Right Renal Vein Augmentation in Deceased Donor Kidney Transplantation: Importance of the Contiguous Inferior Vena Cava

Abstract

INTRODUCTION:The short, thin-walled right renal vein (RRV) makes anastomosis and hilar hemostasis challenging in deceased donor kidney transplantation. The right renal artery is twice the length of the vein. The purposes of the present retrospective study were to: (1) describe a surgical technique that uses the contiguous inferior vena cava (IVC) segment to lengthen the right renal vein, and (2) report the surgical outcomes. METHODS: A total of 44 right deceased-donor kidneys were transplanted into 44 recipients between March 2005and February 2010. Recipient ages ranged from 19-68 years (28 females; 16 males). We used the contiguous IVC to augment short renal veins in the right kidney allografts. This resulted in a horizontal extension of the RRV, with outflow through the orifice of the left renal vein (LRV). Augmented right renal veins were anastomosed end-toside to the external iliac vein, and the right renal arteries with aortic patches were anastomosed end-to-side to the external iliac artery in all recipients except 1. Surgical outcomes were assessed. RESULTS:Among the 44 kidney recipients, 39 were first transplants and 5 were second transplants. The kidneys were placed on the right side (n = 38), left side (n = 5), and into the peritoneum (n = 1). The mean RRV augmentation time was 32 minutes (range, 24-49 minutes); completion of back-table dissection added another 40 minutes. The cold ischemia times ranged from 3 hours 50 minutes to 19 hours. The rewarming times ranged from 34-44 minutes.Immediate graft function was noted in 37 kidneys; 3 patients required dialysis for delayed graft function; 4 patients had slow graft function but did not require dialysis. In a follow-up period ranging from 8 months to 5 years, no graft was lost from vascular complications following the augmentation of the RRV. All 44 venous anastomoses were safe and easy, and kinking of the renal artery was avoided because the reconstructed vein matched the length of the artery. CONCLUSION:Augmentation of the short RRV utilizing the contiguous IVC is a safe, simple, and reliable procedure that avoids graft loss from vascular complications in deceased donor renal transplantation.UroToday International Journal ® UI J

Is the Reluctance for the Implantation of Right Kidneys Justified?

“…The problem with the RK is its vein, which is generally shorter and thinner walled, however, not all RRVs are short. The length of the RRV depends on the angle at which it drains into the vena cava, and the more perpendicular the drainage, the shorter the RRV [2].…”

“…In short RRVs, the author's contention is that a longer renal artery (with Carrell patch) would cause compression of the vein, but to the contrary, we think that the longer artery would knuckle and kink. In such cases, it would be advisable to shorten the artery to match the RRV length to avoid kinking [2].…”

Transplant Renal Artery Stenosis

“…In cases where the renal artery is longer than the vein, kinking and knuckling of the artery is unavoidable because the vein is shorter and prevents a smooth contour. This is especially true in deceased donor right kidney allograft that is without the contiguous inferior vena cava needed for renal vein augmentation to match the length of the right renal artery [11]. This problem is compounded if the renal artery has early bifurcation and cannot be shortened to match the vein because multiple arterial anastomoses would then be required (Fig 1).…”

“…Torsion of the allograft at the time of final placement [11] at the time of closure of the incision can lead to kinking that can cause turbulent flow and simulate TRAS [1]. In cases where the renal artery is longer than the vein, kinking and knuckling of the artery is unavoidable because the vein is shorter and prevents a smooth contour.…”

Transplant Renal Artery Stenosis

“…The usual presentation is worsening or new onset hypertension and /or graft dysfunction in the absence of rejection, drug toxicity, ureteric obstruction and infection. Several etiologic mechanisms have been proposed for TRAS, acute rejection [7], suture technique, atherosclerotic arterial disease in the donor or recipient, arterial trauma during organ procurement or transplant, cytomegalovirus (CMV) [8,9], deceased donor transplants, prolonged cold ischemia and arterial kinking because of a longer renal artery [1,11]. Angiography remains the gold standard for diagnosis and planning appropriate therapy [1].…”