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For citation purposes: He B, Hamdorf JM. Clinical importance of anatomical variations of renal vasculature during laparoscopic donor nephrectomy. OA Anatomy 2013 Oct 18;1(3):25.

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Abstract IntroductionLaparoscopic live donor nephrec-tomy has become a well-accepted practice in most transplant units. However, the variations and complex of renal vasculature may make the surgery even more challenging during laparoscopic donor nephrec-tomy. The aims of this article are to review embryology of the renal vasculature development and the clinical significance of renal vascula-ture anomalies during laparoscopic donor nephrectomy and the conse-quence of kidney transplant. DiscussionThe results were interpreted and summarised as renal artery develop-ment and its anomalies and renal vein development and its anomalies including associated anomalies of the inferior vena cava. The clinical signifi-cance during laparoscopic donor nephrectomy was explored. The value of computed tomography angiog-raphy was emphasised during live donor work-up and before surgery planning.ConclusionIt is paramount for surgeons to have a thorough knowledge of renal vascula-ture development and to readily iden-tify the anomalies of renal vascula-ture on computed tomography angiography prior to laparoscopic donor nephrectomy. The adverse

Clinical importance of anatomical variations of renal vasculature during laparoscopic donor nephrectomy

B He1,2*, JM Hamdorf2

bleeding event can be therefore prevented.

IntroductionLaparoscopic donor nephrectomy has become the standard of care in most transplant centres around the world. It is a unique surgery to predis-pose the surgeons under stress as healthy donors have a major surgery purely for others’ benefits rather than themselves. Renal vessels are known with a wide range of variations that have also been evidenced during live kidney donor work-up in recent years. Most of these variations may otherwise have no clinical signifi-cance other than the surgery for lapa-roscopic donor nephrectomy. These variations can lead to significant surgical complications or even life-threatening events if unrecognised. There are increased reports in the literature identifying variation of renal vasculature during live donor nephrectomy1–11. Undoubtedly, a thorough knowledge in under-standing of the embryologic develop-ment and associated anatomy of renal vessel variations will equip the surgeons to anticipate and manage these potential risks successfully to prevent the complications. Therefore, the aims of this review are to explore the embryology of renal vasculature and associated variations and to emphasise the importance during laparoscopic live donor nephrectomy.

DiscussionThe authors have referenced some of their own studies in this review. These referenced studies have been conducted in accordance with the Declaration of Helsinki (1964), and

the protocols of these studies have been approved by the relevant ethics committees related to the institution in which they were performed. All human subjects, in these referenced studies, gave informed consent to participate in these studies.

Embryology of renal arteriesThe kidneys ascend to the lumbar region below the adrenal glands during the embryological develop-ment between the sixth and ninth weeks possibly due to differential growth of the lumbar and sacral regions of the embryo. As the kidneys ascend they are vascularised by a succession of transient aortic sprouts that arise at higher levels progres-sively. These arteries do not elongate to follow the ascending kidneys; instead they are degenerated and replaced by successive new arteries. The final pair of arteries forms in the upper lumbar region as the definitive renal arteries. Sometimes, the infe-rior pair of arteries is not degener-ated and becomes an accessory lower pole artery. The kidney may become ectopic in the pelvis if it fails to ascend adequately (Figure 1) The horseshoe kidney may be developed if the lower pole is fused and becomes trapped by the inferior mesenteric artery and thus the kidney cannot ascend to the lumbar region12.

The origin of intrarenal vascula-ture has not yet been completely understood. It was postulated that the renal vasculature derived exclu-sively from the branches off the aorta and other pre-existing extrarenal vessels. However, there was evidence that the renal vessels may originate within the embryonic kidney from

*Corresponding author Email: bulang.he@health.wa.gov.au1 Sir Charles Gairdner Hospital, Hospital Ave-

nue, Nedlands, Perth, Australia2 School of Surgery, The University of Western

Australia, Crawley, WA, Perth, Australia

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For citation purposes: He B, Hamdorf JM. Clinical importance of anatomical variations of renal vasculature during laparoscopic donor nephrectomy. OA Anatomy 2013 Oct 18;1(3):25.

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the vascular progenitor cells13,14. It was also thought that both vasculo-genesis and angiogenesis may play a role in the development of renal vasculature12,15.

Renal artery variationsIn the context of live donor work-up on computed tomography angiogram (CTA), the single normal renal artery is about 70%, two renal arteries 25% and three renal arteries 2.6%16–18. The prevalence of multiple renal arteries on both sides is about 12%19. Rarely, four renal arteries on each side may be encountered during imaging work-up of 1.3%16,19,20. The most common variations of renal artery are excess renal arteries and early bifur-cation. The accessory renal artery is defined as the artery that has a sepa-rate aortic ostium from the main renal artery and supply to the upper or lower pole. The aberrant renal artery is defined as the artery that has a separate aortic origin but goes into the renal hilum. The incidence of

excess renal arteries ranges from 25% to 40%17,21,22. In addition, the renal artery can arise at unusual aortic origin such as above the superior mesentery artery or celiac trunk, in which the renal artery may be entrapped in the medial arcuate liga-ment5,16,23. In this situation, the renal artery may be compressed and presented with symptoms of hyper-tension. The compression to renal artery may occur in the presence of low insertion of median arcuate liga-ment or high origin of the renal artery24 (Figure 2a, 2b). As such, the donor nephrectomy should be consid-ered on this side. The inferior renal accessory artery can arise from the iliac artery or as a common trunk with the inferior mesenteric artery25. The right aberrant renal artery may be precaval23. The accessory renal artery can rarely arise from the mesenteric artery or lumbar arteries19. In addi-tion, the main arterial supply of a kidney may be from an extension of the opposite renal artery26.

Laparoscopic donor nephrectomy can be safely performed in the donor with multiple renal arteries with equivalent transplant results to those kidney grafts with a single renal artery27–29. The technique for recon-struction of multiple renal arteries has also been established with satis-factory results29–31. It is essential to interpret CTA accurately prior to surgery and identify the excess renal artery during surgical dissection.

The early branching of renal artery is defined as the branches arising within 15 mm from the origin of the main renal artery ostium18. The inci-dence is around 10%–12%16,17,32. In author’s experience, the one ostium usually can be obtained during lapa-roscopic donor nephrectomy if the early branches are beyond 10 mm from the origin of the main renal artery. Otherwise, the renal arteries can be reconstructed on the back table or separate renal artery anasto-mosis to the recipient can be performed successfully30,31.

Figure 1: Renal artery and renal vein in ectopic kidney. RA, renal artery; RV, renal vein; Lt, left.

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For citation purposes: He B, Hamdorf JM. Clinical importance of anatomical variations of renal vasculature during laparoscopic donor nephrectomy. OA Anatomy 2013 Oct 18;1(3):25.

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posterior abdominal wall, need to be dissected and divided carefully to expose the proximal part of the renal artery for a better length, in particular if there are early renal artery branches. Lumbar vein is usually short in length and big in calibre. It can become a challenge during laparoscopic donor nephrectomy because of the risk of accidental injury and subsequent bleeding, which may lead to conver-sion to open surgery39–41. Therefore, the injury to lumbar veins should be ultimately avoided. In addition, the anomalies of lumbar vein are frequently encountered during left side donor nephrectomy including agenesis and collaterals1. Often, there are one or two lumbar veins, accounting for 65%–80%. Rarely, there are three lumbar veins of 3%1,42. The multiple lumbar veins may make up a net-like structure (Figure 3). The lumbar veins were usually inferior to the renal vein and inferior and poste-rior to the renal artery, usually at the lumbar vertebral level-1. They may not be adequately visualised during surgery by transperitoneal approach, in which the injury of lumbar vein is likely to cause serious bleeding43. Therefore, the retroperitoneal approach offers a better view to iden-tify the details of lumbar vein more

Embryology of the renal veinsThe formation of the renal vein is a complex process during embryologic development. In brief, the initial venous drainage in the embryo is by anterior paired cardinal veins draining the cranial half of the body and by posterior paired cardinal veins draining the caudal half of the body33. The subcardinal veins form subsequently and gradually take over the drainage of the caudal half of the body. Then the posterior cardinal veins start to degenerate. The subcar-dinal veins communicate with hepatic sinusoids in the region of the liver form of the hepatic segment of the inferior vena cava (IVC). The cranial part of the right subcardinal vein becomes the supra renal IVC, while the cranial part of the left subcardinal vein forms the left adrenal vein. During the seventh week of embryo, the supracardinal veins develop and gradually take over the venous drainage of the caudal body. The right supracardinal veins extend and form the infrarenal IVC. The cranial aspect of the right supracardinal vein forms the azygous vein. The caudal aspect of the posterior cardinal vein becomes the common iliac veins. The renal veins are formed as ventral and dorsal veins as a result of the anasto-

mosis of the supra- and subcardinal veins. The ventral vein becomes the definitive renal vein, whereas the dorsal vein is gradually degenerated. The subcardinal veins extend caudally forming the gonadal vessels33. Based on the complex of venous develop-ment during gestation, it is therefore understood that renal vein anomalies are closely associated with malfor-mation of IVC34.

Multiple renal veins and lumbar veinsClinically, conventional single renal vein is the most common anatomy in live donor work-up, but anatomy vari-ations are identified in 5%–30%16,19,35. The most common renal venous anomaly is the occurrence of dual renal veins, accounting for 15%–30%, frequently on the right side18,19,23,36. In this case, the smaller tributary can often be ligated without significant consequence, whereas the larger vein should be preserved to maintain better venous drainage37. Anomalous veins are likely to be dilated and tortuous predisposing injury to occur during surgical dissection38. In addi-tion, the lumbar veins, which are the veins communicating the left renal vein and the left ascending lumbar vein running along the inside of the

Figure 2: (a) Right renal artery arises at the level of SMA. (b) Right renal artery arises at the level of SMA.(a) (b)

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For citation purposes: He B, Hamdorf JM. Clinical importance of anatomical variations of renal vasculature during laparoscopic donor nephrectomy. OA Anatomy 2013 Oct 18;1(3):25.

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accurately during the laparoscopic dissection1,2,8. Li et al. have described a classification of lumbar veins into five main types based on their clinical cases, which may help understanding of variations of the lumbar vein and reduce the risk of surgical injury and subsequent bleeding1.

Double IVC and left-sided IVCDuring the embryo development, the persistence of the left supracardinal vein with degeneration of the right supracardinal vein gives rise to the left IVC. As such, the left gonadal and adrenal veins drain directly into the vena cava, and the right gonadal and adrenal veins drain into the right renal vein44. The persistence of both left and right supracardinal veins forms double IVC. The right vena cava is usually dominant and left vena cava anastomoses to it in front of or behind the aorta. The left IVC may drain into the left renal vein directly33,45.

The prevalence of left-sided IVC is from 0.1% to 0.4%, and double IVC ranges from 0.3% to 0.7%9,16. These anomalies were mostly incidental findings on the images or during surgery. However, these should not be contraindicated for live donor nephrectomy. There are some reports of successful laparoscopic donor

nephrectomy with duplicate IVC or left-sided IVC and subsequent successful kidney transplant46–49. The left-sided IVC should be preserved rather than sacrificed during nephrectomy due to the risk of ipsi-lateral oedema in the pelvis and leg50. In addition, the left-sided IVC and duplicated IVC may increase the risk of thromboembolism due to the increased blood flow stasis. These anomalies may also complicate the management of deep vein thrombosis when consideration of filter insertion is decided51. If one IVC is missed, then recurrence of pulmonary embolism may occur51,52.

Circumaortic renal vein and retroaortic renal veinCircumaortic renal veinThe persistence of the intersupracar-dinal anastomosis and left subsupra-cardinal anastomosis and left dorsal renal vein gives rise to circumaortic renal vein with two left renal veins53. The incidence ranges from 8% to 17% during live kidney donor work-up18,36.

Retroaortic renal veinIt develops due to the persistence of the left subsupracardinal anasto-mosis, the intersupracardinal anasto-

mosis and the dorsal left renal vein, with degeneration of ventral renal vein.38 It is classified as two types: type 1 is developed as a result of persistence of the left subsupracar-dinal anastomosis, the intersupracar-dinal anastomosis and the dorsal left renal vein and type 2 is formed due to the persistence of the left subsupra-cardinal anastomosis and left supra-cardinal vein54. Retroaortic renal vein ranges from 3% to 4.7% on CTA during live donor work-up18,36,55 (Figure 4a–c) while it was reported as 3.3% in cadaver dissections38. The retroaortic renal vein is usually drained into the IVC56, but can be drained into the common iliac vein2.

Circumaortic and retroaortic vari-ants constitute the most common anomalies of the left renal vein with incidence of 6.2%–14%10,57,58. However, it is not contraindicated for laparoscopic live donor left nephrec-tomy in the presence of these anoma-lies. The excellent outcomes in both donor and recipient can be achieved in the experienced units6,8,10. Care must be taken to justify which compo-nent should be preserved for graft transplantation. Usually, the poste-rior segment of the circumaortic renal vein has a smaller size that can be safely divided and sacrificed. In

Figure 3: Net-like lumbar veins of left kidney. RV, renal vein.

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For citation purposes: He B, Hamdorf JM. Clinical importance of anatomical variations of renal vasculature during laparoscopic donor nephrectomy. OA Anatomy 2013 Oct 18;1(3):25.

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the presence of renal vein anomalies, the insertion of the lumbar veins, gonadal vein and adrenal vein may be in various fashions. Therefore, careful review of the CTA prior to the surgery is mandatory to identify possible anomalies. The meticulous dissection is preferred in dealing with these venous anomalies to avoid the risk of injury and bleeding8. In the presence of a retroaortic left renal vein, the retroperitoneoscopic technique will provide an easy approach that is readily accessible to the abnormal veins2,8.

The value of CTA The advent of multidetector row computed tomography (MDCT)

enables comprehensive evaluation of the renal vasculature and has replaced conventional digital subtrac-tion angiography (DSA). The renal artery and segmental arteries can be well visualised in the arterial phase, and veins can be evaluated in the venous phase including adrenal, gonadal, lumbar veins and their trib-utaries. In addition, the variations of renal vasculature can be well assessed by MDCT prior to surgery, which can provide accurate information to guide the laparoscopic donor nephrectomy19,22,59. The accuracy of MDCT for detection of renal vascula-ture anomalies ranged from 96% to 100%16,59–63. Therefore, it is manda-tory to review the donors’ CTA care-

fully prior to laparoscopic donor nephrectomy to minimise the risk of injury to the renal vasculature, in particular in the presence of vascular variations.

ConclusionThe renal vasculature anomalies are commonly encountered during live kidney donor work-up. The overall incidence is added to about 70% including supernumerary renal arteries, early renal artery bifurcation, dual renal veins, dual IVC and circumaortic/retroaortic renal veins. The accuracy of MDCT in detection of the renal vascular anomalies has been well demonstrated in the literature, and it is widely employed for live

Figure 4: (a) Left retroaortic renal vein on CTA. (b) Left retroaortic renal vein. (c) Retroaortic renal vein. Lt, left; IVC, inferior vena cava; RV, renal vein. (d) Retroaortic renal vein on CTA (transverse view).

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For citation purposes: He B, Hamdorf JM. Clinical importance of anatomical variations of renal vasculature during laparoscopic donor nephrectomy. OA Anatomy 2013 Oct 18;1(3):25.

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kidney donor work-up. In general, these variations are not contraindi-cated for consideration of laparoscopic donor nephrectomy and consequence of kidney transplant. However, it is paramount for surgeons to have thor-ough knowledge of renal vasculature development and to readily identify these anomalies of renal vasculature on CTA prior to laparoscopic donor nephrectomy. The surgical safety should be analysed on every individual case within the transplant unit. The adverse bleeding event can therefore be prevented.

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For citation purposes: He B, Hamdorf JM. Clinical importance of anatomical variations of renal vasculature during laparoscopic donor nephrectomy. OA Anatomy 2013 Oct 18;1(3):25.

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