Objective Measurement of
Adequacy of Vascular Anastomosis
in Renal Transplant
Dr Ajay Aspari Raghunath
Dr Dilip C Dhanpal
Department of Nephro-Urology and Transplantation
Sagar Hospitals, Jayanagar
Bangalore
Introduction

Problems with Inadequate Vascular
Anastomosis
◦ Thrombotic complications
 Renal Artery Thrombosis
◦ Stenotic Complications
 Renal Artery Stenosis
◦ Haemorrhagic Complications
AFFECTING GRAFT AND PATIENT
SURVIVAL
Osmany , Shokeir A , Ali-el Dein B et al [2003]Vascular Complications After Live Donor Renal Transplantation: Study of Risk
Factors And Effects on Graft and Patient survival. Journal of Urology 169, 859–862
Introduction contd.

Criteria for assessment of Adequacy of Vascular Anastomosis
in Renal transplant

Subjective Criteria
◦ Thrill
◦ Pulsations

Surrogate Criteria
◦ Colour of Kidney
◦ Turgidity of Kidney
◦ Immediate urine output via transplanted kidney
NO OBJECTIVE CRITERION FOR A GOOD
ANASTOMOSIS INTRAOPERATIVELY
1
2
3
4

If the above are NOT satisfied,
◦ Systemic Measures
 Central Venous Pressure
 Blood Pressure
◦ Local Measures





Intra arterial Papaverine
Periarterial Lignocaine spray
On table USG Doppler
Biopsy of Kidney [ in case of suspected rejection ]
A redo anastomosis is in order if the above
are not satisfactory
. John M Barry, Transplantation as Treatment of End-Stage Renal Disease and
Technical Aspects of Renal transplantation
Aim

To define an objective measurement of
Vascular Anastomotic adequacy

Pilot study

First ever Objective Criteria to be
described
Materials and Methods

Recruitment
◦ Every consecutive patient undergoing transplant
◦ End to End anastomosis [Internal Iliac A. to Tx Renal A. ]

Exclusion
◦ Pediatric
◦ End to side [External Iliac A. To Tx Renal A.]
◦ Thromboendarterectomy [ 1 case ]

22G Cannula for intra arterial pressure
◦ Why 22 Gauge ??
◦ Measurement across anastomosis
 Technique

Study period – January 2011 to Date
SITE OF
ANASTOMOSIS
PRE ANASTOMOTIC
PRESSURE
Follow up

USG Doppler studies
◦ Post Operative Day -1

Evaluation of Renal Blood flow
◦ From Renal artery upto Arcuate arteries
Resistive Index Criteria

Main Renal Artery

Divisional Artery
◦ Anterior
◦ Posterior

Segmental Artery

Interlobar Artery

Lobular Artery

Arcuate Artery
Resistive Index Criteria

Tool for assessing changes in renal
perfusion
Line H , Naesens M , Lerut E et al [2013] Intrarenal Resistive Index after Renal Transplantation. New
England Journal of Medicine. 369:1797-1806
M Darnel, D Schnell, F Zeni [2010] Doppler-Based Renal Resistive Index: A Comprehensive Review.
Yearbook of Intensive Care and Emergency Medicine. pp 331-338
Resistive Index Criteria

Accepted RI Criteria –
◦ 0.6 – 0.8
Line H , Naesens M , Lerut E et al [2013] Intrarenal Resistive Index after Renal
Transplantation. New England Journal of Medicine. 369:1797-1806

Resistive Index

Pulsatility index
◦ [ Systolic Velocity – Diastolic Velocity] / Mean Velocity
Results
13 cases
 Least gradient = 6 mm Hg
 Highest Gradient = 17 mm Hg

◦ Mean Pressure gradient = 10.76 mmHg
◦ Median Pressure Gradient = 9 mm Hg
◦ Mode = 12 mm Hg
Pressure
Gradient
Resistive
Index Hilar
Resistive
IndexSegmental
Arteries
Resistive
Index –
Arcuate
Arteries
1
12
0.76
0.70
0.69
2
14
0.78
0.73
0.7
3
9
0.67
0.51
0.54
4
11
0.64
0.53
0.52
5
14
0.73
0.7
0.67
6
12
0.7
0.67
0.65
7
8
0.6
0.51
0.51
8
7
0.59
0.54
0.52
9
6
0.54
0.58
0.55
10
8
0.57
0.61
0.58
11
10
0.74
0.68
0.61
12
12
0.71
0.66
0.57
13
17
0.79
0.77
0.74

Correlation Coefficients
◦ Pressure gradient vs Resistive index
Hilar
r = 0.9
Segmental Arteries
r = 0.81
ArcuateArteries
r = 0.85
Discussion

Correlation between Pressure gradient
and Vascular resistive index
◦ Higher the gradient, higher the resistance

Utility of pressure gradient
Discussion

Why not Doppler On Table??
◦ Doppler may pick up readings only for
stenosis beyond 60-70%
◦ Not reflective of mild to moderate stenosis

Doppler studies are no longer done to
diagnose Renal Artery Stenosis
Discussion

Such a technique has been recommended for Lung
transplant

Has been carried out in Coronary artery surgeries
◦ > 30mm Hg is unacceptable warranting a redo
anastomosis
No literature for Renal transplant
◦ Since Renal Vessels are bigger than Coronary vessels,
we arbitrarily propose a cut off of 20 mmHg

Siddiqui A ,Bose A K, Ozalp F et al [2013] Vascular anastomotic complications in lung transplantation:
a single institution’s experience. Interactive CardioVascular and Thoracic Surgery 17 - 625–631
Discussion

To define the Criterion based on Pressure
Gradient
◦ Require further studies and also animal
experiments
Conclusion

Simple method for measurement of Vascular
Adequacy

Application of Pressure gradient
measurement will reflect:
◦ Lesser rates of failed transplant
◦ Criterion useful for Young Transplant surgeons
 Eg. at high volume centres and teaching institutes where
in inadequate anastomosis on table is quickly detected
and a redo is done rather than flogging a tired horse
References

Osmany , Shokeir A , Ali-el Dein B et al [2003]Vascular Complications After
Live Donor Renal Transplantation: Study of Risk Factors And Effects on
Graft and Patient survival. Journal of Urology 169, 859–862

John M Barry, Transplantation as Treatment of End-Stage Renal Disease and
Technical Aspects of Renal Transplantation

Line H , Naesens M , Lerut E et al [2013] Intrarenal Resistive Index after
Renal Transplantation. New England Journal of Medicine. 369:1797-1806

M Darnel, D Schnell, F Zeni [2010] Doppler-Based Renal Resistive Index: A
Comprehensive Review.Yearbook of Intensive Care and Emergency
Medicine. pp 331-338

Siddiqui A ,Bose A K, Ozalp F et al [2013] Vascular anastomotic
complications in lung transplantation: a single institution’s experience.
Interactive CardioVascular and Thoracic Surgery 17 - 625–631
Thank You