Clinical impact of adjunctive donor microvascular reconstruction on renal transplantation

Microvascular reconstruction was incorporated into our donor organ harvesting algorithm for kidneys with anatomic anomalies or injury of the vasculature. The impact of adjunctive microsurgery was appraised in terms of organ availability and graft quality procedures.

Out of a total of 441 renal transplant procedures performed by one surgeon (JLC) between 1984 and 1997, 104 allografts (83 cadaveric, 21 living related) required ex-vivo microvascular reconstruction. Micro-reconstruction using 2.5-10 X magnification was employed to create a single artery and vein for subsequent in-situ anastomosis. Side-to-side or end-to-side anastomosis was performed, depending on the vascular arrangement. Multiple vessels and those injured during harvesting were reconstructed with a combination of the above techniques.

Eleven kidneys had two or more arterial anastomoses; 12 had combination (arterial and venous) anastomoses while 74 required a single micro-reconstruction. In addition, seven kidneys with severely traumatized vessels were salvaged. Average bench surgery times were 30 and 50 minutes for single and multiple reconstructions respectively. Mean warm ischemic time was 29 minutes. Three kidneys were lost due to vascular thrombosis (two venous, one arterial) where in-situ technical difficulties were encountered in all three cases. With mean follow-up of 30 months, 23 kidneys had been lost due to chronic rejection with the remainder functioning.

Extensive microvascular reconstruction salvaged 30 suboptimal or previously deemed unusable grafts (30/439 = 7%) and facilitated the vascular anastomosis in another 74 cases (17%). The warm ischemic time and the possibility of in-situ technical errors with small-calibre vessels were minimized. This report affirms the contention that microvascular reconstruction should be available as an adjunctive technique for renal transplantation, to maximize the quantity and quality of donor kidneys.