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

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. 369:1797-1806 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

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. 369:1797-1806

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 = 10.76 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 1120.760.700.69 2140.780.730.7 390.670.510.54 4110.640.530.52 5140.730.70.67 6120.70.670.65 780.60.51 870.590.540.52 960.540.580.55 1080.570.610.58 11100.740.680.61 12 0.710.660.57 13170.790.770.74

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 17 - 625–631

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. 369:1797-1806 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

26. Thank You