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Objective Measurement of Adequacy of Vascular Anastomosis in Renal Transplant Dr Ajay Aspari Raghunath Dr Dilip C Dhanpal Department of Nephro-Urology.

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Presentation on theme: "Objective Measurement of Adequacy of Vascular Anastomosis in Renal Transplant Dr Ajay Aspari Raghunath Dr Dilip C Dhanpal Department of Nephro-Urology."— Presentation transcript:

1 Objective Measurement of Adequacy of Vascular Anastomosis in Renal Transplant Dr Ajay Aspari Raghunath Dr Dilip C Dhanpal Department of Nephro-Urology and Transplantation Sagar Hospitals, Jayanagar Bangalore

2 Introduction Problems 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

3 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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5 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

6 Aim To define an objective measurement of Vascular Anastomotic adequacy Pilot study First ever Objective Criteria to be described

7 Materials and Methods Recruitment ◦ 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  Technique Study period – January 2011 to Date

8 SITE OF ANASTOMOSIS

9 PRE ANASTOMOTIC PRESSURE

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12 Follow up USG Doppler studies ◦ Post Operative Day -1 Evaluation of Renal Blood flow ◦ From Renal artery upto Arcuate arteries

13 Resistive Index Criteria Main Renal Artery Divisional Artery ◦ Anterior ◦ Posterior Segmental Artery Interlobar Artery Lobular Artery Arcuate Artery

14 Resistive Index Criteria Tool 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: M Darnel, D Schnell, F Zeni [2010] Doppler-Based Renal Resistive Index: A Comprehensive Review. Yearbook of Intensive Care and Emergency Medicine. pp

15 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:

16 Resistive Index Pulsatility index ◦ [ Systolic Velocity – Diastolic Velocity] / Mean Velocity

17 Results 13 cases Least gradient = 6 mm Hg Highest Gradient = 17 mm Hg ◦ Mean Pressure gradient = mmHg ◦ Median Pressure Gradient = 9 mm Hg ◦ Mode = 12 mm Hg

18 Pressure Gradient Resistive Index - Hilar Resistive Index- Segmental Arteries Resistive Index – Arcuate Arteries

19 Correlation Coefficients ◦ Pressure gradient vs Resistive index Hilar r = 0.9 Segmental Arteries r = 0.81 ArcuateArteries r = 0.85

20 Discussion Correlation between Pressure gradient and Vascular resistive index ◦ Higher the gradient, higher the resistance Utility of pressure gradient

21 Discussion Why 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

22 Discussion Such a technique has been recommended for Lung transplant Has been carried out in Coronary artery surgeries ◦ > 30mm Hg is unacceptable warranting a redo anastomosis No 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 –631

23 Discussion To define the Criterion based on Pressure Gradient ◦ Require further studies and also animal experiments

24 Conclusion Simple 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

25 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: M Darnel, D Schnell, F Zeni [2010] Doppler-Based Renal Resistive Index: A Comprehensive Review. Yearbook of Intensive Care and Emergency Medicine. pp 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 –631

26 Thank You


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