The Use of Explanted Internal Iliac Artery Grafts in Renal Transplants With Multiple Arteries

Abstract

The use of renal allografts with multiple arteries is challenging, particularly with respect to live kidney donation. With an ongoing shortage of cadaveric organs available, live donor programs continue to be an increasingly important source of kidneys for transplantation. The prevalence of multiple renal arteries in some series is estimated between 18% and 30% and is believed to be bilateral in 15% of cases (1). Previously, multiple arteries were considered as a relative contraindication to live donation and renal transplantation; however, there is now increasing evidence that transplantation of kidneys with multiple arteries is safe with no significant increase in immediate or long-term complications (2–4). We present a series of seven cases where we have successfully used explanted recipient internal iliac artery grafts in live donor renal transplants with multiple arteries. The use of internal iliac artery grafts has been described before (4, 5); however, only small numbers have been reported as part of larger series and no consecutive series have been described. We describe a slightly different technique, which we have successfully reproduced in consecutive renal transplants with multiple arteries. Technique The operative bed is prepared in the usual manner. The internal iliac artery and suitable branches are dissected and then explanted from the recipient after clamping the main trunk of the vessel. On the back table, under cold storage conditions, the internal iliac graft can then be anastomosed to the renal allograft. The individual arteries are anastomosed end-to-end in turn to the branches of the explanted arterial graft over silastic catheters. The kidney is then implanted by reanastomosis of the internal iliac trunk to its parent main stem. Other similar techniques describe the use of end-to-side anastomosis with the external iliac artery rather than to parent internal iliac artery. Patients Seven kidneys of 41 retrieved from live donors by laparoscopic nephrectomy over a 10-month period had multiple arteries. Six of the renal allografts had two renal arteries and one had three arteries. All allografts had single vein and ureter. The mean follow-up was 149 days (range 53–277 days). Demographic details of the seven patients are shown in Table 1.TABLE 1: Patient and transplant demographicsNo intraoperative complications were reported. Table 1 shows the anastomotic and cold ischemic times. There were no immediate vascular complications, and, in all cases, recovery room Doppler ultrasound imaging reported good perfusion throughout the transplanted kidneys. Primary graft function was established in all cases. Since transplantation, two of the seven recipients reported ipsilateral buttock claudication. Neither of these patients had had the contralateral internal iliac artery used previously. One of the recipients has had hypertension that was difficult to control, requiring multiple anti-hypertensive medications. No urological complications have been documented since transplantation. There have been no biopsy-confirmed acute rejection episodes. Summary In summary, this series demonstrates that explanted internal iliac artery grafts can be used successfully to anastomose renal allografts with multiple renal arteries. The main advantage of the technique is that the difficult anastomosis of small vessels can be performed on the back table under hypothermic conditions, and there is no pressure on the surgeon to consider the anastomotic warm time at that point. This technique, literally, takes the heat out of a difficult operative situation. Louisa C. Firmin Michael L. Nicholson Department of Transplant Surgery Leicester General Hospital Leicester, United Kingdom