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Year : 2020  |  Volume : 14  |  Issue : 2  |  Page : 125-129

A prospective comparison of end-to-side and end-to-end renal transplant arterial anastomosis in living donor transplants from an Indian centre

Department of Surgery, Renal Transplant Unit, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, Delhi, India

Date of Submission23-Feb-2020
Date of Acceptance08-Apr-2020
Date of Web Publication06-Jul-2020

Correspondence Address:
Prof. Nitin Agarwal
Department of Surgery, Renal Transplant Unit, Atal Bihari Vajpayee Institute of Medical Sciences, Dr. Ram Manohar Lohia Hospital, Delhi - 110 001
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijot.ijot_16_20

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Background: Chronic kidney disease (CKD) is a major epidemic in India today. Renal transplant offers the best quality of life; however, only about 6000 mostly live donor transplants are performed due to socioeconomic hurdles. Live donor transplants involve tenuous (2–6 mm) graft arteries without a cuff; thus meticulous technique is importance. We have prospectively compared graft anastomosis to the external iliac artery end-to-side (EIA ES) with the internal iliac end-to-end (IIA EE) artery. Materials and Methods: This prospective randomized study was conducted in the renal transplant unit of a teaching hospital in north India for over 2 years. After ethics approval and informed consent, patients with donors were randomly divided into two groups using computer-generated tables and the sealed envelope technique; Group 1 underwent EIA ES; Group 2 underwent IIA EE. Donor nephrectomy was by a supra 11th rib flank incision, and triple immunosuppression was used. The vascular techniques were standardized; outcome parameters were the duration of anastomosis and complications, especially delayed graft function. Follow-up was for 3 months. Results: The mean age was 36.85 ± 13.56 and 29.75 ± 8.06 years while female: male ratio of recipients was 3:17 and 6:14 in Groups 1 and 2, respectively. The groups were comparable in venous anastomosis duration, warm ischemia interval, cold ischemia interval and hospital stay, and other complications, but significantly longer arterial anastomosis time was noted in the IIA EE group (P = 0.001). Conclusions: EIA ES took less time than IIA EE, but was equivalent to in most parameters. More data are needed to answer this debate.

Keywords: End-to-side anastomosis, external iliac artery, India, live related, renal transplant

How to cite this article:
Rana AK, Agarwal N, Hanumanthappa VM, Dokania MK. A prospective comparison of end-to-side and end-to-end renal transplant arterial anastomosis in living donor transplants from an Indian centre. Indian J Transplant 2020;14:125-9

How to cite this URL:
Rana AK, Agarwal N, Hanumanthappa VM, Dokania MK. A prospective comparison of end-to-side and end-to-end renal transplant arterial anastomosis in living donor transplants from an Indian centre. Indian J Transplant [serial online] 2020 [cited 2021 Jun 21];14:125-9. Available from: https://www.ijtonline.in/text.asp?2020/14/2/125/289034

  Introduction Top

Chronic kidney disease (CKD) is a major noncommunicable epidemic worldwide; more so in India due to the unusually high prevalence of diabetes mellitus and hypertension. Renal transplant is the unequivocal first choice as renal replacement therapy (RRT) for end-stage renal disease (ESRD), both for quality of life and longevity.[1],[2] However, India fares poorly in meeting the annual demand for renal transplants; of the more than 200,000 required, a little over 6000 are performed. Mortality on the waiting list is high, and dialysis infrastructure poor, painting an overall bleak outlook for ESRD patients. Compounding the problem are socio-cultural factors leading to a poor ratio of deceased donor to live donor renal transplants (<1:10). One of the advocated ways of improvement is to increase the number of transplants done in public hospitals where the most socioeconomically vulnerable patients visit. The Indian government has focused many recent efforts on increasing organ retrieval and transplant activity co-ordination, through the National Organ and Tissue Transplant Organization.[2],[3]

While waiting for our deceased donor numbers to improve, we must also focus our efforts on the living donor program, which in absolute numbers compares to one of the highest in the world.[4] Training of surgeons and meticulous technique is of paramount importance in the success of any transplant program; the graft artery to external/internal iliac artery anastomosis is a key feature because the surgeon is limited by the warm ischemia time 2 or anastomosis time (warm ischemia time 1 is the time from clamping the graft artery to perfusion, and is negligible for living donor grafts) and the narrow caliber (2–6 mm) of the graft artery. The graft artery from a living donor is particularly important since no aortic cuff is attached after retrieval, limiting its length and caliber. Since we operate mostly on living donors, our focus is on optimizing the rate-limiting step of the arterial anastomosis. While the graft vein is joined to the external iliac vein, and the graft ureter to the bladder, both end-to-side (ES), the arterial anastomosis is a choice between the external iliac artery (EIA) or the internal iliac (end-to-end, IIA EE) artery. This choice is mainly dependent on the surgeon's training; traditionally, the deceased donor grafts are considered more suitable for EIA ES due to the attached aortic cuff.[5]

The basic techniques and principles of vascular anastomosis developed by Carrel and Guthrie are still in use;[6],[7] however, the ideal technique and host artery for renal graft artery anastomosis is still a matter of debate. We have designed a prospective comparative study to compare the outcome of renal transplant surgery using external iliac/internal iliac artery of the recipient for anastomosis with graft renal artery.

  Materials and Methods Top

This prospective randomized study was conducted in the renal transplant unit of the department of surgery of a teaching hospital in north India, from November 2013 to February 2015. Recruited patients were all due to receive an allograft from a living donor; after selection the patients were randomly divided into two groups using computer-generated tables; allocation was done using the sealed envelope technique; Group 1 underwent ES anastomosis between the graft artery and the external iliac artery, while Group 2 underwent EE anastomosis to the internal iliac artery. The study was approved by the institutional ethics committee and written informed consent was obtained from all patients and their donors.

All cases of renal transplant with anastomosis of a single graft artery were included in the study. Children <12 years of age, donors with multiple renal arteries, recipients with extensive atherosclerosis in the external iliac artery or stenosis at the origin of the internal iliac artery or an atheroma in the internal iliac artery diagnosed on Doppler studies, were excluded from the study. Only physically and mentally healthy donors less without evidence of serologically positive viral infection (HIV I and II, hepatitis B surface antigen, and hepatitis C virus) or malignancy were selected. A standard preoperative protocol for live RRT was followed, with scrutiny of legal affidavits and other proofs of relationship as per Government of India guidelines.[2] Donor screening involved computed tomography angiography for the assessment of renal vasculature, radioisotope (diethylenetriaminepentaacetic acid) scanning for differential renal function, human leukocyte antigens (HLA) and blood grouping-crossmatching, and screening for common malignancies and transmissible infections. Recipient evaluation included a complete history and physical examination, ultrasound abdomen including Doppler of iliac vessels, evaluation of the size and status of native kidneys, HLA, and blood grouping-crossmatching, cardiopulmonary evaluation, and screening for cytomegalovirus, HIV, hepatitis B and C infections. Triple immunosuppression protocol was followed with tacrolimus, mycophenolate, and prednisolone. Basiliximab was added as quadruple immunosuppression in high-risk cases. Donor nephrectomy was performed by a supra-11th rib flank incision, reflecting the pleura and peritoneum carefully; selection of side (left or right) was based on differential renal function and anatomical considerations (early branching, vessel diameter, etc.). The grafts were perfused with cold Ringer's lactate (RL) solution and RL ice slush. All the transplants were performed by the same surgeon, and the graft was placed in the right iliac fossa extraperitoneally. Polytetrafluoroethylene (PTFE) 6–0 or 5–0 sutures were used for the arterial and venous anastomosis, the latter was always ES with the external iliac vein. The ES arterial anastomosis with the external iliac artery was performed with PTFE 6–0 continuous sutures, after fixing the angles.[8] The EE anastomosis to the internal iliac artery used interrupted anterior layer sutures for at least one-third of the circumference. Intraoperative assessment was made with respect to the time taken for arterial and venous anastomosis, warm ischemia time 1 and 2 (vide supra), technical difficulties in anastomosis, blood loss after removal of clamps, and time to graft function as evidenced by beginning of diuresis. Postoperative records were made of daily urine output, time taken to normalization of serum creatinine, drain output, surgical site infections, delayed or slow graft function (SGF), evidence of rejection, and any other significant complications. Postoperative follow-up was done at 3 months. For the purpose of the study, SGF was defined as a failure of serum creatinine to fall to 2 mg/dL at the end of postoperative day 7, while delayed graft function (DGF) was defined as a requirement of hemodialysis/ultrafiltration before the end of postoperative day 7. Descriptive statistics were used for demographic and clinical data. For comparison of nonparametric values, Fischer's exact test was used while Chi-square test was used for parametric values.

The patients' consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names, initials would not be published, and all standard protocols will be followed to conceal their identity. The study has been approved by Institutional ethics committee of ABVIMS and RML Hospital, Delhi (formerly PGIMER and RMLH; Institutional Review Board meeting number 23-5/2012/ Acad/ PGIMER/ 2068/12).

  Results Top

The mean age of the kidney transplant recipients was 36.85 ± 13.56 years and 29.75 ± 8.06 years in Groups 1 and 2, respectively. Gender distribution was 3 women and 17 men in group 1 versus 6 women and 14 men in Group 2 [Table 1]. The groups were comparable in venous anastomosis duration, warm ischemia interval, cold ischemia interval, and hospital stay. There was a significant statistical difference in arterial anastomosis time between both the groups (P = 0.001) Blood loss and technical difficulties were negligible in both the groups [Table 1]. High HLA match (≥3/6) was seen in 15 versus 16 pairs of Groups 1 and 2, respectively (P = 0.66).
Table 1: Demographic and intraoperative details

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Immediate diuresis was seen in 16 versus 14 patients (P = 0.72), early graft function was seen in 16 versus 13, SGF in 2 versus 7 in Groups 1 and 2, respectively; DGF was seen in one patient in Group 1 only. The eventual decrease in blood urea and serum creatinine at 3 months showed no difference in both the groups [Figure 1] and [Figure 2]. At 3 months' follow-up, 18/20 cases in Group 1 had normal graft function, compared to 20/20 in Group 2 (two cases underwent graft nephrectomy in Group 1).
Figure 1: Trend of fall of serum urea levels in Group 1 and Group 2

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Figure 2: Trend of fall of serum creatinine levels in Group 1 and Group 2

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[Table 2] shows the overall surgical and clinical complications in both groups (P = 0.33 and P = 0.65, respectively). Lymphoceles were mostly managed by observation and needed to be aspirated in two patients. Ureteric leak in one patient necessitated re-anastomosis.
Table 2: Complications in renal transplant recipients in Group 1 and Group 2

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There were two patients who underwent graft nephrectomy; the indications were renal artery thrombosis and acute rejection. No mortality was observed at 3 months of follow-up. There was one donor mortality in our study due to sudden cardiac arrest on postoperative day 4.

  Discussion Top

The anastomosis of the renal graft artery to either the EIA or IIA has both its advocators and critics. The EIA is easier to anastomose even when there are multiple graft arteries.[8] This is because the graft lumen on both the sides (graft and EIA) is larger. In deceased donors, an aortic cuff, and in live donors, spatulation of the lumen are performed, making it more manageable for anastomosis; early stenosis is also less likely.[9] However, the EIA anastomosis can be a problem with atherosclerotic recipient vessels, where clamping may dislodge an atheroma and cause later obstruction or thrombosis. The “steal phenomenon” with respect to the lower limb and reperfusion injury has also been reported.[5],[10] In the case of IIA EE anastomosis, the main advantage seems to be for use in cases where the EIA has atherosclerosis, or if the graft artery is short. Some authors feel that living donor grafts are more suitably attached with this technique due to comparable lumens; a deceased donor graft with a Carrel patch would be clumsy and disproportionate.[5] The conventional running suture technique for IIA EE has a significant risk of transplant artery stenosis; some have attempted modification with interrupted sutures on the anterior wall, without significant differences in the incidence of stenosis.[11],[12] Hence, the choice between having a larger lumen to anastomose with continuous sutures (EIA ES), versus having comparable lumen sizes (IIA EE), comes down to surgeon preference. In our experience, the use of running sutures in the EIA ES after fixing the angles is easy to perform and eradicates the problem of the discrepancy of lumens.[8]

There are a few reported cases of ES anastomosis of the graft artery to the host internal iliac vessels. This is theorized to preserve the blood supply to the pelvic organs and offer a better quality of life postoperatively.[13],[14] Some authors feel that this technique is inevitable for a second transplant on the contralateral side, and remains relevant for a deceased donor graft with a Carrel patch;[14] however, it is difficult to extrapolate in all the cases due to the limited diameter and course of the IIA.

The main discourse regarding the IIA EE for a considerable period has been erectile dysfunction (ED) due to ligation of the distal IIA.[15] After a review of many papers on the subject, one can conclude that ED in ESRD is multifactorial, and exists preoperatively in many cases. Many studies have demonstrated the decrease in penile blood flow following transplant using IIA EE; however, the effect of the arterial anastomosis on ED is not consistent.[5],[16],[17],[18] Gontero et al. found that renal transplantation using EIA ES is actually associated with an unexpected early worsening of ED, even though penile flow remained within the normal range.[16] El-Bahnasawy et al. prospectively evaluated fifty cases of IIA EE; they concluded that the effect on ED was variable. The penile blood flow was decreased, but not to the extent of causing a deterioration in the quality of erection.[17] In our study, we have not used this parameter for the evaluation due to a short follow-up, and also due to the inconsistencies in the available studies. A specially-designed study in a prospective setting is needed to address this issue.

It is our understanding that, in our setting, where we have to perform mostly live donor transplants, EIA ES would be a more suitable technique for several reasons. Our results and those of others (vide supra) have not shown the two techniques to be significantly dissimilar in terms of short-term graft function and complications.[19],[20],[21] The use of continuous suturing after fixation of the angles has not resulted in long-term stenosis in our series of more than 150 patients. It is also pertinent to note that radiological criteria (by Color Doppler) must be well-established for both types of anastomosis (EE and ES) independently to improve the accuracy of detection, as demonstrated by Gao et al.[22] The EIA ES technique takes significantly less time (vide supra), providing an advantage for living donor transplants.

As mentioned earlier, our study has some limitations, i.e., a short follow-up and nonassessment of ED. Having a larger number of patients would have also satisfactorily eliminated all confounding factors such as HLA mismatch and donor age. Some of the factors we attempted to eliminate were surgeon bias (the same surgeon performed all the anastomosis) and a standard immunosuppressant regimen. Despite these limitations, ours is the first prospective comparative study from India comparing the two types of transplant arterial anastomosis, and one of the few available in literature for living donor grafts. Most other data are retrospective and/or pertain to series with predominantly deceased donor organs, where technical issues are less relevant due to the Carrel patch on the vessels.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Trivedi H, Vanikar A, Patel H, Kanodia K, Kute V, Nigam L, et al. High prevalence of chronic kidney disease in a semi-urban population of Western India. Clin Kidney J 2016;9:438-43.  Back to cited text no. 1
Guidelines. NOTTO: National Organ and Tissue Transplant Organization; 2017. Available from: http://notto.nic.in/. [Last accessed on 2018 May 18].  Back to cited text no. 2
Mohan Foundation. Organ Donation and Transplantation Awareness in Chennai and Tamil Nadu; 2018. Available from: http://www.mohanfoundation.org/activities/index.asp?sltcity=Chennai. [Last accessed on 2018 May 14].  Back to cited text no. 3
Andre M, Huang E, Everly M, Bunnapradist S. The UNOS Renal Transplant Registry: Review of the Last Decade. Clin Transpl 2014; 28: 1-12.  Back to cited text no. 4
Matheus WE, Reis LO, Ferreira U, Mazzali M, Denardi F, Leitao VA, et al. Kidney transplant anastomosis: Internal or external iliac artery? Urol J 2009;6:260-6.  Back to cited text no. 5
Carrel A, Guthrie CC. Anastomosis of blood vessels by the patching method and transplantation of the kidney. 1906 [classical article]. Yale J Biol Med 2001;74:243-7.  Back to cited text no. 6
Cinqualbre J, Kahan BD. René Küss: Fifty years of retroperitoneal placement of renal transplants. Transplant Proc 2002;34:3019-25.  Back to cited text no. 7
Sidawy A, Neville R. Technique: Open surgical. In: Cronenwett J, Johnston K, editors. Rutherford's Vascular Surgery. 8th ed., Ch. 87. Philadelphia: Elsevier Saunders; 2014. p. 1297-302.  Back to cited text no. 8
Ersöz S, Anadol E, Aydintuǧ S, Bumin C, Erkek B, Ateş K. Anastomotic artery stenosis in living related kidney transplantation: The impact of anastomotic technique. Transplant Proc 1996;28:2331-2.  Back to cited text no. 9
Fechner G, von Pezold C, Hauser S, Gerhardt T, Klehr HU, Müller SC. Impairment of long-term graft function after kidney transplantation by intraoperative vascular complications. Int Urol Nephrol 2008;40:869-73.  Back to cited text no. 10
Zomorrodi A, Bohluli A, Tarzamany MK. Evaluation of blood flow in allograft renal arteries anastomosed with two different techniques. Saudi J Kidney Dis Transpl 2008;19:26-31.  Back to cited text no. 11
[PUBMED]  [Full text]  
Moon I, Kim Y, Park J, Kim S, Koh Y. Various vascular procedures in kidney transplantations. Transplant Proc 1998;30:3006.  Back to cited text no. 12
Pal DK, Sanki PK, Roy S. Analysis of outcome of end-to-end and end-to-side internal iliac artery anastomosis in renal transplantation: Our initial experience with a case series. Urol Ann 2017;9:166-9.  Back to cited text no. 13
[PUBMED]  [Full text]  
Mohamed IH, Bagul A, Doughman T, Nicholson ML. Use of internal iliac artery as a side-to-end anastomosis in renal transplantation. Ann R Coll Surg Engl 2012;94:e36-7.  Back to cited text no. 14
Burns J, Houttuin E, Gregory J, Hawatmeh I, Sullivan T. Vascular-induced erectile impotence in renal transplant recipients. J Urol 1979;121:721-3.  Back to cited text no. 15
Gontero P, Oderda M, Filippini C, Fontana F, Lazzarich E, Stratta P, et al. Does kidney transplantation onto the external iliac artery affect the haemodynamic parameters of the cavernosal arteries? Asian J Androl 2012;14:621-5.  Back to cited text no. 16
El-Bahnasawy MS, El-Assmy A, Dawood A, Abobieh E, Dein BA, El-Din AB, et al. Effect of the use of internal iliac artery for renal transplantation on penile vascularity and erectile function: A prospective study. J Urol 2004;172:2335-9.  Back to cited text no. 17
Peng T, Zhang GT, Chen M, Chen SQ, Sun ZY. Erectile function in male kidney transplant recipients and effects of different methods of renal arterial anastomosis. Zhonghua Nan Ke Xue 2007;13:396-9.  Back to cited text no. 18
Benedetti E, Troppmann C, Gillingham K, Sutherland DE, Payne WD, Dunn DL, et al. Short- and long-term outcomes of kidney transplants with multiple renal arteries. Ann Surg 1995;221:406-14.  Back to cited text no. 19
Hwang JK, Kim SD, Park SC, Choi BS, Kim JI, Yang CW, et al. The long-term outcomes of transplantation of kidneys with multiple renal arteries. Transplant Proc 2010;42:4053-7.  Back to cited text no. 20
Chabchoub K, Mhiri MN, Bahloul A, Fakhfakh S, Ben Hmida I, Hadj Slimen M. Does kidney transplantation with multiple arteries affect graft survival? Transplant Proc 2011;43:3423-5. doi: 10.1016/j.transproceed.2011.09.027. PMID: 22099812..  Back to cited text no. 21
Gao J, Li JC, Xiao MS, Ng A, Trost D, Goldstein M, et al. Color duplex sonography in severe transplant renal artery stenosis: A comparison of end-to-end and end-to-side arterial anastomoses. Clin Imaging 2009;33:116-22.  Back to cited text no. 22


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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