Khalid Farouk, Nasimul Majeed, Ishtiaq Ahmed Qureshi.
Results of separate anastomoses of multiple renal arteries with recipient external iliac artery in renal transplant surgery.
Pak J Med Res Jan ;50(2):55-9.

Objectives: To evaluate the results of separate anastomoses of multiple arteries of the donor kidney with the external iliac artery of the recipient in renal transplant surgery. Study design, settings and duration: A descriptive study conducted at department of Urology and Renal Transplantation, Foundation University Medical College, Fauji Foundation Hospital, Rawalpindi and Hearts International Hospital, Rawalpindi from January 2005 to December 2007. Inclusion criteria: Living voluntary kidney donors having multiple renal arteries as seen on preoperative screening. Patients and Methods: During regular renal transplant surgery, donors having multiple renal arteries as diagnosed on preoperative computerized tomographic renal angiography were selected for further study. Such kidneys from volunteer donors were harvested and no ex vivo bench surgery was performed to unite these multiple renal arteries. An arterial punch was used to make separate arteriotomies on the external iliac artery of the recipient and anastomoses of the multiple renal donor arteries were carried out separately with the external iliac artery in an end to side manner using 7/0 prolene suture. Of the fifty grafts harvested, 38 had two renal arteries arising from the aorta and reaching the renal hilum (Group I). These were anastomosed separately to the external iliac artery. Nine grafts had triple renal arteries, two running to the hilum and one entering into the lower pole (Group II). All these three arteries were anastomosed in an end to side manner with the external iliac artery. Three grafts had one main renal artery and a tiny upper polar cortical vessel incapable of anastomoses (Group III). The small upper polar cortical artery was sacrificed and the main renal artery was anastomosed with the external iliac artery. On release of vascular clamps perfusion of the graft was observed. Diuresis of the graft was noticed. Color Doppler Study of the graft was carried out on third postoperative day. Serum creatinine of the recipient was determined on alternate days for one week, after a month and then regularly at three months interval for two years. Early and late vascular and urological complications were observed over a period of two years. Results: A total of 50 kidneys with multiple renal arteries were harvested. On release of vascular clamps, reperfusion of all the allograft occurred within 5 to 75 seconds (mean: 30 seconds). Diuresis from the graft started in ½ to 8 minutes (mean 3.5 minutes). One of the recipients in Group I developed sudden decline of urine output 2 hours postoperatively and a color doppler scan showed lack of perfusion. On re-exploration a positional kink of the arteries was found which was corrected. Color doppler study on third postoperative day revealed normal perfusion of all the grafts. Serum creatinine of all the recipients steadily came down and reached normal values within a week. Serum creatinine levels remained within normal range over two years of follow-up. None of the patients developed postoperative hypertension or other vascular complications during the follow-up period. Three patients in Group I developed lymphocele requiring percutaneous aspiration. Two patients in Group II had wound infection. Conclusions: Performing separate anastomoses for multiple renal arteries of the donor with the external iliac artery of the recipient in renal transplant surgery is a safe, easy to perform and practical with minimal complications. Policy Message: The renal arterial anatomy of the donor kidney should be evaluated by the spiral computed tomographic angiography, prior to harvesting it in the host and this angiography should be available in all renal transplant surgery units.

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