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Volume: 14 Issue: 2 April 2016

FULL TEXT

CASE REPORT
Fax Extension of the Right Renal Vein With a Remodeled Receptor Saphenous Vein in a Living-Donor Kidney Transplant: A Case Report

The right kidney may be chosen for donor safety as the donor kidney in a living renal transplant. However, the short length of the right renal vein may increase technical difficulties and affect the implanted graft. We report a method that uses the remodeled receptor saphenous vein to reconstruct and extend the transplanted renal vein.


Introduction

For the patient with end-stage uremia, renal transplant is the preferred treatment. Owing to the lack of deceased-donor kidneys, more patients choose to adopt living-donor kidney transplants with close relatives as the donors. In living-donor kidney transplant, the donated kidney functions of the donor are evaluated, and the more functional kidney remains in the donor.1 We have to choose the right kidney, which has a shorter renal vein, as a graft. A short or damaged right renal vein may cause difficulties or lead to failure in the renal transplant.2-5 Here, we described a technique that extends the right renal vein with a remodeled receptor saphenous vein in a living-donor kidney transplant

Case Report

A 51-year-old man with renal failure secondary to diabetic nephropathy of 4 years’ duration received a renal transplant from his 46-year-old sister. Because the functioning of the donor’s left kidney was better than that of the right, her right kidney was chosen as a graft. We performed a laparoscopic nephrectomy. During dissection of the renal vein, an ultrasonic knife accidentally damaged the vein. There was venous bleeding, so we used a Hem-o-Lok (Weck Hem-o-Lok Polymer Locking Ligation System [Teleflex Medical, Research Triangle Park, NC, USA]) at the bleeding site. When the donor kidney was taken down, the length of the renal vein was less than 1 cm, and a venous anastomosis could not be completed (Figure 1).

We decided to use the recipient’s autologous saphenous vein to extend the length of the transplanted renal vein. The residual renal vein of the donor kidney was close to the renal hilum, and its diameter was significantly greater than that of the saphenous vein, so it could not be used with the saphenous vein directly for an end-to-end anastomosis. The saphenous vein needed to be remodeled.

The specific operation went as follows: Because the blood vessels of the right iliac fossa are shallower than those of the left and are easy to graft an anastomosis, we implanted the graft on the right iliac fossa. We decided to take the left great saphenous vein from the recipient through a longitudinal incision in the man's left groin. A saphenous vein about 8 cm was cut, beginning from the distal end of the saphenous-femoral vein valve. The branches of the saphenous vein trunk were ligated with 6-0 Prolene. The saphenous vein was cut longitudinally to form a rectangular patch, and the patch was cut into 2 equal parts of approximately 4 cm × 1 cm. On the long side of 1 vein patch and the corresponding side of the other vein patch were continuous sutured with 6-0 Prolene (Figure 2). We sutured another long side of the 2 vein patches, similarly, reshaping the great saphenous vein back to a tube, so that its diameter was wide enough to match the transplanted renal vein.

The remodeled great saphenous vein was sutured end-to-end to the transplanted renal vein (Figure 3). The allograft renal vein was extended effectively this way. After this, the renal transplant was performed in accordance with the routine operation. The serum creatinine concentration at 1 day, 1 week, 1 month, and 6 months after operation were 785 μmol/L, 120 μmol/L, 95 μmol/L, and 93 μmol/L. Three and 6 months after the renal transplant, follow-up Duplex ultrasonographies showed the blood flow in the transplanted renal artery and vein was good, and rich blood flow could reach renal the subcapsule. Postoperatively, the patient’s left lower limb was without swelling or discomfort.

Discussion

With more end-stage uremia patients accepting living-donor kidney transplants provided by their relatives, it is important to ensure the safety of the donor.1 Anatomically, the right renal vein is approximately 5 cm shorter than the left renal vein.6 When the right kidney must be chosen for the graft, the transplanted renal vein is frequently too short. Additionally, the renal vein can be damaged during the course of laparoscopic nephrectomy also contributing to its shortness. The anastomosis between the iliac vein of the receptor and a (short) transplant renal vein may lead to a series of technical problems (eg, angulation or tension of the venous anastomosis,7 reduced mobility, limited placement, and inspection of the graft for hemostasis).8-9 These problems may lead to venous hemorrhage or thrombosis.10 And renal vein thrombosis is a serious complication that can lead to graft nephrectomy, despite medical or surgical therapy.4-5

First, clinicians should try to avoid damaging the transplanted kidney vein during surgery, which is more important than rebuilding the vein is. But when the renal vein is too short, it is important for clinicians to have the appropriate technology to deal with this.

Simforoosh and associates11 have reported that the right renal vein obtained by right laparoscopic donor nephrectomy when using simple clipping of the renal vein is short, but by placing the kidney inverted in the right iliac fossa, transplant is possible, with no increased incidence of vascular thrombosis or graft malfunction. Additionally, using several materials to remodel the transplant renal vein and extend its length is effective. Lengthening the right renal vein cannot rely on dissection of the hilum of the donor kidney, because injury of the blood supply to the pelvis and ureter may cause necrosis to both of them. Various techniques have been used including a vena cava patch, a venous saphenous autograft, a gonadal vein, and a cryopreserved external iliac artery allograft.10,12-14 Venous saphenous autograft is a good natural material, but the difference in the diameter of the venous vessel relative to the renal vein could predispose the patient to thrombosis. We re-formed the great saphenous vein to match the renal vein using the aforementioned method. And the kidney transplant surgery following was successful.

To our knowledge, this technique rarely been reported in the literature. Mastering renal vein reconstruction techniques (eg, by remodeling the autologous saphenous vein) may be effective in dealing with situations that arise during the transplant process and improve its success rate.


References:

  1. Kasiske BL, Ravenscraft M, Ramos EL, Gaston RS, Bia MJ, Danovitch GM. The evaluation of living renal transplant donors: clinical practice guidelines. Ad Hoc Clinical Practice Guidelines Subcommittee of the Patient Care and Education Committee of the American Society of Transplant Physicians. J Am Soc Nephrol. 1996;7(11):2288-2313.
    PubMed
  2. Jordan ML, Cook GT, Cardella CJ. Ten years of experience with vascular complications in renal transplantation. J Urol. 1982;128(4):689-692.
    PubMed
  3. Salaman JR, Clarke AG, Crosby DL. The management of kidney transplants damaged during their removal from the donor. Br J Urol. 1974;46(2):173-177.
    CrossRef - PubMed
  4. Janschek EC, Rothe AU, Hölzenbein TJ, et al. Anatomic basis of right renal vein extension for cadaveric kidney transplantation. Urology. 2004;63(4):660-664.
    CrossRef - PubMed
  5. Nerstrom B, Ladefoged J, Lund F. Vascular complications in 155 consecutive kidney transplantations. Scand J Urol Nephrol. 1972;6:(suppl 15):65-74.
    CrossRef - PubMed
  6. Ciudin A, Musquera M, Huguet J, et al. Transposition of iliac vessels in implantation of right living donor kidneys. Transplant Proc. 2012;44(10):2945-2948.
    CrossRef - PubMed
  7. Taylor RJ, Hakala TR, Rosenthal JT. Use of vena cava to extend the right renal vein in cadaveric transplants. Surg Gynecol Obstet. 1985;160(3):279-280.
    PubMed
  8. Chin JL. Vena caval extension of right renal vein for cadaveric renal transplants. J Urol. 1988;139(3):552-553.
    PubMed
  9. Tan LC, Rahman AU, Walters AM, Sadek SA. The inferior vena caval conduit--a neglected technique in transplantation of the right cadaveric kidney? Transpl Int. 2000;13(suppl 1):S60-S63.
    CrossRef - PubMed
  10. Baptista-Silva JC, Medina-Pestana JO, Verissimo MJ, Castro MJ, Demuner MS, Signorelli MF. Right renal vein elongation with the inferior vena cava for cadaveric kidney transplants. An old neglected surgical approach. Int Braz J Urol. 2005;31(6):519-525; discussion 525.
    CrossRef - PubMed
  11. Simforoosh N, Aminsharifi A, Tabibi A, Fattahi M, Mahmoodi H, Tavakoli M. Right laparoscopic donor nephrectomy and the use of inverted kidney transplantation: an alternative technique. BJU Int. 2007;100(6):1347-1350.
    CrossRef - PubMed
  12. Oertl AJ, Jonas D, Oremek GM, Jones J. Saphenous vein interposition as a salvage technique for complex vascular situations during renal transplantation. Transplant Proc. 2007;39(1):140-142.
    CrossRef - PubMed
  13. Feng JY, Huang CB, Fan MQ, Wang PX, Xiao Y, Zhang GF. Renal vein lengthening using gonadal vein reduces surgical difficulty in living-donor kidney transplantation. World J Surg. 2012;36(2):468-472.
    CrossRef - PubMed
  14. Puche-Sanz I, Pascual-Geler M, Vázquez-Alonso F, et al. Right renal vein extension with cryopreserved external iliac artery allografts in living-donor kidney transplantations. Urology. 2013;82(6):1440-1443.
    CrossRef - PubMed


Volume : 14
Issue : 2
Pages : 224 - 226
DOI : 10.6002/ect.2014.0085


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From the 1Department of Vascular Surgery, YanTai Yuhuangding Hospital; the 2Yantai Hospital Affiliated to Binzhou Medical University; the 3Department of Urology Surgery; and the 4Yantai Drug Rehabilitation Center, YanTai, ShanDong, 264000, China
Acknowledgements: The authors declare that they have no sources of funding for this study, and they have no conflicts of interest to declare.
Corresponding author: Juwen Zhang, M.D., Department of Vascular Surgery, YanTai Yuhuangding Hospital, QingDao Medical School, QingDao University, No. 20, Yuhuangding East Road, YanTai, ShanDong, 264000, China
Phone: +86 139 6459 9862
Fax: +86 53 5666 5711
E-mail: zhangjuwenvascular@163.com