Living Related Renal Transplantation Using a Saphenous Vein Graft: A Case Report

We report a case of living related renal transplantation that used the recipient's saphenous vein as a graft to extend the length of the right donor renal vein.A 41-year-old woman underwent ABO-incompatible living related renal transplantation from her 74-year-old mother in November 2014.A retroperitoneal laparoscopic right donor nephrectomy was performed, because the right kidney showed a cyst on preoperative computed tomography.As the right kidney after donor nephrectomy had a short renal vein and the kidney was large at 280 g, anastomosis with the external iliac vein was difficult. Therefore, we obtained the recipient's 15-cm-long right saphenous vein and created a 1 cm saphenous vein graft. We anastomosed 1 side of the saphenous vein graft to the allograft renal vein in bench surgery and performed end-to-side anastomosis of the other end to the recipient's external iliac vein. The allograft renal artery was used to perform end-to-end anastomosis to the recipient's internal iliac artery. Allograft kidney function was good after transplantation.When the longer axis of the renal graft vein is short, as in the right kidney, a saphenous vein graft may be useful.     

The use of the hypogastric artery in the anastomosis of multiple renal arteries in the transplant patient

Abstract. Alternative techniques for handling multiple renal vessels in living related kidney transplants by use of the hypogastric artery are presented. This vessel can be used either as a tubular vascular graft or as a Carrel patch graft. Details of these techniques are discussed.     

The use of the hypogastric artery in the anastomosis of multiple renal arteries in the transplant patient

Alternative techniques for handling multiple renal vessels in living related kidney transplants by use of the hypogastric artery are presented. This vessel can be used either as a tubular vascular graft or as a Carrel patch graft. Details of these techniques are discussed.     

Occluded persistent sciatic artery

The case of a patient with ischemic symptoms due to occlusion of a persistent left sciatic artery is presented. Femoral arteriography revealed a tapering hypoplastic superficial femoral artery terminating as small branches in the distal thigh and a hyperplastic profunda femoris artery. Also, translumbar aortography demonstrated an abrupt occlusion of a hyperplastic left hypogastric artery just distal to the inferior gluteal artery. The popliteal artery was found to be patent and perfused by collaterals. A bypass graft using a composite E-PTFE prosthesis and an autogenous vein graft was successfully performed.     

Kidney transplantation in patients with end stage congenital renal disease: Report of eighteen cases and review of the organ transplant registry

Eighteen patients with end stage congenital renal disease requiring kidney transplantation constituted 12 per cent of the transplantation recipients at this institution over the past six years. The post-transplantation course in this group was remarkably satisfactory, with a 94 per cent graft survival at three years. In addition, we analyzed survival data from over 9,900 patients in the Organ Transplant Registry and demonstrated that transplant recipients with end stage congenital renal disease have equal or better five year patient survival compared with those with acquired end stage renal disease. Only those patients with adult polycystic disease had a less satisfactory prognosis, probably because of age-related factors. In contrast, there were few statistical correlations between renal allograft survival, age, and original disease.     

活体肾移植供肾多支血管处理的体会

目的探讨活体肾移植供肾多支血管的处理及重建方法。方法 49例供体,供肾有多支动脉变异45例,有多支静脉变异7例,其中3例为肾动脉、静脉同时多支血管变异。供肾切取术中,对于供血面积直径小于3cm且影响操作的分支动脉,术中即予结扎、离断;多支静脉,如直径为主干的1/3以下且试夹闭该静脉未发现明显淤血等血液回流障碍者,给予结扎、离断。5例采用体外血管重建。受体肾移植术中根据分支动脉管径、长度及位置及受者髂动脉和腹壁下动脉的情况等综合条件来选择受者相应的动脉吻合。结果 48例动脉分支吻合者在开放血流后搏动良好、吻合口通畅,术后1～7d内肾功能恢复正常、术后1～2周彩色多普勒超声检查,提示该分支动脉供血区域丰富。肾静脉分支结扎者未发现淤血现象。1例高龄供肾者发生肾功能延迟恢复。术后无出血、肾动脉栓塞、尿瘘、输尿管坏死和新发高血压等并发症。结论正确处理移植肾多支血管变异,可获得良好移植效果。     

Autogenous arterial bypass grafts: durable patency and limb salvage in patients with inframalleolar occlusive disease and end-stage renal disease

OBJECTIVE: The purposes of this study were to determine whether autogenous arterial grafts to distal pedal arteries improve the patency of grafts and limb salvage in patients with end-stage renal disease and nonhealing ischemic wounds and to better define the indications for autogenous arterial grafts. DESIGN: A review of consecutive patients with end-stage renal disease undergoing autogenous arterial grafts from 1994 through 1999 was carried out. The setting was a university hospital. All 11 patients with end-stage renal disease and nonhealing, ischemic wounds (stage IV SVS-ISCVS classification) undergoing autogenous arterial grafting from 1994 to 1999 were evaluated. Noninvasive studies confirmed inadequate perfusion pressures in all patients. Pre-bypass arteriography identified no major arteries patent at the level of the malleolus, with reconstitution of only a distal or branch pedal or plantar vessel less than 1 mm in diameter. Five patients with patent tibial vessels to just above the ankle underwent bypass surgery with autogenous arterial grafts alone. Six patients also had proximal occlusive disease that required grafts longer than the autogenous arterial grafts; in each of these six patients, an autogenous vein graft proximal to the autogenous arterial graft was placed through use of a composite technique. Inflow was from the common femoral artery in one patient, the popliteal artery in five patients, and a tibial artery in five patients. Outflow was to the medial plantar artery in five patients, the distal dorsalis pedis artery in three patients, the lateral plantar artery in two patients, and the superficial arch in one patient. The conduit was the subscapular artery in four patients, the deep inferior epigastric artery in four patients, the superficial inferior epigastric artery in two patients, and the radial artery in one patient. The main outcome measures were assisted primary graft patency and functional limb salvage rate. RESULTS: Follow-up ranged from 6 to 63 months (mean, 20 months); graft patency was determined by means of duplex scanning. All 11 patients are alive, and nine grafts are patent, including three after revision for graft stenosis. Assisted primary patency was 82% at 3 years. All nine patients with patent grafts remained ambulatory and had healed wounds or limited forefoot amputations. CONCLUSION: Autogenous arterial grafts were effective in treating limb-threatening ischemia in patients with end-stage renal disease and inframalleolar arterial insufficiency. Graft patency and limb salvage rates were higher than those reported for autogenous vein graft in these patients. Autogenous arterial grafting may therefore prove to be an effective alternative to autogenous vein grafting in selected patients.     

Long-term results of renal artery reconstruction with autogenous artery in patients with renovascular hypertension

Renal artery reconstruction for the treatment of renovascular hypertension is preferably performed with an autologous graft when a graft is required. Although satisfactory results with vein grafts have been reported, stenosis and dilatation are not infrequent complications which have been observed only occasionally in arterial grafts. We have analysed our long-term results obtained with autogenous arterial grafts for renal artery reconstruction to determine the functional and anatomical results with regard to these complications. The data from 57 survivors operated on from 1959 through 1983 were analysed. All patients were hypertensive and the average systolic and diastolic blood pressure was 173/109 mmHg (mean number of 2.2 drugs). The renal artery stenosis was caused by arteriosclerosis and fibrodysplasia in 24 and 33 patients, respectively. In situ repair was performed in 30 patients (arterial bypass: 17 patients; splenorenal bypass: 13 patients). Extracorporeal repair of fibrodysplastic branch lesions was performed in 27 patients using branched hypogastric artery grafts (mean number of 2.4 branch anastomoses per kidney). Results were evaluated in the short (mean 8.3 months) and long term (mean 7.5 years) and the blood pressure response classified as either beneficial (cured/improved) or failed. Anatomical results were evaluated by angiography in the short-term in 87% of the patients and the long-term in 70%. A beneficial blood pressure response was obtained in 77% and 86% of patients in the short and long-term, respectively. The average blood pressure level after an interval of several years (long term) was 144/87 mmHg (mean number of 0.9 antihypertensive drugs). After in situ reconstruction, 2 and 1 anatomical failures were observed in the short and long-term, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Angioplasty for the intimal dissection of graft artery immediately after blood reflow: a successful case of renal transplantation

A 58-year-old woman, who had been suffering from chronic renal failure on hemodialysis since 1999, underwent living renal transplantation on January 14, 2003. The donor was her husband, and his left kidney was resected by a hand-assisted retroperitoneoscopic technique. Vascular clamps were removed after vascular anastomoses, but the color of two-thirds of the graft back side was dark, and urine excretion was not observed for 1 hour. The intimal dissection of the graft artery developed false lumen that occluded the blood flow to the transplanted kidney. The graft was resected from the recipient, and an angioplasty was performed for the false lumen of the graft artery after the second cold preservation. The graft with repaired artery was re-transplanted, and urine excretion was observed immediately after operation. Total ischemia time was 5 hours. Clinicopathological acute rejection episode and stenosis of graft artery did not occur for 6 months after operation. The intimal dissection of graft artery might occur at the time of catheterization on the perfusion for cold preservation and/or vascular anastomosis.     

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。     

Short- and long-term outcomes of kidney transplants with multiple renal arteries.

OBJECTIVE: The authors determined whether the use of kidney allografts with multiple renal arteries adversely effects post-transplant graft and patient outcome or increases the incidence of vascular and urologic complications. BACKGROUND: Kidney grafts with multiple renal arteries have been associated with an increased incidence of early vascular and urologic complications. Kidney transplants with single versus multiple renal arteries have not been compared in regard to long-term graft and patient outcome or post-transplant incidence of hypertension, acute tubular necrosis, rejection, and late vascular and urologic complications. METHODS: We analyzed 998 adult kidney transplants done from December 1, 1985 through June 30, 1993, in which only the recipient's external or internal iliac artery was used for anastomosis. We divided the study population into 3 groups: Group A-1 renal artery, 1 arterial anastomosis (n = 835), Group B-->1 renal artery, 1 arterial anastomosis (n = 112), Group C-->1 renal artery, > 1 arterial anastomosis (n = 51). We compared the incidence of post-transplant hypertension, acute tubular necrosis, acute rejection, and vascular and urologic complications; mean creatinine levels at 1, 3, and 5 years post-transplant; and patient and graft survival. Univariate and multivariate analyses were done to identify risk factors for vascular complications. RESULTS: We found no significant differences among the three groups for the following variables: post-transplant hypertension, acute tubular necrosis, acute rejection, creatinine levels, early vascular and urologic complications, and graft and patient survival. In kidneys with single arteries, the presence (vs. absence) of an aortic patch and the type of the arterial anastomosis (end-to-end to the hypogastric vs. end-to-side to the external iliac artery) did not have an impact on the incidence of early or late vascular complications. In kidneys with multiple arteries, only the rate of late renal artery stenosis was higher, the rate of early vascular and urologic complications was not different. Our multivariate analysis identified acute tubular necrosis as a risk factor for renal artery and vein thrombosis; graft placement on the left side for arterial thrombosis; and preservation time > or = 24 hours and multiple renal arteries for renal artery stenosis. CONCLUSIONS: Results of kidney transplants using allografts with multiple versus single arteries are similar.     

Donors with renal artery stenosis: fit to donate

Kidney donation from hypertensive donors is now an accepted norm in live related kidney transplantation. The use of hypertensive donors with renal artery stenosis due to atherosclerosis and fibromuscular dysplasia is still debated. The prime concern is about the deleterious effect of hypertension on the donor and the risk of recurrence of such lesions in the solitary kidney. Even as the response of atherosclerotic renal artery stenosis to revascularisation is unpredictable, there is an improvement in blood pressure following revascularisation of kidneys with fibro-muscular dysplasia. The first use of such kidney donors was reported in 1984 and, since then, there have been a few reports of successful use of kidneys from donors with renal artery stenosis. We report here two interesting cases of successful transplantation of kidneys from live related kidney donors with hypertension due to renal artery stenosis who became normotensive with good graft function in the recipient. We conclude that moderately hypertensive donors with renal artery stenosis are fit to donate.     

Renal allograft torsion associated with prune-belly syndrome

We report a 26-month-old child diagnosed with prune-belly syndrome and end-stage renal disease who received intraperitoneal implantation of an adult cadaveric renal graft which functioned very well for approximately 6 weeks. The patient then presented with acute renal failure which was proved to be secondary to torsion of the graft, twisting the artery and vein. The ureter was wrapped 360° around the graft. These conditions resulted in loss of the graft and nephrectomy. Ours is the second report of such an occurrence; the first was from a living-related kidney donor. We believe the lack of abdominal wall tone contributes to graft mobility and risk of torsion of the kidney. We recommend that nephropexy be considered in these patients. In addition, the risk of torsion must be at the forefront of the differential diagnosis in a prune-belly renal transplant patient with acute onset of oliguria. Renal sonorgraphy with Doppler should be employed as soon as possible so that the graft can be saved.     

Maximizing renal artery length in right laparoscopic donor nephrectomy by retrocaval exposure of the aortorenal junction

Laparoscopic donor nephrectomy (LDN) has become the standard of care at increasing numbers of renal transplant programs worldwide. As in open donor nephrectomy, the left kidney has remained the preferred organ for LDN because of the greater renal vessel lengths. Currently, the overwhelming majority of donor operations are performed on the left kidney. This disparity may be due to an unfamiliarity with the technique of right LDN and technical difficulties encountered in obtaining adequate arterial and venous vessel lengths. Modifications in the laparoscopic technique have increased the length of the renal vein obtained from either side; however, further techniques are needed to maximize the length of the right renal artery in LDN. Herein the authors present a technique to provide exposure of the right aortorenal junction that provides maximal length of the right renal artery. This technique has currently been used in 20 consecutive right LDN operations without vascular complications or technical graft losses.     

Successful Kidney Transplantation Using a Deceased Donor Graft With Fibromuscular Dysplasia

All over the world there is serious concern about the shortage of organs available for transplantation. In an effort to address this, transplantation with grafts, which was previously considered a contraindication, are now performed. In some cases, this practice has contributed to increasing the organ pool. Fibromuscular dysplasia (FMD) is the second-most-common cause of renovascular hypertension and is observed in 2%–6.6% of potential live kidney donors. Kidney with FMD is generally considered to be a contraindication for renal transplantation because renal artery stenosis may progress after transplantation and cause graft loss. Here, we report on a successful case of kidney transplantation using a graft with FMD of a deceased donor who had multiple aneurysms in the renal artery.     

Aortobisiliac Bypass Using a Venous Homograft Concomitant With Kidney Transplantation in a Patient With Severe Bilateral Iliac Occlusive Disease: A Case Report

Aortoiliac occlusive disease (AOD) is a great threat for kidney transplantation (KT). Here we report the case of an aortoiliac bypass, performed simultaneously with renal transplantation using venous grafts obtained from the deceased donor. The recipient was a 68-year-old woman with significant stenosis of the aortoiliac axis. We performed an aortobisiliac bypass using donor’s femoral veins because presence of methicillin-resistant Staphylococcus aureus was detected on donor hemoculture and contraindicated a prosthetic implant on the recipient. KT was then carried out using standard technique. Operative time amounted to 330 minutes and cold ischemia time of the renal graft was 900 minutes. Delayed graft function was observed until postoperative day 12, but the patient showed a good urine output and a serum creatinine of 2.1 mg/dL at discharge. AOD is not an absolute contraindication to renal transplantation, and simultaneous surgical repair of aortoiliac lesions with KT seems feasible. The patient’s return to function after initial delayed graft function suggests that such interventions may allow transplantation to be offered to those patients who otherwise may be excluded for severe vascular comorbidities. Homologous vascular grafts are an excellent choice because prosthetic vascular replacement during immunosuppression must be avoided as long as possible, especially in patients with coexisting infective risk.     

Isolated bilateral renal artery thrombosis: an unusual consequence of blunt abdominal trauma--case report

Bilateral renal artery thrombosis with anuria following blunt abdominal trauma is distinctly unusual. We report a 16-year-old female in whom emergency revascularization with a primary reimplantation on the right and a hypogastric artery interposition graft on the left was performed following angiographic documentation of bilateral renal artery occlusion. Excellent renal function was demonstrated bilaterally at 7 weeks. Bilateral renal revascularization is feasible in the acute setting and can yield excellent results.     

Renal artery stenosis: a complication of needle puncture for manometry. Case of subintimal dissection with spontaneous resolution.

After aortorenal bypass for renovascular hypertension secondary to atherosclerosis of the renal artery of a solitary left kidney a high-grade stenosing lesion developed distal to the site of insertion of a Dacron graft. In the immediate postoperative period the blood pressure was restored to normal, but one week later hypertension recurred. An arteriogram disclosed an area of stenosis 1 cm distal to the site of insertion of the graft in the renal artery. During the next year, serial arteriograms were made, renal function remained normal, and hypertension gradually abated. One year after the discovery of the postbypass stenosis, an arteriogram showed disappearance of the constricting lesion. The postoperative stenosis was, in all probability, caused by subintimal dissection secondary to needle puncture for strain gauge manometry.     

Fibromuscular dysplasia in donor kidneys — experience with three cases

In 1987, three patients received kidney grafts bearing medial fibroplasia at our hospital. Two of the grafts were from a cadaveric donor and one was from a living related donor kidney. The vascular affection was known before transplantation. Only one of the recipients developed stenosis and hypertension. With balloon catheter dilatation, the progressive stenosis of the renal graft artery could, however, be successfully corrected.     

Fibromuscular dysplasia in donor kidneys - experience with three cases

Abstract. In 1987, three patients received kidney grafts bearing medial fibroplasia at our hospital. Two of the grafts were from a cadaveric donor and one was from a living related donor kidney. The vascular affection was known before transplantation. Only one of the recipients developed stenosis and hypertension. With balloon catheter dilatation, the progressive stenosis of the renal graft artery could, however, be successfully corrected.