Arterial reconstruction using the donor's gonadal vein in living renal transplantation with multiple renal arteries: a case report and a literature review

Abstract

Background: Arterial reconstruction is one of the paramount procedures in kidney transplantation (KT) and greatly important if the procured kidney has multiple renal arteries (MRA). Despite various established techniques for arterial reconstruction, sometimes, the surgeon finds performing arterial anastomoses challenging in case of MRA. In our case, the donor's gonadal vein and recipient's internal iliac artery graft were used for arterial anastomoses, and 3 years after KT, the allograft did not present vascular complications.

Case presentation: A 34-year-old man underwent ABO-incompatible preemptive living KT. The allograft had three renal arteries and four renal veins. After donor nephrectomy, arterial reconstruction was performed on a back table. These arteries were reconstructed into one piece using the recipient's internal iliac artery graft. The two arteries at the middle of the renal hilum were reconstructed using the conjoined method. As the superior renal artery was too short to anastomose, the donor's gonadal vein was used for extension. The internal iliac artery graft was anastomosed to the original internal iliac artery. Intraoperative Doppler ultrasonography revealed that the blood flow in each renal artery was adequate, resulting in sufficient blood flow throughout the allograft. The allograft function was maintained with a serum creatinine level of approximately 0.9 mg/dL without vascular complications 3 years after KT.

Conclusions: The donor's gonadal vein can be a candidate for extension of the renal artery in the allograft with MRA. Further follow-up is needed for the assessment of long-term outcomes.

Keywords: Arterial reconstruction; Case report; Gonadal vein; Kidney transplantation; Multiple arteries.

Fig. 1

Three-dimensional computed tomography images and schemas of the renal blood vessels. Three renal arteries branched from the aorta, and the superior and middle arteries (1, 2) branched into two arteries (1-1, 1-2, 2-1, 2-2) (a). The renal arteries were cut at the dotted line (b). The superior artery was cut distal to the branch point due to bleeding. Four renal veins branched from the vena cava (c). The two veins at the middle (2, 3) were cut simultaneously with the vena cava wall (d)

Fig. 2

Schema and image of reconstruction of the renal blood vessels. The two arteries at the middle of the renal hilum were reconstructed using the conjoined method, and the superior renal artery was lengthened using the donor’s gonadal vein (a). The renal arteries were reconstructed into one using the internal iliac artery graft (b). The superior two veins (1, 2) were reconstructed using the end-to-end method (c). d Representative images of the reconstruction. The yellow arrow shows the gonadal vein graft. The internal iliac artery graft was anastomosed to the original internal iliac artery (e), and the renal veins were anastomosed to the external iliac and gonadal veins (f)

Fig. 3

Representative images of the allograft obtained by Doppler ultrasonography (a, postoperative day 10; b, 1 year post-transplantation; c, 2 years post-transplantation; d, 3 years post-transplantation)