The presence of multiple renal vessels and short renal vessels are frequent in living donor kidney transplantation. The importance of greater involvement of vascular surgeons has been recognized in these procedures in which complex vascular reconstructions are often required. The surgeon's ability to deal with such vascular challenges is critical to avoid wasting organs.

We performed a retrospective analysis of kidney graft vascular reconstructions performed in living donor kidney transplantation over ten years, at our institution, from January 2009 to December 2019. The surgical team was composed of a vascular surgeon and a urologist for all kidney transplants. All recipients underwent a detailed preoperative assessment, and all donors made a computed tomography angiography to identify structural kidney anomalies and vascular and urological anatomical variations. We evaluated intervention time, vascular complications, acute tubular necrosis, delayed graft function, serum creatinine levels, graft rejection episodes, and graft and patient survival rates. Statistical analysis was performed using SPSS V. 27, with p <0.05 considered significant.

From January 2009 to December 2019, 264 living donor kidney transplants were performed, 14 of which were ABO incompatibility. Of the total number of donors, 56 grafts (21%) had multiple renal vessels, and in 3 donors, saccular aneurysms of the renal artery branches (1%) were identified. Kidney harvesting was performed laparoscopically in 216 patients (82%). Arterial anastomoses were done to the external, internal, and common iliac arteries, and for venous anastomoses, we used the external iliac vein and the vena cava. Eighty-six of the grafts (33%) required vascular reconstruction on the bench, namely arterial reconstructions in 44 patients (17%) and venous reconstructions in 17 patients (6%). In 25 patients (10%), reconstructions of both artery and vein were done. Arterial reconstructions were more frequent in left kidneys (78%) and venous reconstructions in right kidneys (64%). There were no significant differences between transplants with and without the need for vascular reconstruction in what concerns delayed graft function, acute tubular necrosis, rejection episodes, and post-transplantation serum creatinine levels at 1, 2, and 5 years (p. >0.05). The rate of vascular complications, namely, bleeding requiring reintervention, vascular thrombosis, and arterial stenosis, was also not significantly different between the two groups (p>0.05). At 5 and 10 years, graft survival rates were 93.0% and 90.6% in the vascular reconstruction group and 97.7% and 93.3% in the no-reconstruction group. The 5-year patient survival rates were 97.6% and 98.3% in the groups with and without vascular reconstruction. There were no significant differences in patient and transplanted kidney survival between the two groups.

The results of kidney transplants submitted to vascular reconstructions are not significantly different from grafts in which such reconstruction is not necessary. The integration in kidney transplantation teams of vascular surgeons with adequate technical capacity for vascular reconstructions allows the transplantation of grafts with complex vascular anatomies, thus increasing the pool of available donors for kidney transplantation from living donors.

Lejay A, Caillard S, Thaveau F, Chakfe N. Why Should Vascular Surgeons be More Involved in Kidney Transplantation? Eur J Vasc Endovasc Surg 2018; 55(4): 455-6.