Recipient Aorta Research Articles

Ischemically Damaged Heart After Preservation by the Cavitary Two-layer Method as a Possible Donor in Rat Heart Transplantation

The purpose of this study was to examine the possibility of using an ischemically damaged heart, after preservation by the cavitary two-layer (CTL) method, as a donor in heart transplantation. Each donor heart was heterotopically transplanted to the recipient aorta. The grafts in Group 1 were immediately transplanted. In Group 2, the grafts with (a) 15- or (b) 30-minute warm ischemia were transplanted. The ischemically damaged grafts were transplanted after preservation for 3 hours in University of Wisconsin (UW) solution (Group 3) or CTL (Group 4). Five-day animal survival, tissue adenine triphosphate (ATP) concentration, biochemical assay and histopathologic data were obtained. Five-day survival in Group 4a was 7 of 8, with significant recovery of the ATP tissue level (9.31 +/- 0.80 micromol/dry weight). Biochemical and pathologic examinations demonstrated that ischemia-reperfusion injury was prevented in Group 4a compared with Group 2a. An ischemically damaged rat heart preserved for 3 hours by CTL was found to be a potential donor in rat heart transplantation.

Applications of Bilateral Vascularized Femoral Bone Marrow Transplantation for Chimerism Induction Across the Major Histocompatibility (MHC) Barrier

Bilateral vascularized bone marrow transplant (VBMT) model was designed to induce chimerism across the major histocompatibility (MHC) barrier under combined alphabeta T-cell receptor monoclonal antibody and cyclosporine A (alphabeta-TCRmAb/CsA) protocol. Seventeen transplants were performed between BN(RT1) donors and Lewis(RTI) recipients. Group I, isograft controls; Group II, allografts rejection controls; Group III, allografts under 7-day protocol of alphabeta-TCRmAb/CsA. Donor bilateral femoral bones were bilaterally anastomosed to the abdominal aorta and inferior vena cava of recipient. At day 7 posttransplantation, all bone flaps were viable. Groups I and III survived without signs of rejection. In Group III, peak level of chimerism in peripheral blood was evaluated at day 21 (24.2%), at day 63 declined to 1.5%, and was maintained at this level thereafter. Donor-derived cells were present in the bone marrow of recipients at 28.2% at day 21 posttransplant. Histology confirmed viability of bone marrow cells in isograft during the entire follow-up and up to 35 days in treatment Group III. Bilateral VBMT induced donor-specific chimerism across the MHC barrier under the immunomodulatory protocol of alphabeta-TCRmAb/CsA.

Improved technique of heterotopic auxiliary rat liver transplantation with portal vein arterialization

In acute, potentially reversible hepatic failure, auxiliary liver transplantation is a promising alternative approach. Using the auxiliary partial orthotopic liver transplantation (APOLT) method--the orthotopic implantation of auxiliary segments--most of the technical problems (lack of space for the additional liver mass, the portal vein reconstruction, and the venous outflow) are avoided, but extensive resections of the native liver and the graft are necessary. Erhard described the heterotopic auxiliary liver transplantation (HALT) with portal vein arterialization (PVA). Initial clinical results demonstrated that an adequate liver function can be achieved using this technique. We developed and improved a technique of HALT with flow-regulated PVA in the rat to perform further investigations. The aim of this paper is to explain in detail this improved experimental surgical technique. Liver transplantations were performed in 122 male Lewis rats: After a right nephrectomy, the liver graft, which was reduced to about 30% of the original size, was implanted into the right upper quadrant of the recipient's abdomen. The infrahepatic caval vein was anastomosed end-to-side. The donor's portal vein was completely arterialized to the recipient's right renal artery in stent technique. Using a stent with an internal diameter of 0.3 mm, the flow in the arterialized portal vein was regulated to achieve physiologic parameters. The celiac trunk of the graft was anastomosed to the recipient's aorta, end-to-side. The bile duct was implanted into the duodenum. After improvements of the surgical technique, we achieved a perioperative survival of 90% and a 6-week survival of 80% in the last 112 transplantations. We developed a standardized and improved technique, which can be used for experiments of regeneration and inter-liver competition in auxiliary liver transplantation. Furthermore, this technique is suitable for the investigation of the influence of portal vein arterialization and portal hyperperfusion on liver microcirculation, function, and morphology.

Retransplantation for liver transplanter with poor graft function

To summarize the experience of liver retransplantation for patients with poor graft function. The clinical data of 9 patients undergone liver retransplantation at our center from April 1993 to April 2005 were retrospectively analyzed. The main indications for liver retransplantation at our center were early hepatic artery thrombosis (2/9), early portal vein thrombosis (1/9), and biliary tract complication (6/9). Of the 9 patients received liver retransplantation with cadaveric allografts, 3 received classic orthotopic liver transplantation, and 6 piggyback liver transplantation. Roux-en-Y biliary tract reconstruction was performed in 6 patients, Donor spleen vein was used as a conduit between donor portal vein and recipient portal vein in 1, and donor spleen artery as a conduit between donor hepatic artery and recipient aorta in 1. No perioperative mortality occurred. Of them, 5 had no complications after the operation, 1 had stricture in anastomotic stoma of portal vein, and 3 died in 6 months after the operation. Poor graft function due to biliary tract complications and vessel complications after primary liver transplantation are the chief indications of liver retransplantation. Liver retransplantation is the only suitable treatment of poor graft function.

Liver Transplantation for Fulminant Hepatic Failure Without Venovenous Bypass and Without Portacaval Shunting

Preservation of the caval vein during liver transplantation (OLT) has gained wide acceptance but portosystemic bypass or temporary portocaval shunt is still believed to be indicated in patients with fulminant hepatic failure. Herein we have described our initial experience with piggyback OLT without venovenous bypass and without portocaval shunting in five such patients. Division of the portal vein was always delayed until the native liver was completely dissected off the caval vein. The donor hepatic artery was anastomosed to the recipient aorta via an iliac interposition graft placed in the supraceliac position in two and at an infrarenal site in three patients. The ahepatic phase urinary output was low in the two patients in whom we applied supraceliac cross-clamping of the aorta. The mean ahepatic phase was 53 (45 to 67) minutes in four recipients who remained hemodynamically stable throughout surgery and prolonged to 5 hours in one patient due to a complicated supraceliac aortic anastomosis. Its repair resulted in hemodynamic instability, multiorgan failure, and death at 4 days following OLT. Four (80%) patients are alive in good condition with normal liver function after a mean of 12 (5 to 25) months of follow-up. In summary, liver transplantation for fulminant hepatic failure may be safely performed without venovenous bypass and without temporary portocaval shunting if the ahepatic phase is minimized and portal flow to the liver maintained up to the moment of hepatic excision. Arterial anastomosis with the supraceliac aorta prolongs the ahepatic phase and may impair kidney function: therefore, it should be avoided in these patients.

Donor arterial variations in liver transplantation: management and outcome of 527 consecutive grafts.

The impact of donor arterial variations and their management was investigated retrospectively in 527 consecutive allografts. Anomalous arteries were found in 161 grafts (30.6 per cent). There was no significant difference in the overall incidence of arterial complications between grafts with normal (3.6 per cent) and abnormal (5.6 per cent) anatomy. However, there was a higher incidence of arterial complications in transplants requiring multiple arterial anastomoses (P = 0.02), or anastomosis of donor vessels to recipient aorta with (P = 0.0003) or without (P = 0.04) an interposition graft for arterial reconstruction. The incidence of biliary complications was similar in grafts with a normal (18.8 per cent) or anomalous (18.0 per cent) arterial supply. Anomalies of hepatic arterial anatomy occur in one-third of all livers and do not compromise graft outcome unless multiple anastomoses or direct anastomosis to the recipient aorta are required for arterial reconstruction.

Simplified Rat Model of Intestinal Transplantation

Rat intestinal transplantation is an optimal model for research; nevertheless, it requires a complex and difficult microsurgical technique (1–5). We have recently developed a simplified rat model for intestinal transplantation using portal cuff anastomosis to overcome these technical difficulties (Fig. 1A).FIGURE 1.: (A) Figure illustrating the present model of intestinal transplantation. G, intestinal graft in shady color; SMA, superior mesenteric artery of the graft; VC, recipient vena cava; AO, recipient aorta. (B) Micropicture (16×) showing details of the portal cuff.Preoperative procedures, anesthesia and laparotomy are performed as previously described (1–4). In the donor operation, middle and descending colons are isolated from small bowel and ascending colon. Superior mesenteric vein is dissected and encircled. Splenic and pyloric veins are divided and portal vein is dissected up to hepatic hilum. Abdominal aorta is dissected and celiac trunk, right renal artery and lumbar branches are divided. Aorta is clamped at the diaphragm, tied below the mesenteric artery and this arterial segment is resected allowing a long aortomesenteric conduit. Entire small bowel, cecum and ascending colon are harvested on a vascular pedicle consisting of right colonic vessels, aortomesenteric conduit and portal vein. The graft is flushed and stored in cold preservation solution. Polyethylene catheter is used to create the cuff as described elsewhere (5). In this modified technique, the vein is introduced into the cuff and everted, covering the outer wall and fixed with three equidistant stitches (Fig. 1B). In the recipient, the superior mesenteric vein is exposed, and a segment between the first and second jejunal branch is dissected and prepared for cuff anastomosis. Eventually, the second jejunal branches and the right colonic vein may be divided in order to increase this segment. The graft is implanted in the recipient with an end-to-side aorto-aorta anastomosis as previously described (1–5). The dissected segment of mesenteric vein is isolated between clamps to insert the portal cuff and a 6-0 suture is used to fix the cuff into recipient’s mesenteric vein. The clamps are released and immediate graft reperfusion is observed. The recipient jejunum, ileum, cecum, and ascending colon are removed en bloc. Finally, anastomosis between the graft and the remaining intestine restores the digestive tract (Fig. 1A). The present model offers many possibilities for intestinal transplantation research with the following advantages: reconstitutes the natural and physiologic portal graft drainage; the portal cuff anastomosis is performed within few minutes without bleeding or venous thrombosis. This alternative technique avoids recipient visceral ischemia and hemodynamic instability because there is no obstruction on inferior vena cava and portal vein. Furthermore, it maintains grafts ileocecal valve and preserves the extrinsic enervation along the mesenteric-aortic segment that may improve bowel movement. This modified technique can be easily performed within two hours after a short period of training (8±3 week) and may reach excellent success rates. This rat model may surmount technical obstacles precluding microsurgical techniques and may ultimately spread this model in centers with low technical resources. Flávio H.F. Galvão Rafael M.N. Santos Marcel A.C. Machado Telesforo Bacchella Marcel C.C. Machado Transplantation and Liver Surgery Discipline University of Sao Paulo School of Medicine Sao Paulo, Brazil

Microsurgical Techniques in Rat Heterotopic Small Bowel Transplantation: Analysis of 450 Cases

Background We sought to review 450 rat small bowel transplantation (SBT) operations having a modified microsurgical technique to discuss the key steps for a successful operation. Methods Four hundred fifty rat heterotopic small bowel transplantations were performed in 3 stages: the first 80 cases were a training stage, the following 330 cases were for formal experiments, and, in the last stage, 40 cases were to analyze the relationship between the duration of cold preservation and recipient mortality. For all cases, revascularization of the graft was accomplished by an end-to-side anastomosis between the donor superior mesenteric artery or aorta and the recipient infra-renal aorta, and cuffed end-to-end anastomosis between the donor portal vein and the left renal vein of the recipient. The duration of each operation, graft warm ischemia time, and recipient survival rate were compared. Results In the first stage, the graft warm ischemia time was about 90 minutes where as it was only 35 minutes in the second stage. The longterm survival rates (>5 days) of recipients were 8.8% and 97.3%, respectively. In the 3rd stage, long cold preservation period significantly increased recipient mortality. Conclusions Graft warm ischemia time was a key issue associated with recipient mortality; a well-trained, simplified microsurgical anastomosis between graft superior mesenteric artery and recipient aorta accomplished in a shorter time rendered intravenous transfusion not essential for the recipient.

Auxiliary liver-heart transplantation in the rat: a new microsurgical model inducing tolerance

Objective To establish a model of immunological tolerance induced by simultaneous auxiliary liver transplantation and heterotopic heart transplantations using PVG and DA rats as donors and recipients respectively, to provide a new method for the research of liver transplantation. Methods The recipient's whole portal vein blood was transfered to the auxiliary liver allograft. The donor's heart was transplanted to the recipient's abdominal cavity by end-to-side anastomosis of the donor aorta and pulmonary artery to the recipient aorta and vena cava, respectively. Results In the syngeneic control group and the test group the recipient rats and their transplanted hearts both survived more than 100 days, while the hearts of alloheart control group only survived 6 days. The weight of the liver graft increased slowly. Conclusions In the presence of recipient liver, the auxiliary liver graft functioned well to induce tolerance. At 100 days, the auxiliary liver graft had increased in volume and weight with maintenance of its tolerance-inducing effects.

Novel technique for isolated accessory right heart transplantation for congenital heart disease

Background Our prior laboratory work has permitted adding a whole donor heart to a preserved recipient right heart, producing a heart-and-a-half preparation able to cope with pulmonary hypertension in the recipient. The experiments in the present study explore the feasibility of the converse operation: adding an isolated donor right heart to an entire preserved heart. Methods Eight adult mongrel dogs (4 donors and 4 recipients) were used in 4 transplant operations performed through a right thoracotomy without cardiopulmonary bypass (using side-biting control of recipient vessels). The donor heart underwent resection of the left atrium and left ventricle, leaving an isolated donor right heart. Blood supply to the donor right ventricle was preserved from the donor ascending aorta. Through a right thoracotomy, the donor right heart was transplanted in parallel to the native right heart of the recipient by using the following anastomoses: (1) donor superior vena cava to recipient superior vena cava (end-to-side anastomosis); (2) donor pulmonary artery to recipient pulmonary artery (end-to-side anastomosis); (3) donor ascending aorta to recipient aorta (through a great vessel [end-to-end anastomosis] to provide arterial inflow to donor coronary arteries). Animals were euthanized within 1 hour after completion of transplantation. Results Isolation of the right ventricle by excision of the left chambers was technically feasible. Transplantation without cardiopulmonary bypass was feasible in all cases. The isolated right heart beat well after transplantation in all animals, demonstrating sinus rhythm. Three of 4 animals were able to sustain good hemodynamics on support with epinephrine. Bleeding from the septum or aortic valve of the donor (now open to the pericardial space) was not problematic. Mean arterial pressure was 85 mm Hg (mean) at a right atrial pressure of 6 mm Hg (mean). In 2 animals the recipient superior vena cava was ligated to obligate upper body flow to pass through the accessory ventricle; hemodynamics were preserved under these circumstances. Conclusion Transplantation of an isolated right heart is feasible. Such a technique has potential as a novel therapeutic alternative for obstructive or hypoplastic lesions of the right heart in human children.

New model for simultaneous heart and kidney transplantation in mice.

In clinical settings, combined heart and kidney transplantation results in a lower incidence of cardiac graft and renal graft rejection as compared to isolated heart and kidney transplantation. To study the phenomenon in an experimental setting, we developed a model of combined heart and kidney transplantation in mice. According to our technique, we kept the patch of the infrarenal aorta and inferior vena cava (IVC) as long as possible during the donor's kidney explantation, and then, after finishing the kidney implantation with conventional techniques, we anastomosed the innominate artery and pulmonary artery of the heart graft to the patch of the infrarenal aorta and IVC of the renal graft, respectively, instead of the recipient's aorta and IVC. With the use of our method, combined heart and kidney transplantation in mice can be performed to get enough suture room for the second graft, to avoid prolonging the occlusion time of the recipient's circulation, and to profoundly decrease postoperative complications such as paraplegia and mortality. Of the 14 recipients with combined heart-kidney isografting, 10 have been successful (71.4%), surviving over 100 days with normal function of both grafts, and with lack of change in histological appearance. This suggests that the technique is feasible and reliable.

Restoration of fertility in oophorectomized rats after tubo-ovarian transplantation.

Improved microsurgical techniques for en bloc vascularized adnexal isograft in the rat is described. The graft of the right ovary together with its fallopian tube and upper third of uterus was transplanted orthotopically with end-to-side anastomoses between the donor aortic segment and recipient aorta and between the donor vena cava segment and recipient inferior vena cava, with end-to-end anastomosis of the donor and recipient uterus in a syngeneic, bilaterally oophorectomized rat. All transplantations were successful in terms of immediate vascular patency rate (10/10, 100%). Evidence of resumed ovarian function was obtained in 9 out of 10 rats (9/10, 90.0%) by histological demonstration of the vaginal smear, in which pregnancies were achieved in six rats (6/10, 60.0%) and six litters of healthy offspring were delivered 9 weeks later after transplantation. These results suggest that microsurgical ovarian transplantation provide a new and potential experimental model for the study of fertility restoration in humans.

Auxiliary liver transplantation with portal arterialization in the rat: description of a new model.

In recent years, portal arterialization has been used in liver transplantation to increase the portal flow, as a solution for singular technical problems. We have developed a new auxiliary liver transplantation model in the rat with portal arterialization, so the native hepatic hilium remains untouched, consisting on a graft with a previous 70% hepatectomy. It is sited on the right renal bed, joining the infrahepatic inferior vena cava (IVC) of the graft with the recipient IVC. With an abdominal aortic graft, we connect the recipient aorta with the portal vein from the auxiliary liver. All the animals survived at the seventh day. No thrombosis was seen in any graft and an important rejection was observed in all the fields. We have developed a new experimental model of an auxiliary liver with portal arterialization, avoiding the utilisation of the native hepatic hilium, necessary for the possible recovering of the proper liver in the case of a reversible fulminant hepatitis.

The technique for heterotopic cardiac transplantation in mice: experience of 3000 operations by one surgeon

Introduction The mouse heterotopic fully vascularized cardiac transplantation model has come into widespread use. However, the technique is still difficult. Therefore, simple anastomosis was introduced. Methods The donor ascending aorta was sutured end-to-side to the recipient abdominal aorta and the donor pulmonary artery was anastomosed to the recipient inferior vena cava. The main point was only 4 stitches on 1 side between proximal and distal anastomosis of the recipient aorta and inferior vena cava. Results When beginners tried to perform the same procedure, they were able to complete the first successful procedure after 11 trials and achieved 90% success after 78 operations. Summary The simple anastomosis is safe and shortens the operation time.

Effects of simultaneous kidney-pancreaticoduodenal transplantation on diabetes-induced renal insufficiency in rats.

An investigation of the functional and histological changes was done after en-bloc kidney-pancreaticoduodenal transplantation (kpdt) in the diabetes-induced, renal insufficient Lewis rats. For donor preparation, an end-to-side portocaval shunt was performed, and the aortic, vena caval segments, and ureter-bladder patch were obtained. They were anastomosed microsurgically to recipient's aorta, vena cava, and bladder in end-to-side fashion. Of 15 diabetes-induced kpdt rats, 14 survived. Two of the 14 surviving rats showed ischemic necrosis. The remaining 12 transplants showed well-preserved glomeruli and Langerhans islets for 5 months postoperatively. Biochemical data comparing diabetic and sham-operated rats (six rats each), six diabetic controls, and 12 kpdt rats showed no significant statistical difference at said observation period. The diabetes-induced kpdt rats showed improvement of following biochemical data: within 1 week postoperatively, the glucose level fell from 300 to 115 mg/dL; BUN level from >20 to <20 mg/dL; the creatinine level from 1.5 to <1.2 mg/dL. The insulin level returned to normal, 1.1 ng/mL, in 2 weeks. The results demonstrate that the kpdt model is an effective and successful operative technique in diabetic rats and may provide effective therapeutic methods for diabetes-induced renal insufficiency.

Experimental Orthotopic Heart and Bilateral Lung Transplantation Completed Without Cardiopulmonary Bypass

Most experimental studies of orthotopic heart and lung graft failure are complicated by an inability to eliminate the rejection-specific inflammatory mediator from the cardiopulmonary bypass. The following model was developed in our laboratory to investigate the feasibility of performing an orthotopic heart and bilateral lung transplantation without performing a cardiopulmonary bypass. Nineteen transplants were attempted using 19 pairs of mongrel dogs. The recipient dog (mean weight, 23 kg) was anesthetized, and the ascending aorta, the superior vena cava (SVC), the inferior vena cava (IVC), and the main bronchus were dissected. Then, the donor dog (mean weight, 20 kg) was anesthetized, and the heart and lung block was prepared and explanted from the chest under cardioplegic arrest. A Gore-tex shunt (W. L. Gore; Flagstaff, AZ) was placed side-to-side between the recipient IVC and SVC, and then the donor right atrium was anastomosed to the Gore-tex shunt. The donor ascending aorta was anastomosed to the recipient ascending aorta with a partial clamp. On completion of these anastomoses, the donor heart was reperfused by the recipient heart and allowed to beat. When hemodynamic conditions were stable with double hearts, the recipient SVC and IVC were ligated just proximal to the venous anastomosis and the recipient aorta was ligated proximal to the anastomotic site. The recipient trachea was anastomosed to the donor trachea with an end-to-end anastomosis. Finally, the recipient heart and lungs were removed from the chest and the sternum was closed. Four of the 19 transplants failed. Three died due to left ventricular dysfunction, and one died due to bleeding. Mean (+/- SD) ischemic time was 67 +/- 11 min with a mean (+/- SD) anastomotic time of 54 +/- 12 min. The 15 survivors were hemodynamically stable with or without the minimal use of inotropic support (dopamine, 2 to 3 microg/kg/min) 6 h after grafting, with normal cardiac output, satisfactory oxygenation, and normal wall motion. The sternotomy was repaired without loss of cardiopulmonary function. On the basis of our experiences, the experimental model of orthotopic heart and bilateral lung transplantation completed "off pump" can be technically feasible without the loss of cardiac and pulmonary functions.

The spectrum of aortic complications after heart transplantation

Background. The connection between the donor and the recipient aorta is a potential source of early and late complications as a result of infection, compliance mismatch, and technical and hemodynamic factors. Moreover, the abrupt change in systolic pressure after heart transplantation involves the entire thoracic aorta in the risk of aneurysm formation. The aim of this study was to analyze the types of aortic complications encountered in our heart transplantation series and to discuss etiology, diagnostic approach, and modes of treatment.Methods. Of the 442 patients having orthotopic heart transplantation and the 11 patients having heterotopic heart transplantation at our center, 9 (2%) sustained complications involving the thoracic aorta. These 9 patients were divided into four groups according to the aortic disease: acute aortic rupture (2 patients); infective pseudoaneurysm (3 patients); true aneurysm and dissection of native aorta (2 patients); and aortic dissection after heterotopic heart transplantation (2 patients). Surgical intervention was undertaken in 8.Results. Five (83%) of 6 patients who underwent surgical treatment for noninfective complications survived the operation, and 4 are long-term survivors. One patient who underwent a Bentall procedure 712 years after heterotopic heart transplantation died in the perioperative period of low-output syndrome secondary to underestimated chronic rejection of the graft. One patient with pseudoaneurysm survives without surgical treatment but died several years later of cardiac arrest due to chronic rejection. Both patients operated on for evolving infective pseudoaneurysm died in the perioperative period.Conclusions. Infective pseudoaneurysms of the aortic anastomosis are associated with a significant mortality. In noninfective complications, an aggressive surgical approach offers good long-term results. The possibility of retransplantation in spite of complex surgical repair should be considered in the late follow-up after heart transplantation, due to the increasing incidence of chronic rejection.

Vascular complications post orthotopic liver transplantation

From October 1991 to May 1998, 63 OLT in 57 patients were performed at Hadassah Hebrew University Medical Center. These included 58 whole liver transplantations, four reduced size, and one living-related liver transplantation. There were 25 females and 32 males with a mean age of 40.7 year (range 3.5–68). The follow-up was a mean of 21 months (range of 0.1–78). In 52 OLT donor liver arterial inflow was based on recipient hepatic artery (HA), and in 10 OLT on recipient aorta (Ao). In one OLT, this information was not available. Portal vein (PV) reconstruction was by end-to-end anastomosis in all transplants except in one OLT with recipient PV thrombosis (PVT), in which an interposition donor iliac vein was used. Inferior vena cava (IVC) reconstruction was performed in a standard manner in 53 OLT, and piggy-back in 10 OLT. Vascular complications were diagnosed based on clinical, ultrasonographic, angiographic, and operative findings. Statistical analysis was performed using Fisher’s exact test with significance accepted at P , .05.

Vascular thrombosis in small bowel transplantation: a comparative study in the pig

Forty-six mini-pigs with an average weight of 36 kg underwent small bowel transplantation with four different vascular anastomosis: group 1(4 SBT): arterial (end-to-side) graft mesenterica cranealis (GMC) to recipient aorta (RAo), venous (end-to-side) graft mesenterica ranealis (GMC) to recipient vena cava; group 2(6 SBT): arterial (end-to-side) GMC with aortic graft (AoG) to RAo, venous (end-to-end) GMC to recipient mesenterica cranealis (RMC); group 3(21 SBT): arterial (end-to-end) GMC to RMC, venous (end-to-end) GMC to RMC; group 4(15 SBT): arterial GMC with AoG to RAo, venous (end-to-side, “piggy-back”) GMC to recipient portal vein. Vascular thrombosis (VT) was diagnosed by necropsy, and thrombosis was considered a technical failure from 0 to 72 hours. Heparine (5000 u/12 hours) was used prophylactically.

Alternative techniques for arterialization in multivisceral grafting

For a small group of carefully selected patients, multivisceral grafting is a viable treatment. While early data suggest that the 3-year survival is less than 50%, 1 it is unlikely that any of these patients would have survived without transplantation. While improving results rely on advances in management, particularly in technique and immunosuppression, it is essential that the acquisition of the multivisceral graft does not compromise the procurement of the donor kidneys for transplantation. Described techniques generally employ the use of an aortic conduit or large aortic patch, 2,3 but these techniques have a number of drawbacks. For example, the use of the aortic conduit compromises the aortic patch around the orifices of the donor renal arteries which is a particular problem if there are multiple renal arteries. In addition, these techniques require mobilization of a long length of recipient aorta, often appear cumbersome, and can be difficult to orientate satisfactorily. In addition, the thoracic aorta needs to have the multiple intercostal arteries oversewn. If an aortic patch bearing the origins of the celiac and superior mesenteric arteries is used, the short length of vessels can make the anastomosis of the patch to recipient aorta difficult and hazardous.