|Year : 2004 | Volume
| Issue : 2 | Page : 130-133
Multiple vessel renal transplant - army hospital (research and referral) experience
Rajesh Khanna, R Sood, P Madhusoodanan, T Sinha, AS Sandhu, SK Gupta, AA Pradhan, A Kumar, GS Sethi, A Srivastava
Department of Urology, Army Hospital (Research and Referral), Delhi Cantt, India
Department of Urology, Army Hospital (Research and Referral), Delhi Cantt - 110 010
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives: Over the past three decades graft and patient outcomes in kidney transplantation have improved dramatically. The aim of our study was to measure the prevalence of multiple artery renal transplants, and to analyze the rates of vascular and urologic complications in these recipients.
Methods: Between July 1991 andAugust 2003 the transplantation team at our hospital performed 340 kidney transplantations. Twenty-nine patients (8.53%) who underwent multiple-artery anastomosis were compared with 311 patients (91.47%) with single-artery anastomosis. Of the 29 grafts with multiple arteries, 23 (79.3%) had double arteries and 5 (17.2%) had 3 arteries. The solitary patient with quadruple arteries (3.5%) underwent a successful double pyjama anastomosis. Postoperatively all patients were placed on immunosuppression and graft outcomes assessed.
Results: Multiple vessel transplantation was attended by minimal postoperative complications. There was no significant different in graft function, assessed by the incidence of acute tubular necrosis (ATN) and post-transplantation hypertension. The patient survival rates were comparable and none of the patients who received multiple renal artery grafts developed vascular or urologic complications.
Conclusions: Transplantation of kidneys with multiple renal arteries is generally avoided. However, shortage of organs continues to be critical. Our results confirm that multiple artery grafts can be successfully transplanted with results similar to single vessel kidney grafts.
Keywords: Renal transplantation, multiple renal arteries, anastomosis.
|How to cite this article:|
Khanna R, Sood R, Madhusoodanan P, Sinha T, Sandhu A S, Gupta S K, Pradhan A A, Kumar A, Sethi G S, Srivastava A. Multiple vessel renal transplant - army hospital (research and referral) experience. Indian J Urol 2004;20:130-3
|How to cite this URL:|
Khanna R, Sood R, Madhusoodanan P, Sinha T, Sandhu A S, Gupta S K, Pradhan A A, Kumar A, Sethi G S, Srivastava A. Multiple vessel renal transplant - army hospital (research and referral) experience. Indian J Urol [serial online] 2004 [cited 2019 Sep 16];20:130-3. Available from: http://www.indianjurol.com/text.asp?2004/20/2/130/21528
| Introduction|| |
Kidney transplantation is the preferred treatment for endstage renal disease because, out of all renal replacement therapies, it offers the recipient the best quality and quantity of life. Over the past 3 decades graft and patient survival have improved dramatically, as an outcome of standardized surgical technique, better immunosuppression, organ preservation and antimicrobial therapy. 
The use of kidneys with multiple renal arteries from live donors has been discouraged, because of increased risk to the donor while obtaining a common aortic cuff, technical difficulty of completing multiple arterial anastomoses, prolonged ischemia time, and poorly controlled hypertension from segmental infractions of the allograft. 
However, multiple renal arteries occur unilaterally in 23% and bilaterally in 10% of the population and there is increasing pressure to use such kidneys, to expand the potential donor pool, and thereby overcome a critical limiting factor to organ availability. This is especially relevant as most transplant programmes in India rely, almost exclusively, on live related donors. Kidneys from liver donors with bilateral double renal arteries have been transplanted successfully. 
The aim of our study was to measure the prevalence of multiple artery renal transplants, and to analyze the rates of vascular and urologic complications in these recipients. Graft and patient survival for single versus multiple artery transplants were also compared.
| Patients and Methods|| |
Between July 1991 and August 2003 the transplantation team at our centre performed 340 kidney transplants. The renal grafts were obtained from live donors in 334 (98.2%) and from cadaver donors in 6 (1.8%). The graft was transplanted to the contralateral iliac fossa of the recipient using the standard technique.  Ureteroneocystostomy was initially performed by the modified Politano-Leadbetter technique, however, since 1995 the extravesical Lich Gregoir method with a double J stent has been used. The stent was removed on the 14th postoperative day.
Twenty-nine patients (8.53%) who underwent multipleartery anastomosis were compared with 311 patients (91.47%) with single-artery anastomosis. We analyzed the incidence of vascular and urologic complications, acute tubular necrosis, and graft and patient survival. Of the 29 undergoing multiple artery anastomosis, 18 (62.1%) were males and 11 (37.9%) were females. The average age of these patients was 34 years, range 18 to 46 years. Two (7%) of these grafts were from cadaver donors and 27 (93%) from live donors.
Of the 29 grafts with multiple arteries, 23 (79%) had double arteries. In 19 (65.5%) recipients, pyjama anastomosis with the external iliac artery (EIA) was done. Three cases (10.3%) underwent, end-to-side anastomosis of the second vessel to the main renal artery, and one an end-toend anastomosis to a branch of the internal iliac artery.
Five (17.2%) of the renal grafts had 3 arteries. Two had small upper polar vessels, which could be safely divided. In the other 3 patients, 2 of the vessels were pyjama anastomosed to the EIA, with the 3' vessel anastomosed endto-side to the larger of the above vessels.
The solitary patient with quadruple arteries underwent a successful double pyjama anastomosis to the EIA.
Amongst the double vessels, in 8 cases the 2 nd vessel was missed on preoperative conventional / digital subtraction angiography (DSA), or resulted from very early division of the main renal artery. The quadruple vessels were delineated as double on angiography, with the two accessory vessels discovered on table.
All arteries were separately cannulated and perfused with a chilled solution comprising Ringer's Lactate-818 ml, 20% Mannitol-140 ml, Sodium bicarbonate-40 ml and Heparin-2 ml.
Postoperatively, all patients were placed on immunosuppression [Table - 1] and graft outcomes assessed.
| Results|| |
Multiple vessel transplantation at our institution has been visited by minimal postoperative complications, with rates comparable to most centers worldwide. None of the patients who received multiple renal artery grafts developed post-transplantation vascular or urologic complications.
We did however face our share of vascular complications in the single vessel group in 11 patients (3.5%). These included:
(a) Positional kinking of renal artery - in 4 cases, presenting as an acute reduction of urinary output in the early postoperative period. Color Doppler showed reduced graft arterial flow and on re-exploration, with repositioning of the kidney, function recovery was seen.
(b) One recipient developed an aneurysm of the EIA, leading to eventual graft loss.
(c) Graft arterial thrombosis - in 4 cases, 3 were reexplored and a thrombectomy done and the 4 th underwent a minimal invasive angiographic catheter embolectomy. However, all grafts were lost.
(d) Graft vein thrombosis resulted in loss of the grafts in 2 patients.
There was no significant difference in cold ischemia times between recipients of single arteries (65 ± 10 min) and multiple vessels (80 ± 15 min). However, in cadaveric grafts, which had to be brought from another institution, the average ischemia time was more (120 ± 45 min).
There was also no significant difference in graft function assessed by the incidence of ATN and post-transplantation hypertension. The patient survival rates at 1, 3 and 5 years were 96%, 89% and 80% for recipients of grafts with multiple arteries. The corresponding rates for single artery transplants were 96%, 87% and 79%. The graft survival rates were 96%, 84% and 78% for multiple and 96%, 86% and 79% for single vessel transplants at 1, 3 and 5 years respectively.
| Discussion|| |
"It was of fundamental importance to first discover a suitable method of uniting the blood vessels of the new organ to those of its host," said Alexis Carrel (1912). He was the youngest person ever to be awarded the Nobel Prize, for his vascular anastomosis technique, which revolutionized organ transplantation. 
Transplantation of kidneys with multiple renal arteries is generally avoided. The disadvantages of a multiple vessel graft include technical difficulty to anastomose, with inability to use a Carrel patch from live donors. A longer warm ischemia time, increased incidence of ATN, rejection episodes, and decreased graft function have also been cited. Besides, the failure to properly anastomose all arteries can lead to graft necrosis, graft rupture, segmental renal infarction, and postoperative hypertension and calyceal fistula formation. 
Having said that, shortage of organs continues to be the critical limiting factor for transplantation. In cases of only a single available donor, it becomes imperative that suitable kidneys are not be refused on anatomic or technical grounds. Large autopsy series have placed the incidence of multiple renal arteries at 18 to 30%, with bilateral multiplicity in 10 to 15%.
Our rate of 8.7% kidney allografts with multiple renal arteries corresponds with series in world literature using the same donor selection criteria.  Multiple vessel kidneys identified during the pre-transplantation angiography are taken only if bilateral, or if the other kidney cannot be used for medical reasons. We also insist on scouting for an alternative donor, if available.
Conventional angiography and/or DSA failed to preoperatively pick up multiple vessels in 9 (31 %) of our multiple artery grafts. Spiral helical computed tomography (CT) angiography with 3-dimensional reconstruction has been advocated as also noninvasive, primary imaging modality for potential renal donors capable of substituting both conventional angiography and IVU. , We have recently introduced this modality into our armamentarium.
Cadaveric kidney grafts are harvested with a Carrel patch and can be reimplanted without further bench surgery. For living donor kidneys with multiple arteries extracorporeal surgery in the form of pyjama grafts (side-to-side), or end-to-side reimplantation into the main renal artery can be done. For widely separated vessels, or those of grossly unequal diameters, end-to-side / end-toend anastomoses to the recipient arteries is recommended. This limits compromise of the lumen of the larger diameter vessel, and ensures adequate revascularization by using aortic punches of various sizes corresponding to vessel diameters.
The larger vessel is anastomosed first to revascularize the majority of the kidney, while the 2 nd vessel anastomosis is in progress. Reasonable manual dexterity is essential to avoid ischemic injury. The four-quadrant running suture arterial anastomosis technique is known to minimize technical complications for a safer and more efficient anastomosis.  The use of color doppler and even angiography, to enable early detection of vascular compromise of graft, and a low tolerance level for re-exploration, and if necessary, revision of the vascular anastomosis is essential to prevent graft loss. It is imperative that no graft be lost from lack of technical competence.
Our results confirm that multiple artery grafts can be successfully transplanted with results similar to single artery kidney grafts. There is no significant difference between these with regard to patient and graft survival, ATN, postoperative hypertension, rejection and vascular and urologic complications.
| Conclusions|| |
Kidneys with multiple arteries can be successfully transplanted. Accurate radiologic imaging is imperative to avoid surprises on table. Anastomotic technique can be modified according to the situation. Arterial punches of varying diameters and meticulous bench surgery is important. Kidney graft and patient survival and the incidence of vascular and urologic complications do not depend on the number of vessels in the graft.
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[Table - 1]