脏病理学变化。结果40只大鼠门腔静脉转位后近、远期存活良好,术后24h至2月存活率均为97．50％（39／40）。术后2周核磁共振检查显示血流通畅。与对照组比较,实验组大鼠术后2月白蛋白、谷丙转氨酶、碱性磷酸酶和总胆红素、体重等指标差异均无统计学意义。术后2月肝组织病理检查结果正常。结论采用同种异体血管借助袖套方法建立大鼠门腔静脉转位模型是可行的。     

Catheter-directed therapy for DVT after pancreas transplantation

INTRODUCTION: Iliac vein deep venous thrombosis (DVT) ipsilateral to the pancreas transplant can lead to severe leg edema and compromise graft function. Treatment modalities for iliac vein DVT in the pancreas transplant recipient are limited. METHODS: Medical records of patients receiving pancreas transplants at a single center from November 1989 to July 2003 were reviewed retrospectively, identifying patients with iliac vein DVT. There were 287 pancreas transplants performed during this time. Pancreas transplantation in all recipients was performed in the right iliac fossa with the arterial supply consisting of a donor iliac artery Y interposition graft. Systemic venous drainage was to the iliac vein. Exocrine drainage was enteric or to the bladder. RESULTS: Four (1.4%) cases of iliac DVT were identified. All patients manifested lower extremity edema ipsilateral to the pancreas transplant. DVT was detected by ultrasound on days 4, 5, 13, and 60 post-transplant. In all cases, the iliac vein caudad to the pancreatic venous anastomosis was noted to be stenotic. Management involved balloon dilatation and endovascular stent placement in one patient, thrombolysis with tissue plasma antigen (t-PA) followed by stent placement in one patient, and percutaneous mechanical thrombectomy in two patients. All patients had improvement in leg edema and two patients continue to have good pancreatic allograft function. CONCLUSIONS: Iliac DVT is a rare complication of pancreas transplantation that usually develops in an area of stenosis caudad to the pancreatic venous anastomosis. Catheter-based treatment modalities with use of endovascular stents for treatment of underlying stenoses can serve as an adjunct in treating these complications.     

The importance of the superficial venous anatomy of the abdominal wall in planning a superficial inferior epigastric artery (SIEA) flap: case report and clinical study

The importance of the venous drainage of the anterior abdominal wall to free tissue transfer in deep inferior epigastric artery perforator flap surgery has been highlighted in several recent publications in this journal, however the same attention has not been given to superficial inferior epigastric artery (SIEA) flaps, in which the flap necessarily relies on the superficial venous drainage. We describe a unique case, in which the presence of two superficial inferior epigastric veins (SIEVs) draining into separate venous trunks was identified. The use of only one trunk led to a well-demarcated zone of venous congestion. A clinical study was also conducted, assessing 200 hemiabdominal walls with preoperative computed tomographic angiography imaging. The presence of more than a single major SIEV trunk was present in 80 hemiabdominal walls (40% of overall sides). There was considerable variability in the source of drainage of the SIEV, draining variably into the deep inferior epigastric vein, the great saphenous vein, the saphenous bulb, a common trunk with the superficial circumflex iliac vein or a common trunk with a second branch of the SIEV. These findings highlight the considerable variation in the number of SIEV trunks as well as their source of regional drainage, and show the importance of consideration of such variation.     

Selective approach for venous drainage in right iliac vein and cava vein for combined pancreas-kidney transplantation

In this paper, the authors evaluate if the use of a venous drainage system in the cava vein (instead of the external iliac vein) presents differences in pancreatic transplantation. Between December 2000 and 2004, 105 pancreas-kidney transplants were performed. Patients in group A (n=49) underwent complete liberation of the right iliac vein for venous drainage. In group B (n=56), the venous drainage system was placed in the cava vein or in the confluence. Analyzed clinical parameters included: insulin replacement, vascular thrombosis in the graft, intraabdominal collections, graft loss, reoperation, and deaths. When compared to the external iliac vein, venous drainage to the cava vein did not result in significant differences. Venous drainage to the cava vein is a valuable alternative when the right iliac fossa has been previously approached. It is a practical, rapid procedure and it is not necessary to expose the internal iliac vein.     

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.     

Successful renal transplantation with ipsilateral femoral arteriovenous grafts

BACKGROUND: The choice of location for revascularization of a renal allograft is frequently influenced by the presence of previous pelvic surgery or failed allografts that remain in situ. The presence of polytetrafluoroethylene (PTFE) loop grafts in the femoral vessels may potentially result in iliac venous hypertension, thereby compromising the function of a renal allograft placed nearby. The purpose of this study is to report the hemodynamic changes within the iliac veins as a result of PTFE femoral grafts and report the outcome of renal allografts placed ipsilateral to such grafts. METHODS: THREE patients with a failed renal allograft in the right iliac fossa and functioning left groin PTFE loop grafts underwent left iliac venography and hemodynamic measurements of the iliac venous system. All three patients underwent renal transplantation in the left iliac fossa without ligation or alteration of the loop graft. Standard clinical data were collected after transplantation. RESULTS: All three patients demonstrated widely patent external iliac and common iliac veins ipsilateral to the loop graft. Elevated pressures measured within the venous limb of the loop graft dissipated rapidly within the common femoral and external iliac veins. All three kidneys were well perfused, as documented by posttransplant technetium 99m-diethylenetriaminepentaacetic acid nuclear renography. All three patients have normal renal function past 7 months after transplant, and all three femoral loop grafts are still functioning. CONCLUSIONS: PTFE loop grafts to the femoral vessels are not associated with local venous hypertension in the ipsilateral external iliac veins. Revascularization of a renal allograft may be performed ipsilateral to a femoral loop graft provided other venous diseases, such as strictures, have been excluded.     

Endovascular treatment of obliterative hepatocavopathy with inferior vena cava occlusion and renal vein thrombosis

We describe the endovascular treatment of an occlusion of the inferior vena cava (IVC) due to obliterative hepatocavopathy with renal and iliac vein thrombosis. A 34-year-old man with nephrotic syndrome and hepatic dysfunction presented to the hospital after a 3-month history of lower extremity swelling with an acute deterioration in his condition. Magnetic resonance venography diagnosed a massive IVC occlusion with thrombosis of the entire IVC, iliac veins, and renal vein. He was treated with thrombolysis, and a chronic occlusion of the infrahepatic IVC was discovered. After venous stenting of the IVC and iliac veins, he dramatically improved. After 24 months, he remains symptom-free with a patent IVC and iliac veins.     

Anomalies of Inferior Vena Cava and Left Renal Vein: Risks in Aortic Surgery

Although most aortic surgery is now routinely performed without incident, major venous anomalies can cause unexpected bleeding. In the last 6 years, 4 of 166 patients undergoing abdominal aortic surgery at our institution were found to have a major venous anomaly, including a double inferior vena cava (2), a preaortic iliac vein confluence (1), and a circumaortic renal collar (1). The 3 men and 1 woman had a mean age of 62.3 years (range, 56 to 68 years). All four patients underwent surgery for an abdominal aortic aneurysm. Preoperative imaging revealed all of the venous anomalies except for the renal collar. Unexpected venous injuries complicated the operation in one patient who had a double inferior vena cava and an inflammatory abdominal aortic aneurysm and in the patient with the circumaortic renal collar. Major venous anomalies are rarely encountered in patients undergoing aortic surgery. Preoperative assessment and intraoperative awareness are important to prevent unexpected venous injuries. Patients with an anomaly of the left renal vein and an inflammatory abdominal aortic aneurysm are at a particularly high risk.     

Palma Procedure for Acute Intraabdominal Major Venous Injury

We report a patient with multiple vascular injuries, including a ruptured anterior wall of inferior vena cava at the point of bifurcation, a ruptured anterior and posterior wall of left external iliac vein, ruptured urinary bladder and ligated left common iliac artery immediately proximal to the origin of internal iliac artery. These injuries were caused iatrogenically at the time of hysterectomy due to treat massive vaginal bleeding due to placenta previa and accreta. Due to the complexity of the injuries, a staged management was used in the treatment of this patient. First stage consisted of bleeding control and patient stabilization. Second stage of management consisted of definitive arterial and venous reconstruction by endovascular and vascular surgery intervention, which included a left femoral vein thrombectomy and a Palma procedure to restore venous drainage of the left extremity.