WEBVTT

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A United States Army Medical Department,

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continuing Education program,

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technical problems,

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vascular with

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John D Welchel,

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Lieutenant Colonel US Air Force Medical Corps

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Chief Transplant unit,

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Wilford Hall US Air Force Medical Center,

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Lackland Air Force Base.

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As experience in renal transplantation has

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increased over the years.

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The instance of primary vascular complication

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appears to be decreasing as reflected in the

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transplant registry.

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The time honored use of the hypogastric artery and the

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iliac vein of the recipient to revascularize a

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graft still appears to be the preferred

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technique in the majority of transplant centers.

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The increasing utilization of donor graphs with

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multiple renal arteries,

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pediatric transplants and

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occlusive vascular disease and transplant recipients

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and donors have tested the ingenuity of the

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of the transplant surgeon and has

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resulted in the development of various

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techniques for the successful re vascularization

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of renal graphs.

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The development of preservation methods that enable

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the maintenance of kidneys outside of the donor

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has enabled the surgeon to repair damaged vessels

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or to modify the vascular anatomy to

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facilitate revascularization in the

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recipient.

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Thrombosis of the arterial and venous anastomosis are

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complications that have been seen in most if not

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all major transplant programs.

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First,

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slide.

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The suggested claw causes of these problems include

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poor suture,

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technique,

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excessive vessel linked with acute kinking,

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obstruction of the renal vessels by poor location or

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positioning of the graft.

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Incomplete endarectomy of the donor

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recipient arteries,

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infection and rejection,

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partial thrombosis of an arterial or a

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Venus anastomosis may be relatively asymptomatic

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or it may be associated with deterioration of renal

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function.

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Complete obstruction of the renal artery results in

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sudden oligo and rapid death of the

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graft.

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If a graph fails to produce or ceases

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to produce urine following transplant,

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the possibility of a vascular inclusion must be different.

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Differentiated from acute tub of

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necrosis,

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renal obstruction or hyper acute rejection.

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We have found that the

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use of magnesium scans to quickly rule out the

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arterial collusion in such situations can

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frequently help you avoid the use of

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arteriography or invasive techniques.

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Partial venous inclusion is frequently difficult to

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diagnose as the symptoms may vary from none

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to deterioration of renal function,

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hematuria and massive Proia

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depending depending upon the degree of obstruction.

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The recommended treatment for partial venus seclusion is

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he?

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While immediate surgical intervention is required

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for complete obstruction of the arterial of

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venus anastomosis if

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success in our graph survival is

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expected.

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Although the problems encountered with graphs that have

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multiple vessels are not truly vascular

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complications.

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The increasing use of such graphs especially from living

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related donors makes this subject worthy of

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further discussion.

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First,

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slide when small polar vessels

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such as one scene in this slide are present.

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Past reports indicated that they could be safely located

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if they appeared to supply only approximately 10% of the renal

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graft.

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In the past,

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there was also a reluctance to utilize kidneys from living related

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donors with several renal vessels due to the

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multiple sometimes difficult anastomoses

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and the prolonged ischemia time encountered to

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complete these animes.

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The University of Minnesota recently reviewed

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their experience with the use of living related

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donors that had multiple vessels.

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They concluded that living related donors did slightly

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better than those with multiple vessels.

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But those donor grass with multiple vessels did significantly better

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than cadaver grass with single vessels.

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They also concluded that ligation of small

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polar vessels resulted in a greater instance of

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complications and a more serious and more serious

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rejection episodes.

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It was their conclusion and recommendation that

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vascularization of all arteries should be performed

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if at all possible.

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A number of interesting techniques have been devised for this

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purpose.

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The first,

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I think I'm sure you,

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most of you are familiar with is use of a corral patch and

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cadaver transplants which has been done for

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several years or for a prolonged time.

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Dr Belser has recently described the obstructive

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effect of suturing a small thin wall

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vessel to a larger thick wall vessel.

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He has devised a technique to

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avoid this constricting effect by

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constructing a type of corral patch,

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utilizing a vein wall has demonstrated on this

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slide.

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This has been successfully used by myself and

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by other surgeons.

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Other methods include suturing

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small accessory arteries to the

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large renal artery.

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If one is present or this could be done in the case of three

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suturing both to the main renal

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artery.

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I have done this on one occasion and found it very

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satisfactory

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when a short renal vessel exists a

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vein patch or a vein graft or even a

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small artery from the donor can be used to extend the

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length for either swinging it up for the Anestis

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shown in the upper portion of the slide for

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inclusion of a double Anestis to an

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iliac vessel,

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whichever seems to,

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whichever is the most easiest is easiest at the time.

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Or another technique when you have two vessels of a similar

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size is to suit the two vessels together,

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forming one and thus one and assis

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frequently this is a nice technique to utilize when you have

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a large hypogastric artery and two small or two

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equal size vessels.

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When multiple renal veins are present,

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small veins can usually be safely ligated.

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If there is one large renal vein.

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And due to the rich in renal venus and asses,

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if there are two renal veins of approximately the same

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size,

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then it's probably best to revascularize both

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as the ligation of one of such veins can

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sometimes result in massive protein area as seen in

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one patient reported from the Medical College of Georgia.

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If there is damage to the renal vein during the

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framing resulting in an excessively short length of

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vein.

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The following technique has been successfully used to

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revascularize the graft with minimal

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difficulty.

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Ring artery stenosis is being reported with

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increasing frequency.

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Clinically.

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This lesion is usually associated with a brewing over the

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renal artery,

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uncontrollable hypertension and deterioration of renal

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function.

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Thrombosis has also been a complication of renal artery

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stenosis.

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The value of R levels and diagnosing this lesion in the

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face of hypertension is a is remains a

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controversy and the exact role of this

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test at the present time is undetermined.

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Doll recently described two types of renal large

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stenosis angulation and segmental

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angulation,

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stenosis.

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He attributed to excessive vessel length and binding

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adhesions.

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He described three patients in his series with this lesion

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whose hypertension was relieved by release

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of the adhesions.

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Segmental stenosis is the type most frequently

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seen and it's characterized by

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stenotic area occurring distal to

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the patent anastomotic area,

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vessel damage due to either flow dist services

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or immunological reaction have been considered

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as a possible ideology of this tono lesion.

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The methods of repair include vein patch,

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angioplasty vein vein,

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uh bypass graft are a primary excision of

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the sona area and

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this is a slide of one of our three

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patients who have developed surgically

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correctable lesions and this lesion is a

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very tight stenotic area which is distal to the

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anastomosis.

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All three of our patients have been successfully

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treated by primary excision of the

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stenotic area and re Anestis of the vessel.

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All three had sustained hypertension refractory to

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anti hypertensive medication and breweries that

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developed late in their transplant course.

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We've had two other patients who have developed renal artery

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problems both related to hypertension.

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This particular patient had a correctable lesion,

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although it would have been correct with great difficulty as it

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was in one of the branches of the renal artery.

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The next patient had a lesion that was not correctable and it was

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intrarenal.

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But I don't think we could have surgically corrected either of these

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lesions without a significant risk to the kidney.

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Fortunately,

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both of these kidneys,

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both of these patients hypertension could be

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controlled with medical therapy and further

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treatment or further surgical intervention was not

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necessary slides off,

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please.

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Disruption of the vascular estos

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occurs and has been reported.

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But this complication is almost always associated

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with infection of the su line,

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except in unusual circumstances,

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the graphs should be removed.

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In summary,

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the vascular problems encountered in renal transplantation are

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varied and require thorough knowledge of the

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techniques and principles of vascular surgery on the part of the

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transplant surgeon and sometimes a rather

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creative imagination.

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I must confess in my experience,

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there have been multiple occasions when I wondered if the creative

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imagination was not the most important

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technical problems vascular

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with John D Welchol.

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Lieutenant Colonel US Air Force Medical Corps

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Chief Transplant Unit,

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Wilford Hall,

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us Air Force Medical Center Lackland Air

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Force Base was produced through the mobile

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facilities of the television division,

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Academy of Health Sciences.

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United States Army,

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Fort Sam Houston,

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Texas.