Objective Measurement of Adequacy of Vascular Anastomosis in Renal Transplant
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Objective Measurement of Adequacy of Vascular Anastomosis in Renal Transplant
Dr Ajay Aspari RaghunathDr Dilip C DhanpalDepartment of Nephro-Urology and TransplantationSagar Hospitals, JayanagarBangalore
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IntroductionProblems with Inadequate Vascular
Anastomosis
◦Thrombotic complications Renal Artery Thrombosis
◦Stenotic Complications Renal Artery Stenosis
◦Haemorrhagic Complications
AFFECTING GRAFT AND PATIENT SURVIVAL
Osmany , Shokeir A , Ali-el Dein B et al [2003]Vascular Complications After Live Donor Renal Transplantation: Study of Risk Factors And Effects on Graft and Patient survival. Journal of Urology 169, 859–862
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Introduction contd. Criteria for assessment of Adequacy of Vascular
Anastomosis in Renal transplant
Subjective Criteria◦ Thrill◦ Pulsations
Surrogate Criteria◦ Colour of Kidney◦ Turgidity of Kidney◦ Immediate urine output via transplanted kidney
NO OBJECTIVE CRITERION FOR A GOOD ANASTOMOSIS INTRAOPERATIVELY
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If the above are NOT satisfied,◦ Systemic Measures
Central Venous Pressure Blood Pressure
◦ Local Measures Intra arterial Papaverine Periarterial Lignocaine spray On table USG Doppler Biopsy of Kidney [ in case of suspected rejection ]
A redo anastomosis is in order if the above are not satisfactory
. John M Barry, Transplantation as Treatment of End-Stage Renal Disease and Technical Aspects of Renal transplantation
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AimTo define an objective
measurement of Vascular Anastomotic adequacy
Pilot study
First ever Objective Criteria to be described
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Materials and MethodsRecruitment
◦ Every consecutive patient undergoing transplant◦ End to End anastomosis [Internal Iliac A. to Tx Renal A. ]
Exclusion◦ Pediatric◦ End to side [External Iliac A. To Tx Renal A.]◦ Thromboendarterectomy [ 1 case ]
22G Cannula for intra arterial pressure◦ Why 22 Gauge ??◦ Measurement across anastomosis
TechniqueStudy period – January 2011 to Date
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SITE OF ANASTOMOSIS
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PRE ANASTOMOTIC PRESSURE
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Follow upUSG Doppler studies
◦Post Operative Day -1Evaluation of Renal Blood flow
◦From Renal artery upto Arcuate arteries
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Resistive Index Criteria Main Renal Artery
Divisional Artery◦ Anterior◦ Posterior
Segmental Artery
Interlobar Artery
Lobular Artery
Arcuate Artery
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Resistive Index CriteriaTool for assessing changes in
renal perfusion
Line H , Naesens M , Lerut E et al [2013] Intrarenal Resistive Index after Renal Transplantation. New England Journal of Medicine. 369:1797-1806
M Darnel, D Schnell, F Zeni [2010] Doppler-Based Renal Resistive Index: A Comprehensive Review. Yearbook of Intensive Care and Emergency Medicine. pp 331-338
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Resistive Index Criteria
Accepted RI Criteria –◦0.6 – 0.8
Line H , Naesens M , Lerut E et al [2013] Intrarenal Resistive Index after Renal Transplantation. New England Journal of Medicine. 369:1797-1806
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Resistive Index
Pulsatility index◦ [ Systolic Velocity – Diastolic Velocity] /
Mean Velocity
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Results13 casesLeast gradient = 6 mm HgHighest Gradient = 17 mm Hg
◦Mean Pressure gradient = 10.76 mmHg
◦Median Pressure Gradient = 9 mm Hg
◦Mode = 12 mm Hg
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Pressure Gradient
Resistive Index -Hilar
Resistive Index- Segmental Arteries
Resistive Index –Arcuate Arteries
1 12 0.76 0.70 0.692 14 0.78 0.73 0.73 9 0.67 0.51 0.544 11 0.64 0.53 0.525 14 0.73 0.7 0.676 12 0.7 0.67 0.657 8 0.6 0.51 0.518 7 0.59 0.54 0.529 6 0.54 0.58 0.5510 8 0.57 0.61 0.5811 10 0.74 0.68 0.6112 12 0.71 0.66 0.5713 17 0.79 0.77 0.74
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Correlation Coefficients◦Pressure gradient vs Resistive index
Hilarr = 0.9
Segmental Arteriesr = 0.81
ArcuateArteriesr = 0.85
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DiscussionCorrelation between Pressure
gradient and Vascular resistive index
◦Higher the gradient, higher the resistance
Utility of pressure gradient
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DiscussionWhy not Doppler On Table??
◦Doppler may pick up readings only for stenosis beyond 60-70%
◦Not reflective of mild to moderate stenosis
Doppler studies are no longer done to diagnose Renal Artery Stenosis
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DiscussionSuch a technique has been recommended
for Lung transplant
Has been carried out in Coronary artery surgeries◦ > 30mm Hg is unacceptable warranting a
redo anastomosisNo literature for Renal transplant
◦ Since Renal Vessels are bigger than Coronary vessels, we arbitrarily propose a cut off of 20 mmHg
Siddiqui A ,Bose A K, Ozalp F et al [2013] Vascular anastomotic complications in lung transplantation: a single institution’s experience. Interactive CardioVascular and Thoracic Surgery 17 - 625–631
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DiscussionTo define the Criterion based on
Pressure Gradient
◦Require further studies and also animal experiments
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ConclusionSimple method for measurement of Vascular
Adequacy
Application of Pressure gradient measurement will reflect:
◦Lesser rates of failed transplant
◦Criterion useful for Young Transplant surgeons Eg. at high volume centres and teaching institutes where
in inadequate anastomosis on table is quickly detected and a redo is done rather than flogging a tired horse
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References Osmany , Shokeir A , Ali-el Dein B et al [2003]Vascular
Complications After Live Donor Renal Transplantation: Study of Risk Factors And Effects on Graft and Patient survival. Journal of Urology 169, 859–862
John M Barry, Transplantation as Treatment of End-Stage Renal Disease and Technical Aspects of Renal Transplantation
Line H , Naesens M , Lerut E et al [2013] Intrarenal Resistive Index after Renal Transplantation. New England Journal of Medicine. 369:1797-1806
M Darnel, D Schnell, F Zeni [2010] Doppler-Based Renal Resistive Index: A Comprehensive Review. Yearbook of Intensive Care and Emergency Medicine. pp 331-338
Siddiqui A ,Bose A K, Ozalp F et al [2013] Vascular anastomotic complications in lung transplantation: a single institution’s experience. Interactive CardioVascular and Thoracic Surgery 17 - 625–631
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Thank You