Images in Vascular Surgery
A Forgotten Vascular Technique in Renal Transplantation
Vascular and Endovascular Surgery 2014, Vol. 48(3) 281-282 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574413518116 ves.sagepub.com
Alex Barlas, MD1, Demetrios Moris, MD1, John Bokos, MD1, and Georgios Zavos, MD, PhD1 Keywords renal transplantation, Carrel patch, multiple arteries, shorten an aortic patch, surgical techniques, neo-patch
Vascular Image A 33-year-old man (end-stage renal disease due to Alport syndrome) received a right kidney from a 37-year-old dead female donor, with 3 arteries on a Carrel patch, a single vein, and a single ureter (Figure 1). The renal vein was anastomosed to the external iliac vein in the conventional end-to-side fashion. Because renal vein was short, venoplasty was previously performed to extend the renal vein that was explanted along with vena cava. Accessory superior pole renal artery had a diameter less than 1 mm and was ligated (Figure 1). The distance between the main renal artery and the inferior pole renal artery was above 2.5 cm, so we decided to shorten the patch instead of proceeding in 2 separate arterial anastomoses (Figure 2). The aortic patch was anastomosed to the external iliac artery in the conventional end-to-side fashion (Figure 3). On clamp release, there was good hemostasis and the kidney perfused well (video). The ureter was implanted to the bladder with an onlay-extravesical ureteroneocystostomy using a double-J stent for ureter. The anastomosis time was 27 minutes and the total operation time was 2 hours. The patient was
Figure 2. An illustration of the technique of ‘‘neo-patch.’’
discharged on the 12th postoperative day, with no immediate complications. Multiple renal arteries in renal transplantation can cause an increased risk of complications such as longer operative times
1
Transplantation Unit, Athens University School of Medicine, ‘‘Laikon’’ General Hospital, Athens, Greece
Figure 1. Preparing renal graft at the back table.
Corresponding Author: Demetrios Moris,Transplantation Unit, Athens University School of Medicine, ‘‘Laikon’’ General Hospital, Anastasiou Gennadiou 56, 11474, Athens, Greece. Email: [email protected]
282
Vascular and Endovascular Surgery 48(3) patch to shorten its length in a manner not to stretch the arteries, which may lead to narrowing of the lumen and increase the risk of dissection of the endothelium and subsequent arterial and graft thrombosis on the recipient.2 This technique is described and illustrated in the literature2 but still lacks wide application in clinical practice. To our knowledge, this is the first case of intraoperative presentation of the shortening of Carrel patch to deal with multiple arteries. Authors’ Note Alex Barlas and Demetrios Moris equally contributed to this work. Informed consent was obtained for this study.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Figure 3. The shortened patch after its anastomosis to external iliac artery.
because of more complicated dissection that makes the need for back-table vascular reconstruction imperative. In donors with multiple arteries, 2 arteries should be unified as a single artery via trouser-like stenting, if possible (artery diameter >3 mm), and used as a single anastomosis in the recipient with the smaller graft artery to be anastomosed end-to-side to the larger one.1 Otherwise, there can be 2 separate anastomoses performed on the internal iliac and the external iliac arteries.1 If they are more than 2 cm apart, consideration could be given to perform 2 separate anastomoses or to proceed to segmental resection of the
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental Material The online video is available at http://ves.sagepub.com/supplemental.
References 1. Hwang JK, Kim SD, Park SC, et al. The long term outcomes of transplantation of kidneys with multiple renal arteries. Transplant Proc. 2010;42(10):4053-4057. 2. Kahan BD, Ponticelli C. Surgical Principles of the Operation. In: Principles and Practice of Renal Transplantation. London: Martin Dunitz Ltd; 2000:191-218.
A Forgotten Vascular Technique in Renal Transplantation
Vascular and Endovascular Surgery 2014, Vol. 48(3) 281-282 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574413518116 ves.sagepub.com
Alex Barlas, MD1, Demetrios Moris, MD1, John Bokos, MD1, and Georgios Zavos, MD, PhD1 Keywords renal transplantation, Carrel patch, multiple arteries, shorten an aortic patch, surgical techniques, neo-patch
Vascular Image A 33-year-old man (end-stage renal disease due to Alport syndrome) received a right kidney from a 37-year-old dead female donor, with 3 arteries on a Carrel patch, a single vein, and a single ureter (Figure 1). The renal vein was anastomosed to the external iliac vein in the conventional end-to-side fashion. Because renal vein was short, venoplasty was previously performed to extend the renal vein that was explanted along with vena cava. Accessory superior pole renal artery had a diameter less than 1 mm and was ligated (Figure 1). The distance between the main renal artery and the inferior pole renal artery was above 2.5 cm, so we decided to shorten the patch instead of proceeding in 2 separate arterial anastomoses (Figure 2). The aortic patch was anastomosed to the external iliac artery in the conventional end-to-side fashion (Figure 3). On clamp release, there was good hemostasis and the kidney perfused well (video). The ureter was implanted to the bladder with an onlay-extravesical ureteroneocystostomy using a double-J stent for ureter. The anastomosis time was 27 minutes and the total operation time was 2 hours. The patient was
Figure 2. An illustration of the technique of ‘‘neo-patch.’’
discharged on the 12th postoperative day, with no immediate complications. Multiple renal arteries in renal transplantation can cause an increased risk of complications such as longer operative times
1
Transplantation Unit, Athens University School of Medicine, ‘‘Laikon’’ General Hospital, Athens, Greece
Figure 1. Preparing renal graft at the back table.
Corresponding Author: Demetrios Moris,Transplantation Unit, Athens University School of Medicine, ‘‘Laikon’’ General Hospital, Anastasiou Gennadiou 56, 11474, Athens, Greece. Email: [email protected]
282
Vascular and Endovascular Surgery 48(3) patch to shorten its length in a manner not to stretch the arteries, which may lead to narrowing of the lumen and increase the risk of dissection of the endothelium and subsequent arterial and graft thrombosis on the recipient.2 This technique is described and illustrated in the literature2 but still lacks wide application in clinical practice. To our knowledge, this is the first case of intraoperative presentation of the shortening of Carrel patch to deal with multiple arteries. Authors’ Note Alex Barlas and Demetrios Moris equally contributed to this work. Informed consent was obtained for this study.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Figure 3. The shortened patch after its anastomosis to external iliac artery.
because of more complicated dissection that makes the need for back-table vascular reconstruction imperative. In donors with multiple arteries, 2 arteries should be unified as a single artery via trouser-like stenting, if possible (artery diameter >3 mm), and used as a single anastomosis in the recipient with the smaller graft artery to be anastomosed end-to-side to the larger one.1 Otherwise, there can be 2 separate anastomoses performed on the internal iliac and the external iliac arteries.1 If they are more than 2 cm apart, consideration could be given to perform 2 separate anastomoses or to proceed to segmental resection of the
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental Material The online video is available at http://ves.sagepub.com/supplemental.
References 1. Hwang JK, Kim SD, Park SC, et al. The long term outcomes of transplantation of kidneys with multiple renal arteries. Transplant Proc. 2010;42(10):4053-4057. 2. Kahan BD, Ponticelli C. Surgical Principles of the Operation. In: Principles and Practice of Renal Transplantation. London: Martin Dunitz Ltd; 2000:191-218.
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