The Use of Iliac Y-Graft for Arterial Revascularization in Simultaneous Double-Kidney Transplantation

Abstract

Double-kidney transplantation (DKT) has gained popularity because of results comparable with single-kidney transplantation when applied to marginal old-age donors, aiming at expanding the donor’s pool (1). Initially, the surgical technique of DKT consisted of placing the kidneys by two separate surgical incisions in the right and left iliac groin and performing vascular anastomosis on both the right and left iliac vessels (2, 3). Thereafter, Ekser et al. (4) described the monolateral access, transplanting both kidneys in the right iliac groin with a single surgical incision, and using the right iliac vessels for double venous and arterial anastomoses. The monolateral access has comparable results for graft function, with clear advantages for shorter operative time and leaving the left side untouched for an eventual retransplantation (5). However, this approach always requires two separate arterial anastomoses on the same iliac vessel to provide blood inflow to both grafts. Because well-known patients with chronic kidney disease are affected by severe and diffuse atherosclerotic lesions and many recipients of DKT are older than single-transplant recipients on dialysis for many years before, performing double arterial anastomoses, with two arteriotomies, on the same iliac artery can be risky and challenging because of the high probability of encountering severe atherosclerotic damage (6, 7). To overcome this problem, we developed a new technique of arterial anastomosis adopted from the experience of pancreas transplantation, using a donor’s interposed iliac Y-graft anastomosed during back-table surgery to the renal arteries of both grafts in an end-to-end fashion. This technique allowed performing a single anastomosis on the recipient’s external iliac artery, avoiding additional arterial anastomosis and thereby theoretically reducing the risk of vascular complication on the recipient’s atherosclerotic vessels. Moreover, another advantage of this approach could be the reduction of cold ischemia time of the second kidney and the possibility to revascularized simultaneously both grafts. Finally, also in the presence of more than one renal artery on a separate patch, the additional artery can be anastomosed to the bifurcation of the internal iliac artery of the Y-graft, providing a careful retrieval of the Y-graft including the internal iliac artery. A single venous anastomosis was performed on the external iliac vein of the recipient; in all cases, the left renal vein was reimplanted on the vena cava during bench surgery in the same way as previously described by Nghiem (8). Since now, we applied this approach without encountering any problem or complications related to back-table reconstruction of the renal arteries on the Y-graft (Fig. 1). The only limitation to the widespread use of this technique is the availability of the Y-graft not affected by atherosclerotic lesions, easily and safely usable for back-table reconstruction, which is not always possible in old-age marginal donors.FIGURE 1: Arterial anastomosis using a donor’s iliac y-graft.