Management of infrarenal duplicated inferior vena cava during living related kidney transplantation

Abstract

Congenital anomalies of the inferior vena cava (IVC) arerelatively rare pathologies, usually with an asymptomaticcourse.During open donor nephrectomy, we incidentallyfound two left infrarenal duplicated IVCs (Fig. 1):In the first case, left infrarenal IVC was sacrificed. Leftkidney was harvested with a normal length renal vein(Fig. 2a). The recipient had uneventful post-op course.Only mild edema was seen in his donor, around pelvisgirdle and proximal left thigh, persisting for 2 weeks.In second donor, we divided left renal vein more prox-imally with an acceptable short renal vein to preserve thecontinuity of left IVC (Fig. 2b). Both donor and recipienthad good renal function and no surgical complication onfollow-ups was seen.DiscussionCongenital anomalies of IVC are usually diagnosed bychance during surgery. From bioptic material their inci-dence has been estimated to be 2–3% [1]. The frequencyof accidental intraoperative finding in different series var-ies between 0.2% and 0.6%. Caval duplication and a leftpositioned vena cava are the most common incidentalanomalies [2]. They are known to be associated with var-ious urogenital tract anomalies such as horseshoe kidneysand circum-aortic renal collar [3,4].Nowadays, in many transplant centers, helical CT angi-ography and MR angiography have replaced conventionalangiography. They give a better view of the renal paren-chyma and the computer reconstruction shows the arter-ial anatomy as well. Ureteric and renal anomalies are alsoseen well with these methods; the accuracy is 95% andthey are quicker and cheaper [5].Up to now, few cases with complete duplication ofIVC have been reported to be found during live donornephrectomy (LDN) [6,7]. In previous literature, onlyone case with infrarenal duplicated IVC was found thatwas managed as the first case in this report [8]. They didnot mention any complication in post-op course. How-ever, as we mentioned earlier, due to ligation of left IVC,our first case suffered from edema. In complete duplica-ted IVC, usually each kidney drains to the ipsilateral IVCand nephrectomy has no effect on limb drainage. How-ever, infrarenal duplicated IVC is totally different, as ipsi-lateral limb drains partially or totally to renal vein andligation of this vein compromises drainage of limb, atleast early in post-op. So, it seems reasonable to take thesecond surgical technique.We advise to perform imaging technique in LDN. Ifthe donor has duplicated IVC, it is essential to carefullyconduct advance imaging techniques to investigate otherpossible anomalies and blood flow of the renal vein.Although it is preferred to use kidney with longer renalvein, the graft must be carefully selected so it is not dis-advantageous to the donor.Hamid Reza Davari, Seyed Ali Malek-Hosseini,Heshmatollah Salahi, Ali Bahador, Saman Nikeghbalian,