8.3_B7_Ttla - English- Vu Ngoc Thang.docx

MINISTRY OF EDUCATION AND TRAININGMINISTRY OF DEFENCE MILITARY MEDICAL UNIVERSITY VU NGOC THANG RESEARCH ON VASCULAR CHARACTERISTICS AND EVALUATE THE RESULTS OF VASCULAR ANASTOMOSIS TECHNIQUES IN LIVI[.]

MILITARY MEDICAL UNIVERSITY

VU NGOC THANG

RESEARCH ON VASCULAR CHARACTERISTICS AND EVALUATE THE RESULTS OF VASCULAR ANASTOMOSIS

TECHNIQUES IN LIVING DONOR KIDNEY

TRANSPLANTATION AT 103 MILITARY HOSPITAL

Speciality: SURGERY Code: 9720104

PhD THESIS ABSTRACT

HA NOI– 2023THIS WORK WAS COMPLETED

Scientific Supervisors:

1 Assoc.Prof PhD Nguyen Anh Tuan

2 Assoc.Prof PhD Pham Quang Vinh

Reviewer 1: Assoc.Prof PhD Nguyen Quang

Reviewer 2: Assoc.Prof PhD Bui Van Lenh

Reviewer 3: Assoc.Prof PhD Tran Van Hinh

The thesis is presented at the Council of Vietnam Military MedicalUniversity at: h(date) / (month)/2023

The thesis can be founded at:

1 Vietnam National Library

2 Library of Military Medical University

LIST OF WORKS PUBLISHING RESULTS OF THESIS

characteristics of transplanted kidney and grafts blood vessels fromliving donors kidney transplatation at 103 Military Medical

Hospital Vietnam Medical Journal; 516 (1): 207-211.

2 Vu Ngoc Thang, Le Anh Tuan (2022) Evaluation of some vascularcharacteristics of transplanted kidney and results of anastomosistechniques in living donor kidney transplant at 103 Military

Medical Hospital Journal of Military Pharmaco-medicine; 47 (5):

236-245

1 The neccessary of the subject

Kidney transplantation is a renal replacement therapy for patientswith end-stage chronic kidney disease and it is a superior option forpatients with end-stage renal failure

The quality of transplantation depends primarily on the quality ofthe blood vessels and anastomosis All researchers have shown that theresults of vascular stitching of the transplanted kidney are greatlyinfluenced by the vascular characteristics of the transplanted kidney andthe vascular characteristics of the recipient

In Vietnam, in the past few years, kidney transplantation hasbecome a routine technique in major organ transplant centres such as

103 Military Hospital, Viet Duc Hospital, Hue Central Hospital, andCho Ray Hospital Clinically, there are many early and latecomplications after kidney transplantation related to vascularanastomosis To contribute to perfecting the techniques of suturing andhandling when there are changes in both the transplanted kidney's bloodvessels and the recipient's pelvic blood vessels, thereby reducingvascular complications and improving the quality of the transplantedkidney, we conducted a study to present the title: “Research on vascularcharacteristics and evaluate the results of vascular anastomosistechniques in living donor kidney transplantation at 103 MilitaryHospital” with two objectives:

1 Research on some vascular characteristics of the transplanted kidney, the recipient's pelvic blood vessel in kidney transplant surgery from a living donor at 103 Military Hospital

2 Evaluate the results of vascular anastomosis techniques in kidney transplant surgery from living donors at 103 Military Hospital.

2 The new main scientific contributions of the thesis

- This is the first research to study the pelvic vascularcharacteristics of kidney recipients, affecting the vascular anastomosistechniques in kidney transplantation from living donors

- From the results of the thesis, methods of treatment have beenproposed if there are pelvic arterial abnormalities, or if there are manyarteries and veins or transplanted kidney veins are short, comparingresults between the two groups anastomosis of the end-to-endanastomosis with the internal iliac artery (IIA) and the end-to-sideanastomosis with the external iliac artery (EIA) Since then, there have

been new valuable contributions in technology, especially problems inmanagement, suturing, vascular transposition in kidney transplantation,limiting complications, and improving the quality of transplantedkidneys.

3 Structure of the thesis

The thesis consists of 137 pages (excluding references andappendices), include: introduction (2 pages), overview (35 pages),subjects and methods (23 pages), results (35 pages), discussion (40pages), conclusion (2 pages) The thesis consists of 43 tables, 10figures, 30 images and 1 diagram The thesis also used 136 referencesincluded in Vietnamsese and in English

CHAPTER 1 OVERVIEW 1.1 Kidney anatomy related to kidney transplant

1.1.1 Kidney morphology

The normal person has 2 kidneys located behind the peritoneum.The kidney consists of two faces, two poles, and two sides Thedepression in the inner border is called the renal hilum

1.1.2 Kidney size:

The Vietnamese kidney volume in men is about 150cm3, and inwomen, it's about 136cm3

1.2 Vascular anatomy related to kidney transplantation

1.2.1 Renal vascular anatomical features related to kidney transplantation

The renal peduncle is classically described as consisting of anartery and a vein that enter the kidney through the middle part of thehilum The renal vein is located anteriorly more than the artery Theright renal artery is about 1 cm longer than the left renal artery The leftrenal vein is longer than the right

*Application in kidney transplant:

The renal veins are interconnected, so the pole veins can be ligatedwithout affecting blood flow from the kidney to the inferior vena cava Renal vein length affects the selection of the kidney fortransplantation, the placement of the transplanted kidney and thevascular anastomosis technique

1.2.2 Pelvic vascular anatomical features related to kidney transplantation

The common iliac artery (CIA): separates from the descending abdominal aorta and divides into the EIA and the IIA Internal iliac artery: during surgery, it is possible to tie the IIA or its branches on one

or both sides without any necrosis of the pelvic viscera because it has a

branch from the rectum to the inferior colic artery External iliac artery:

goes from deep to shallow, has many small branches, and has littleabnormal changes, so it is easy to reveal during surgery

Pelvic veins: The external iliac vein (EIV) and the internal iliac

vein (IIV) receive blood from the pelvic organs, external genitalia, andlower extremities and then drain into the common iliac vein (CIV) andinferior vena cava The iliac veins follow significant branches of the IIA

Application in kidney transplant: After separating from the

inferior vena cava, the CIV descends posteriorly and into the CIA Itdivides one or more branches of the IIV and then continues posteriorly

to the EIA and runs parallel to the media but remains in the posteriorplane of the plane containing the arteries Therefore, surgeons willprefer to transplant the left kidney into the right pelvis and vice-versa

1.3 Techniques of vascular anastomosis in kidney transplantation

1.3.1 Arterial anastomosis

1.3.1.1 There is 1 renal artery

- End-to-end anastomosis of the renal artery to the IIA

- End-to-side anastomosis of the renal artery to the EIA

- End-to-side anastomosis of the renal artery to the CIA

1.3.1.2 There are multiple renal arteries

- Two or three renal arteries shaped together in gun barrel style andconnect to the EIA by end-to-side anastomosis or to the IIA by end-to-end anastomosis

- End-to-side anastomosis of a small artery from the poles to themain renal artery

- End-to-end anastomosis with the terminal branches of the IIA

- End-to-end anastomosis of the accessory artery to the inferiorepigastric artery End-to-end anátomosis with IIA or end-to-sideanastomosis with EIA

- Renal polar artery with a diameter of ≤ 1 mm: can be ligated

1.3.1.3 Anastomosis in the case of atherosclerosis of the aorta of the pelvis.

- If the IIA is severe atherosclerosis, suture end-to-sideanastomosis with the EIA or CIA

- EIA is severe atherosclerosis, cut the EIA segment, the defectposition will be replaced by an artificial or Homograft circuit, and thenthe grafted renal artery will be connected to the replacement vessel.

1.3.2 Anastomosis renal vein

1.3.2.1 There is a renal vein

- End-to-side anastomosis of the renal vein to the EIV

- End-to-side anastomosis of the renal vein to the CIV

- End-to-side anastomosis of the renal vein to the inferior venacava

1.3.2.2 There are two or more renal veins or the short renal vein

- End-to-side anastomoses with the iliac veins by separate joints

- Gun barrel shaping

- Short renal vein: lengthen the renal vein by curled, spiral shaping

or transposition of blood vessels

1.4 Vascular complications in kidney transplantation

1.4.1 Bleeding: This is a complication that requires early intervention

(30-60%) because it can cause loss of kidney transplant function

1.4.2 Arterial stenosis: most common after kidney transplantation 1.4.3 Arterial thrombosis: rare, accounting for 1-2% of cases

1.4.4 Venous thrombosis: rare, usually occurring within the first 7 days

after transplantation

1.4.5 Postoperative external iliac artery dissection: rare and should be

diagnosed and treated early because it can cause graft loss and lowerextremity vessel obstruction

CHAPTER 2 SUBJECTS AND METHODS 2.1 Subjects

2.1.1 Subjects

Patients with end-stage chronic renal failure who have anindication for kidney transplantation performed a kidney transplanttaken from a living donor, and the results of the MSCT film of thekidney taken for transplantation were collected in pairs of kidneydonors and recipients at the 103 Military Hospital from December 2019

to December 2020

The process of selecting a kidney transplant pair is carried outregularly according to the regulations of the Ministry of Health ofVietnam

2.1.2 Criteria of exclusion

- The patients received a kidney transplant from a living donor atMilitary Hospital 103 during the study period but it is not enoughinformation and documents for data analysis

- The patients did not come to 103 Military Hospital for follow-updue to many reasons (such as transfer of monitoring place, loss ofinformation, etc.)

2.2 Methods

2.2.1 Design of study

The research was a prospective, cross-sectional descriptive, withlongitudinal follow-up, no control, from December 2019 to December2020

= 44.7 Thus, the minimum number of case studies is 45

2.2.3 Research content

2.2.3.1 The common characteristics of recipients

- Age, gender, history, time of dialysis before transplantation,combined diseases

- Blood test: urea, creatinine before transplantation

2.3.2 The characteristics of the transplanted kidney, the transplanted kidney vessels, the characteristics of the iliac vessels of the recipients

2.3.2.1 Characteristics of the transplanted kidney and the transplanted kidney vessels

* Surgical method and side to take kidney transplant

* Characteristics of transplanted kidneys on MSCT: transplantedkidney volume (cm3), combined disease

* Characteristics of arterial grafts on MSCT: number, length,diameter, and arterial distribution

* Characteristics of venous grafts on MSCT: number, length,diameter

* Characteristics of the arterial grafts after washing: arteries andveins: number, length

2.3.2.2 Characteristics of the iliac vessels of kidney recipients

* Characteristics of the iliac artery assessed by pre-transplant Doppler ultrasound:

- Diameter of common, internal and external iliac arteries

- Atherosclerosis status

* Observation and assessment during surgery:

- Characteristics of the IIAs and EIAs after surgery Evaluation ofthe degree of atherosclerosis after angioplasty/opening

- Characteristics of the EIV walls Is there a blood clot in the blood vessel?

2.3.3 Evaluation the results of vascular anastomosis techniques in

living donor kidney transplantation

2.3.3.1 The technical process

- Preparation before vascular suture

- Perform a kidney transplant:

2.3.3.2 Techniques used in the vascular anastomosis

- Position of renal artery anastomosis:

* Group one renal artery:

+ End-to-side anastomosis of the renal artery to the EIA

+ End-to-end anastomosis of the renal artery to the IIA

+ End-to-side anastomosis of the renal artery to the CIA

* Group of many renal arteries:

+ Anastomosis of the main renal artery to the IIA, the accessoryrenal artery to the EIA

+ 2 anastomosis between the renal artery and the EIA

+ Shaping the gun barrel by end-to-end anastomosis with the IIA

or end-to-side anastomosis with the EIA

- Position of renal vein anastomosis:

+ Anastomosis of the renal vein to the external iliac vein

+ Anastomosis of the renal vein to the common iliac vein

+ 2 anastomosis of the renal vein to the external iliac vein

- Techniques to manage when the kidney has many arteries, atherosclerotic pelvis, many veins or short renal veins.

2.3.4 Criteria for evaluating results of vascular anastomosis techniques

2.3.4.1 Evaluation at the operating table

- Evaluation of arterial anastomosis:

+ Good: the mouth is closed, not dissected, the flow into thekidney is enough for the kidney to stretch and red, and there is novibration The artery is not twisted, not bent

+ Not good: have to redo the anastomosis for one of the following

reasons: endarterial dissection, irreversible renal ischemia due totwisting or folding of the artery, and narrowing of the anastomosis.

- Evaluation of venous anastomosis:

+ Good: closed mouth, swollen, good circulation, no venousaneurysm

+ Not good: the bleeding venous anastomosis has to be stitched inmany places Veins are twisted

- Evaluation of renal excretory activity immediately aftertransplantation

- Evaluation of the transplanted kidney at the operating table

- Evaluation of complications during surgery

- Time to make arterial and venous anastomoses (unit of minutes)

- Surgery time

2.3.3.3 Evaluation of results in the postoperative period

Post-transplant monitoring indicators during treatment immediatelyafter surgery: the first day, the third day, the fifth day aftertransplantation and the day of hospital discharge

- Monitor kidney function: the amount of urine in the first 24 hoursand serum urea and creatinine levels

- Evaluation of kidney transplant function related to vascularanastomosis techniques

- Evaluation of transplanted kidney function in relation to singleand multi-artery group

- Doppler ultrasound evaluates the condition of the transplantedkidney: parenchyma, vessels

- Early postoperative vascular complications: bleeding,thromboembolism

- Postoperative hospital stay

- Time of drainage withdrawal

- Time of urinary circulation

- Evaluation of overall results at discharge: Good, Medium, Poor

2.3.3.4 Evaluation after follow up (re-examination after discharge)

All patients after surgery were scheduled to go to 103 MilitaryHospital for re-examination to evaluate the results of vascularanastomosis by kidney function tests (urea, creatinine in blood), andDoppler ultrasound of the transplanted kidneys: 1 month, >1 to 3months, >3 to 6 months, >6 months to 1 year, and after 1 year

2.4 Data analysis:

Data were stored and processed using Epidata 3.1 and SPSS 20.0.

2.5 Ethics in research

The study was conducted on the basis of science and a safe andeffective organ transplant model that has been applied in other countriesand in Vietnam for many years

All kidney donations and kidney transplants are approved by thehospital's ethics and professional committees prior to kidneytransplantation The study was approved by the ethics committee of 103Military Hospital

CHAPTER 3 RESULTS

During the period from December 2019 to December 2020, therewere 127 patients with end-stage chronic renal failure with anindication for kidney transplantation, who received a kidney transplantfrom a living donor and 127 results of the MSCT film of the kidneyobtained for transplantation were collected according to each pair ofkidney donors - recipients at 103 Military Hospital who are eligible forresearch The results were recorded as follows:

3.1 General characteristics of recipients

3.1.1 Gender and age: Male: 88 cases (69,3%) Female: 39 cases

(30,7%) Age: mean age is 38,12 ± 9,8

3.1.2 Caused by chronic kidney failure and co-morbidities

Figure 3.1: kidney disease 38,6%, only chronic kidney failure wasdetected at medical examination 37,8%, hypertension 18,9%, diabetes0,8%, systemic disease 0,8%, other causes 3,1% Table 3.2: Combineddisease in which hypertension is 76,4; hepatitis B: 16,5%; hepatitis C:9,4%, diabetes 2,4% and systemic disease 1,6%

1.1.3 Pre-transplant dialysis time: Table 3.3: Mean time of dialysis is

3.2.1.1 Anatomical characteristics of transplanted kidney

Table 3.5: Nephrectomy by laparoscopy 70,9%, by open surgery29,1% The proportion of the left kidney removed for transplantationwas higher than that of the right (56,7% vs 43,3%)

Table 3.6: Volume of left kidney transplanted in male: 145,76 ±22,48 cm³, in female: 157,14 ± 43,71 cm3 Right kidney transplant inmale: 146,68 ± 28,83 cm3, in female: 139,94 ± 22,12 cm3 There was

no statistically significant difference in volume between the 2 groups(p > 0,05)

3.2.1.2 Characteristics of transplanted renal vessels

Table 3.7: Number of of transplanted kidney vessels on MSCT:

Characteristics

Left kidney (n=72) Right kidney (n=55) Tot

al Ratio (%) Number Ratio (%) Number Ratio (%)

2nd 25,011,3 11,1 48,6 6,42,6 2,95 10,25

Table 3.9: the number of graft renal vessels after removal: 22/127cases (17,3%) were 2 arteries and 3/127 cases (2,4%) were 3 arteries.There were 10/127 cases (7,9%) that have 2 arteries, having 3 arterieswas 1/127 case (0,8%).

Table 3.10: length of blood vessels of the transplanted kidney afterremoval: mean length of group 1 artery (n=102) was 3,1mm Group ofmultiple arteries: in group of 2 arteries (n=22): mean length of the firstartery was 14,42,9mm, of the second artery was 14,45,9mm; ingroup 3 arteries (n=3): mean length of the first artery: 16,33,2mm;2nd artery: 13,02,6mm; 3rd artery: 21,316,3mm

3.2.2 Characteristics of pelvic blood vessels in kidney recipients

- During surgery:

+ Evaluation of the iliac artery wall after dissection:

Table 3.15: the walls are soft: IIA: 106 cases (83,46%), EIA: 125cases (98,42%); thick and strong: IIA: 3 cases (2,36%), EIA: 1 case(0,79%); atheroma: IIA: 13 cases (10,24%), EIA: 1 case (0,79%); hard,palpable with calcified atherosclerotic plaque: IIA: 5 cases (3,94%),EIA: 0%

+ Some factors related to atherosclerosis: Table 3.16: The rate ofatherosclerosis is mainly seen from the age of 31 to 50 years old with13/127 cases Table 3.17: more than 24 months of dialysis time in 10/19cases of atherosclerosis account for the majority The longer the dialysistime, the higher the rate of atherosclerosis

+ Characteristics of the EIV wall after dissection

 Soft venous wall: 123/127 cases (96,85%)

 Hardening of the vessel wall, atrophy: 1/127 case (0,79%)

 Having thrombosis when opening the vein: 3/127 cases (2,36%)

3.3 Evaluation of the results of vascular anastomosis techniques

3.3.1 Vascular anastomosis techniques

3.3.1.1 Location of the transplanted kidney

124 cases of transplanted kidneys were placed in the recipient'sright iliac fossa, accounting for 97,6% Three cases of kidneytransplants were placed in the recipient's left iliac fossa, accounting for2,4%, because the first kidney transplant was in the right iliac fossa

3.3.1.2 Techniques on abnormality vessel of the transplanted kidney

 Multiple renal arteries graft

Table 3.18 Management techniques if multiple renal arteries Arterial

distribution Techniques arteries 2 arteries 3 Total (%)

All renal arteries

(RA) enter the renal

hilum (n=15)

Gun barrel shaping 9 9 9(36%)

2 separate anastomosiswith the EIA 1 0 1 (4%)

2 separate anastomosiswith the IIA, and the

The main RA enters

the renal hilum (RH),

the accessory RA

enters the superior

pole (n=7)

2 separate anastomosiswith the IIA, and the EIA + Small vein ligation

Small vein ligation 5 0 (20%)5

The main RA enters

the RH, the accessory

Small vein ligation 1 0 1 (4%)

 Multiple renal vein grafts:

Table 3.19: 2 separate anastomoses: 1/11 cases (9,1%); Gun barrelshaping 8/11 cases (72,7%); ligation of 1 small vein 1/11 case (9,1%),Gun barrel shaping + Small vein ligation: 1/11 case (9,1%)

 Management if the renal vein was short:

Table 3.20: dissection the renal hilum, renal vein lengthening,change the position of the renal vein posterior to renal artery: 4/39 cases