Upload
abigail-hudson
View
215
Download
1
Tags:
Embed Size (px)
Citation preview
Objective Measurement of Adequacy of Vascular Anastomosis in Renal Transplant
Dr Ajay Aspari RaghunathDr Dilip C DhanpalDepartment of Nephro-Urology and Transplantation
Sagar Hospitals, Jayanagar
Bangalore
IntroductionProblems with Inadequate Vascular
Anastomosis
◦Thrombotic complications Renal Artery Thrombosis
◦Stenotic Complications Renal Artery Stenosis
◦Haemorrhagic Complications
AFFECTING GRAFT AND PATIENT SURVIVALOsmany , 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
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
AimTo define an objective
measurement of Vascular Anastomotic adequacy
Pilot study
First ever Objective Criteria to be described
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
Technique
Study period – January 2011 to Date
Follow upUSG Doppler studies
◦Post Operative Day -1Evaluation 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 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
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
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
Pressure Gradient
Resistive Index -Hilar
Resistive Index- Segmental Arteries
Resistive Index –Arcuate Arteries
1 12 0.76 0.70 0.69
2 14 0.78 0.73 0.7
3 9 0.67 0.51 0.54
4 11 0.64 0.53 0.52
5 14 0.73 0.7 0.67
6 12 0.7 0.67 0.65
7 8 0.6 0.51 0.51
8 7 0.59 0.54 0.52
9 6 0.54 0.58 0.55
10 8 0.57 0.61 0.58
11 10 0.74 0.68 0.61
12 12 0.71 0.66 0.57
13 17 0.79 0.77 0.74
Correlation Coefficients◦Pressure gradient vs Resistive index
Hilarr = 0.9
Segmental Arteriesr = 0.81
ArcuateArteriesr = 0.85
DiscussionCorrelation between Pressure
gradient and Vascular resistive index
◦Higher the gradient, higher the resistance
Utility of pressure gradient
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
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
DiscussionTo define the Criterion based on
Pressure Gradient
◦Require further studies and also animal experiments
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
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