Transcript Objective Measurement of Adequacy of Vascular Anastomosis in
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
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
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
1 3 4 2
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
Aim
To define an objective measurement of Vascular Anastomotic adequacy Pilot study First ever Objective Criteria to be described
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
SITE OF ANASTOMOSIS
PRE ANASTOMOTIC PRESSURE
Follow up
USG Doppler studies ◦ Post Operative Day -1 Evaluation of Renal Blood flow ◦ From Renal artery upto Arcuate arteries
Resistive Index Criteria
Main Renal Artery Divisional Artery ◦ Anterior ◦ Posterior Segmental Artery Interlobar Artery Lobular Artery Arcuate Artery
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
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
Resistive Index ◦ Pulsatility index [ Systolic Velocity – Diastolic Velocity] / Mean Velocity
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
1 2 3 4 5 6 7 8 9 10 11 12 13 12 14 9 11 14 12 8 7 6 8 10 12 17 Pressure Gradient Resistive Index Hilar 0.76
0.78
0.67
0.64
0.73
0.7
0.6
0.59
0.54
0.57
0.74
0.71
0.79
Resistive Index Segmental Arteries 0.70
0.73
0.51
0.53
0.7
0.67
0.51
0.54
0.58
0.61
0.68
0.66
0.77
Resistive Index – Arcuate Arteries 0.69
0.7
0.54
0.52
0.67
0.65
0.51
0.52
0.55
0.58
0.61
0.57
0.74
Correlation Coefficients ◦ Pressure gradient vs Resistive index
Hilar r = 0.9
Segmental Arteries r = 0.81
ArcuateArteries r = 0.85
Discussion
Correlation between Pressure gradient and Vascular resistive index ◦ Higher the gradient, higher the resistance Utility of pressure gradient
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
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
Discussion
To define the Criterion based on Pressure Gradient ◦ Require further studies and also animal experiments
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
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