A United States Army Medical Department,

continuing Education program,

technical problems,

vascular with 

John D Welchel,

Lieutenant Colonel US Air Force Medical Corps 

Chief Transplant unit,

Wilford Hall US Air Force Medical Center,

Lackland Air Force Base.

As experience in renal transplantation has 

increased over the years.

The instance of primary vascular complication 

appears to be decreasing as reflected in the 

transplant registry.

The time honored use of the hypogastric artery and the 

iliac vein of the recipient to revascularize a 

graft still appears to be the preferred 

technique in the majority of transplant centers.

The increasing utilization of donor graphs with 

multiple renal arteries,

pediatric transplants and 

occlusive vascular disease and transplant recipients 

and donors have tested the ingenuity of the 

of the transplant surgeon and has 

resulted in the development of various 

techniques for the successful re vascularization 

of renal graphs.

The development of preservation methods that enable 

the maintenance of kidneys outside of the donor 

has enabled the surgeon to repair damaged vessels 

or to modify the vascular anatomy to 

facilitate revascularization in the 

recipient.

Thrombosis of the arterial and venous anastomosis are 

complications that have been seen in most if not 

all major transplant programs.

First,

slide.

The suggested claw causes of these problems include 

poor suture,

technique,

excessive vessel linked with acute kinking,

obstruction of the renal vessels by poor location or 

positioning of the graft.

Incomplete endarectomy of the donor 

recipient arteries,

infection and rejection,

partial thrombosis of an arterial or a 

Venus anastomosis may be relatively asymptomatic 

or it may be associated with deterioration of renal 

function.

Complete obstruction of the renal artery results in 

sudden oligo and rapid death of the 

graft.

If a graph fails to produce or ceases 

to produce urine following transplant,

the possibility of a vascular inclusion must be different.

Differentiated from acute tub of 

necrosis,

renal obstruction or hyper acute rejection.

We have found that the 

use of magnesium scans to quickly rule out the 

arterial collusion in such situations can 

frequently help you avoid the use of 

arteriography or invasive techniques.

Partial venous inclusion is frequently difficult to 

diagnose as the symptoms may vary from none 

to deterioration of renal function,

hematuria and massive Proia 

depending depending upon the degree of obstruction.

The recommended treatment for partial venus seclusion is 

he?

While immediate surgical intervention is required 

for complete obstruction of the arterial of 

venus anastomosis if 

success in our graph survival is 

expected.

Although the problems encountered with graphs that have 

multiple vessels are not truly vascular 

complications.

The increasing use of such graphs especially from living 

related donors makes this subject worthy of 

further discussion.

First,

slide when small polar vessels 

such as one scene in this slide are present.

Past reports indicated that they could be safely located 

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

graft.

In the past,

there was also a reluctance to utilize kidneys from living related 

donors with several renal vessels due to the 

multiple sometimes difficult anastomoses 

and the prolonged ischemia time encountered to 

complete these animes.

The University of Minnesota recently reviewed 

their experience with the use of living related 

donors that had multiple vessels.

They concluded that living related donors did slightly 

better than those with multiple vessels.

But those donor grass with multiple vessels did significantly better 

than cadaver grass with single vessels.

They also concluded that ligation of small 

polar vessels resulted in a greater instance of 

complications and a more serious and more serious 

rejection episodes.

It was their conclusion and recommendation that 

vascularization of all arteries should be performed 

if at all possible.

A number of interesting techniques have been devised for this 

purpose.

The first,

I think I'm sure you,

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

cadaver transplants which has been done for 

several years or for a prolonged time.

Dr Belser has recently described the obstructive 

effect of suturing a small thin wall 

vessel to a larger thick wall vessel.

He has devised a technique to 

avoid this constricting effect by 

constructing a type of corral patch,

utilizing a vein wall has demonstrated on this 

slide.

This has been successfully used by myself and 

by other surgeons.

Other methods include suturing 

small accessory arteries to the 

large renal artery.

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

suturing both to the main renal 

artery.

I have done this on one occasion and found it very 

satisfactory 

when a short renal vessel exists a 

vein patch or a vein graft or even a 

small artery from the donor can be used to extend the 

length for either swinging it up for the Anestis 

shown in the upper portion of the slide for 

inclusion of a double Anestis to an 

iliac vessel,

whichever seems to,

whichever is the most easiest is easiest at the time.

Or another technique when you have two vessels of a similar 

size is to suit the two vessels together,

forming one and thus one and assis 

frequently this is a nice technique to utilize when you have 

a large hypogastric artery and two small or two 

equal size vessels.

When multiple renal veins are present,

small veins can usually be safely ligated.

If there is one large renal vein.

And due to the rich in renal venus and asses,

if there are two renal veins of approximately the same 

size,

then it's probably best to revascularize both 

as the ligation of one of such veins can 

sometimes result in massive protein area as seen in 

one patient reported from the Medical College of Georgia.

If there is damage to the renal vein during the 

framing resulting in an excessively short length of 

vein.

The following technique has been successfully used to 

revascularize the graft with minimal 

difficulty.

Ring artery stenosis is being reported with 

increasing frequency.

Clinically.

This lesion is usually associated with a brewing over the 

renal artery,

uncontrollable hypertension and deterioration of renal 

function.

Thrombosis has also been a complication of renal artery 

stenosis.

The value of R levels and diagnosing this lesion in the 

face of hypertension is a is remains a 

controversy and the exact role of this 

test at the present time is undetermined.

Doll recently described two types of renal large 

stenosis angulation and segmental 

angulation,

stenosis.

He attributed to excessive vessel length and binding 

adhesions.

He described three patients in his series with this lesion 

whose hypertension was relieved by release 

of the adhesions.

Segmental stenosis is the type most frequently 

seen and it's characterized by 

stenotic area occurring distal to 

the patent anastomotic area,

vessel damage due to either flow dist services 

or immunological reaction have been considered 

as a possible ideology of this tono lesion.

The methods of repair include vein patch,

angioplasty vein vein,

uh bypass graft are a primary excision of 

the sona area and 

this is a slide of one of our three 

patients who have developed surgically 

correctable lesions and this lesion is a 

very tight stenotic area which is distal to the 

anastomosis.

All three of our patients have been successfully 

treated by primary excision of the 

stenotic area and re Anestis of the vessel.

All three had sustained hypertension refractory to 

anti hypertensive medication and breweries that 

developed late in their transplant course.

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

problems both related to hypertension.

This particular patient had a correctable lesion,

although it would have been correct with great difficulty as it 

was in one of the branches of the renal artery.

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

intrarenal.

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

lesions without a significant risk to the kidney.

Fortunately,

both of these kidneys,

both of these patients hypertension could be 

controlled with medical therapy and further 

treatment or further surgical intervention was not 

necessary slides off,

please.

Disruption of the vascular estos 

occurs and has been reported.

But this complication is almost always associated 

with infection of the su line,

except in unusual circumstances,

the graphs should be removed.

In summary,

the vascular problems encountered in renal transplantation are 

varied and require thorough knowledge of the 

techniques and principles of vascular surgery on the part of the 

transplant surgeon and sometimes a rather 

creative imagination.

I must confess in my experience,

there have been multiple occasions when I wondered if the creative 

imagination was not the most important 

technical problems vascular 

with John D Welchol.

Lieutenant Colonel US Air Force Medical Corps 

Chief Transplant Unit,

Wilford Hall,

us Air Force Medical Center Lackland Air 

Force Base was produced through the mobile 

facilities of the television division,

Academy of Health Sciences.

United States Army,

Fort Sam Houston,

Texas.