Renal artery reconstruction for harvesting injuries in kidney transplantation with particular reference to the use of vascular allografts

Abstract

At the University of Pittsburgh during the calendar year 1986, an arterial injury occurred during harvesting in 20 (7.5%) of the 270 grafts used to perform kidney transplantation (KTx). Four cases required reconstruction, using extension iliac arterial allografts from cadaveric donors of the same blood type; 6 patients, remodelling of the aortic patch in multiple arteries; 4 cases, repairs for injuries to the smaller segmental/polar arteries; 6 cases, a combination of the above techniques. These ex vivo arterial reconstructions are described and the use of donor arterial homografts is emphasized. No deaths have occurred at an average follow-up of 19 months. The postoperative acute tubular necrosis (ATN) rate was significantly higher (90%) compared with non-reconstructed kidneys during the same year (30%). The 1-year graft survival of kidneys undergoing arterial reconstruction (75%) was statistically no different than the overall kidney-transplant survival. Whenever extension iliac allografts were utilized, the cyclosporin-steroid immunosuppression required to control the kidney rejection contributed to the long-term patency rate of the graft. Since the number of organs available for grafting is limited, reconstruction of injured renal vessels has become justified, allowing valuable kidneys to be used that would otherwise be lost.

Fig. 1

Extension of single renal artery using a donor external iliac graft

Fig. 2

Remodeling of the aortic patch in a double-artery kidney

Fig. 3a, b

Repair of injuries to segmental artery, a Direct repair and b reimplantation into a larger renal vessel

Fig. 4a, b

Repair of injuries of segmental artery with a side-to-side “conjoined” anastomosis a with the hypogastric artery and b with a donor vascular graft

Fig. 5

Combined reconstruction techniques

Fig.6

Extensive arterial reconstruction using aortoiliac homografts. Arteriogram: the first graft replaces the aortic bifurcation, the second bridges the right iliac system, and the third is used to connect the donor renal artery previously injured. In addition, a right femoropopliteal bypass with a reversed autologous saphenous vein graft was needed distally. All anastomoses and vessels are patent 12 months after the kidney transplant. Immunosuppression with cyclosporin and steroid