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. 2022 Apr 14:35:10212.
doi: 10.3389/ti.2022.10212. eCollection 2022.

Creating a Single Inflow Orifice From Living Donor Kidney Allografts With Multiple Renal Arteries

Marina M Tabbara  1   2 , Giselle Guerra  3   2 , Juliano Riella  1   2 , Phillipe Abreu  1   2 , Angel Alvarez  2 , Rodrigo Vianna  1   2 , Linda Chen  1   2 , Mahmoud Morsi  1   2 , Jeffrey J Gaynor  1   2 , Javier Gonzalez  4 , Gaetano Ciancio  1   2   5
Affiliations

Creating a Single Inflow Orifice From Living Donor Kidney Allografts With Multiple Renal Arteries

Marina M Tabbara et al. Transpl Int. .

Abstract

Background: Multiple renal arteries (MRA) are often encountered during living-donor kidney transplantation (LDKT), requiring surgeons to pursue complex renovascular reconstructions prior to graft implantation. With improvements in reconstruction and anastomosis techniques, allografts with MRA can be successfully transplanted with similar outcomes to allografts with a single renal artery. Here, we describe in detail various surgical techniques for reconstruction of MRA grafts with the intent of creating a single arterial inflow. Methods: We retrospectively reviewed the medical records of all LDKT recipients with laparoscopically procured MRA kidneys between March 2008 and July 2021. Recipient and donor characteristics, operative data, type of reconstruction, and recipient outcomes were analyzed. The primary outcomes were the incidence of developing delayed graft function (DGF) and/or a vascular or urological complication within 12 months post-transplant. Results: Seventy-three LDKT recipients of MRA donor allografts were evaluated. Two renal arteries (RA) were encountered in 62 allografts (84.9%) and three RA in 11 allografts (15.1%). Renal artery reconstruction was performed in 95.8% (70/73) of patients. Eighteen different reconstruction techniques of MRA were utilized, the most common being side-to-side anastomosis in allografts with two RA (N = 44) and side-to-side-to-side anastomosis in allografts with three RA (N = 4). Interposition grafting was performed in seven cases (9.6%). A single ostium was created in 69 cases (94.5%), and the median warm ischemia time was 27 (range 20-42) minutes. None of the patients developed DGF or post-operative vascular or urological complications. Median creatinine at 3, 6, and 12 months post-transplant remained stable at 1.1 mg/dl. With a median follow-up of 30.4 months post-transplant, only one graft failure has been observed-death-censored graft survival was 98.6%. Conclusion: Complex reconstruction techniques to create a single renal artery ostium for graft implantation anastomosis in allografts with MRA show acceptable warm ischemic times, with no increased risk of post-operative vascular or urological complications.

Keywords: kidney allografts; living donors; multiple renal blood vessels; renal transplantation; surgical innovation.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

FIGURE 1
FIGURE 1
Conjoined anastomosis techniques. (A) Single ostium side-to-side anastomosis. (B) Single ostium side-to-side-to-side anastomosis.
FIGURE 2
FIGURE 2
Techniques for grafting a main RA and an accessory pole artery. (A) UPRA anastomosed end-to-side to main RA. (B) LPRA anastomosed end-to-side to main RA. (C) Short UPRA anastomosed end-to-side to a branch of the main RA. (D) Short LPRA anastomosed end-to-side to a branch of the main RA. (E) Short LPRA anastomosed end-to-side to a branch of the main RA inside the hilum.
FIGURE 3
FIGURE 3
Creation of a single inflow orifice for grafts with 3RA. (A) Two main RA conjoined side-to-side and UPRA anastomosed end-to-side to the upper main RA. (B) LPRA conjoined in a single lumen with the main RA, and short middle RA anastomosed end-to-side to the upper branch of the main RA. (C) Two RA conjoined side-to-side in a single lumen and short UPRA anastomosed end-to-side to a branch of the upper renal artery inside the hilum. (D) Short UPRA anastomosed end-to-side to a branch of the main RA inside the hilum, and the LPRA was anastomosed end-to-side to main RA.
FIGURE 4
FIGURE 4
Creation of two separate anastomoses for implantation. (A) Short LPRA (8 cm from the main RA) anastomosed end-to-end to the recipient inferior epigastric artery. (B) Two RA were conjoined in a single lumen and the LPRA (7 cm from the 2 RA) anastomosed end-to-end to the recipient ipsilateral inferior epigastric artery.
FIGURE 5
FIGURE 5
Interposition grafting. (A) Segment of recipient inferior epigastric artery anastomosed end-to-end to the short UPRA, and then anastomosed side-to-side to the main RA. (B) Segment of recipient inferior epigastric artery anastomosed end-to-end to the short UPRA, and then anastomosed end-to-side to the main RA. (C) Segment of recipient internal iliac artery anastomosed end-to-end to the two main RA, and the short UPRA anastomosed end-to-side to one of the main RA. (D) Segment of deceased donor external iliac artery anastomosed end-to-end to two short RA conjoined in a single lumen. (E) Short UPRA extended with a segment of donor gonadal vein, then anastomosed end-to-side to the one of the 2 main RA that were conjoined in single ostium.
FIGURE 6
FIGURE 6
(A) LPRA (white arrow) anastomosed side-to-side the main RA with 8–0 Prolene, middle RA anastomosed end-to-side to the main RA (black arrow) with 8–0 Prolene. (B) LPRA (white arrow) anastomosed end-to-side to the main RA with 8–0 Prolene. The UPRA was short, so it was anastomosed end-to-side to one of the branches of the main RA inside the hilum. (C) UPRA anastomosed end-to-end to the donor gonadal vein with 8–0 Prolene, then end-to-side with 8–0 Prolene to the main RA (white arrow). The 2 RA were conjoined side-to side with 8–0 Prolene (black arrow).
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