Bridging of renal arteries: a simple technique for the management of double arteries in living donor renal allograft transplantation
Article Outline
Renal allografts represent an established treatment modality for patients with end-stage renal disease. With the widening gap between the demand and availability for organs, it is important to be able to use every vital organ irrespective of the vascular anatomy. Living donor renal transplantation has a definite edge over cadaveric organ donation in graft survival rates. In developing countries, the major sources of organs are living donors who are screened preoperatively to use organs with simple vascular anatomy. However, often there is only one potential donor available in about 15% of cases bilateral multiple renal arteries are encountered.1 Surgical acumen requires development of innovative and simple techniques to improve outcomes in these cases.
Multiple renal arteries no longer present a surgical dilemma and have been successfully used without increased intraoperative or post-operative complications.2 We have highlighted our experience in 16 renal allografts with double renal arteries which have been managed with a bridging of renal arteries technique as an alternative to the classical double-barrelling technique.
Material and methods
Living renal allografts donors were evaluated preoperatively using magnetic resonance imaging or ultra-fast multi-slice computed tomography. The organ with a single renal artery was preferably chosen, but in the cases with bilateral multiple vessels, the organ with the lesser number of arteries or the left kidney was harvested. Since March 2001, bridging of renal arteries and their subsequent anastomosis to the external iliac artery (EIA) has been the preferred technique for implanting living-related donor kidneys with double renal arteries of almost equal caliber that are not too far apart. Before the adoption of this technique, the age old double barrelling of arteries was the common method of managing such arteries.
Surgical technique
The renal allograft is received on the back table and placed in ice slush. All arteries are perfused using cold Ringer/lactate solution. The renal artery is cleared of hilar fat. Care is taken to avoid any kink in the vessels. This technique is useful in those cases where both the arteries have adjacent origins from the aorta and run parallel to each other without a great disparity in size. Using a 7-0 prolene continuous suture, one-third of the adjacent circumference of both the renal arteries is sutured together and the thread tied at both the ends (Fig 1). An aortic punch is used to make an opening in the EIA; the common channel so created is anastomosed to this single arteriotomy. Stay sutures are applied on both ends to prevent a purse string effect. Care is exerted at the junction of both the vessels to avoid any gaps or to invaginate the previous knot.
Fig 1.
Technique of bridging of renal arteries.
Results
From March 2001 to February 2002, we performed 43 renal transplants from living donors with double renal arteries evident on donor imaging. Among the 16 cases managed using the technique described above (Group 1) and the remaining cases managed using various other techniques (Group 2), there was a marginal reduction in cold ischemia time using the bridging technique. No case of acute tubular necrosis or delayed graft function was noted among both the groups. The follow-up color Doppler scan revealed good graft function and the absence of stenosis or vascular thrombosis in all patients in both the groups. No patient developed a urologic complication. There was no significant difference in the antihypertensive drug requirements among both groups. At a mean follow-up of 32 weeks the mean serum creatinine was 1.6 ± 0.9 mg% and 1.4 ± 0.5 mg% for patients in groups 1 and 2, respectively.
Discussion
Complex vascular anatomy has always posed a challenge to the surgical skills of the operating team. A number of techniques have been used for the safe and successful management of these variations.3 The common technique for the equal sized parallel vessels is double barrelling of both vessels with anastomosis of the common lumen to the external iliac artery. The intima of the arteries is thin at the site of splitting and often requires an additional suture after completion of the anastomosis. Moreover, if there is bleeding from the heel, the application of an additional suture has the risk of compromising the lumen. In cadaver transplant situations, with two renal arteries on separate Carrel patches, it is a common practice to sew them together without tension for anastomosis of the common patch to the EIA.2 In the experience presented here, a similar technique was used for grafts from living donors where obviously a patch is not available. This technique is relatively easier than double barrelling because the artery is not slit open and there is minimal handling of the vessels. The cold ischemia time is definitely less using the bridging technique as compared to the older technique. In addition, there have been no instances of early vascular or urologic complications. The double barrelling technique is apparently less cosmetic and involves invasion of the arterial intima. This creates at least three stress points along the suture line that carry an inherent danger of aneurysmal dilatation in the postoperative period.
The technique of bridging double graft arteries should be considered as an easier, simple, more cosmetic, and less time-consuming alternative to double barrelling with a low risk of vascular or urologic complications.
References
PII: S0041-1345(02)03886-1
doi:10.1016/S0041-1345(02)03886-1
© 2003 Elsevier Science Inc. All rights reserved.
