Surgical Challenge in Pediatric Kidney Transplant
Vascular Anastomosis
Atsushi Aikawa,1 Masaki Muramatsu,2 Yusuke Takahashi,1,2 Yuko Hamasaki,2
Junya Hashimoto,1,2 Mai Kubota,2 Takeshi Kawamura,1 Yoshihiro Itabashi,1 Yoiji Hyodou,1
Seiichiro Shishido1,2
Abstract
During pediatric kidney transplant, surgical challenges
occasionally occur. In particular, vascular anastomosis
should be considered for children with small body
weight < 12 kg, multiple renal arteries, vascular
anomaly, and inferior vena cava occlusion. In pediatric
patients, a living-donor renal graft is usually donated
from a parent. Therefore, the renal artery and vein are
too large to be anastomosed with the recipient’s
internal iliac artery and external iliac vein. In children
who are > 12 kg, the renal artery and vein could be
anastomosed with the external iliac artery and the
external iliac vein. In children who are < 10 kg, the
renal artery and vein should be anastomosed directly
with the aorta and inferior vena cava. A pediatric
transplant surgeon should consider arterial and
venous anastomosis sites before transplant surgery. In
small children with partial or total inferior vena cava
occlusion, the venous anastomosis site should be
evaluated. If the graft is placed on the left side, a
venous graft must be used as a bridge between the
renal vein and inferior vena cava. In 13 kidney
transplants in children with inferior vena cava
occlusion, 7 were on the left and 6 were on the right
side. A patent segment of the inferior vena cava, the
left original renal vein, an ascending lumbar vein, an
azygos vein, the first graft renal vein, and a portal vein
were used for venous anastomosis in 6, 2, 2, 1, 1 and 1
recipient, respectively. One child had graft loss due to
renal vein thrombosis and one died of hemorrhage
immediately posttransplant. Three had grafts with
relatively long-term function, but these were lost due
to chronic allograft nephropathy 100, 122, and 137
months posttransplant. However, the other 8 recipients
From the 1Department of Nephrology and the 2Department of Pediatric Nephrology, Toho
University, Toho, Japan
Acknowledgements: The authors have no sources of funding for this study and have no conflicts
of interest to declare.
Corresponding author: Atsushi Aikawa, Department of Nephrology, Toho University, Toho,
Japan
Phone: +81 90 3478 0053 E-mail: aaikawa@med.toho-u.ac.jp
Experimental and Clinical Transplantation (2018) Suppl 1: 14-19
Copyright © Başkent University 2018
Printed in Turkey. All Rights Reserved.
have so far maintained graft function from 6 to 138
months since transplant.
Key words: Living-donor renal transplant, Small body
weight, Vascular anastomosis
Introduction
For kidney transplant, young children usually receive
a living-related transplant from a parent donor.
However, this adult renal allograft is transplanted in a
small space in young children. In small children who
are less than 10 kg body weight, we usually make a
paramedian incision and the intraperitoneal approach
is preferred, although recently the extraperitoneal
approach has been also used in children who are less
than 10 kg body weight.1
When a renal allograft has double arteries, a
conjoined and end-to-side anastomoses to one orifice
are performed. Procedure times for multiple
anastomoses are lengthy, leading to long ischemic
time in the lower extremities and pelvic organs. In
addition, a multiple arterial anastomosis to a direct
aorta increases the risk of massive bleeding.
In children with a thrombosed inferior vena
cava (IVC), a pretransplant evaluation with
three-dimensional computed tomographic (3D-CT)
venography is important.2-4 This procedure can allow
clear discussion of the venous anastomosis site5-14
and the necessity of a venous graft5-12,13 before
transplant surgery.
In this report, we outline our pretransplant
evaluation of the donor’s renal artery and vein and the
recipient’s vascular system, including the aorta and
the IVC, for vascular anastomosis in small children.
We also outline the vascular surgical techniques that
we use in small children with compromised arteries
and veins, including thrombosed IVC. Previously,
kidney transplants for small children with
thrombosed IVC were not performed and were
DOI: 10.6002/ect.TOND-TDTD2017.L41
 Atsushi Aikawa et al/Experimental and Clinical Transplantation (2018) Suppl 1: 14-19 15

contraindicated because the vascular anastomosis renal arteries into one orifice. When there is a long
was difficult and complicated. However, a successful distance between these arteries, the graft is placed
kidney transplant promises no dialysis, normal upside down and the lower artery is anastomosed
growth, and normal child life. The benefits of with the aorta or common iliac artery and the upper
transplant outweigh the challenges of vascular artery is anastomosed with the external or internal
surgery in small children. iliac artery. A ureter should be placed with reversed
U shape to avoid a sharp bend (Figure 2).
Incision and Approach
Figure 1. End-to-Side Anastomosis Between a Larger Upper and a Smaller
In our center, we prefer the hockey stick incision; Lower Renal Artery Pair
occasionally, the incision is extended to the subcostal
area in children who are more than 12 kg. In children
who are less than 10 kg, we make a paramedian
incision. Usually, the right side is chosen because
venous anastomosis with IVC is much easier than a
left-side procedure.
The extraperitoneal approach is used for children
who are more than 12 kg, and the intraperitoneal Figure 2. Graft Placed Upside Down When the Upper Renal Artery Is Smaller
approach is preferred for children who are less than Than the Lower Artery

12 kg. Exposure of an operative field is better with

vascular anastomosis in the intraperitoneal approach
than in the extraperitoneal approach. However, an
ileus due to bowel adhesion may occasionally occur
posttransplant with the intraperitoneal approach.
With the intraperitoneal approach, the graft,
including the renal pedicle, should be surrounded by
retroperitoneum as much as possible. A ureter also
should be placed in the retroperitoneal space.

Presence of Double Renal Arteries

Double renal arteries of the same size

The conjoined ex vivo method is preferred for joining
double renal arteries to one orifice. This is a lengthy
method and a risk to children when anastomosis of
each renal artery with each aorta is needed.
Upper renal artery is larger than the lower artery
When there is a short distance between the upper
and lower arteries, the lower artery is anastomosed
with the upper artery end-to-side to join double renal
arteries to one orifice (Figure 1). When there is a long
distance between these arteries, the upper artery is
anastomosed with the aorta or the common iliac
artery and the lower artery is anastomosed with the
external or internal iliac artery.
Upper renal artery is smaller than the lower artery
When there is a short distance between the upper
and lower arteries, the upper artery is anastomosed
with the lower artery end-to-side to join the double
The graft was turned over and placed upside down. As shown in 3-
dimensional computed tomographic venography image, the upper renal
artery was anastomosed with the internal iliac artery and the lower main
artery was anastomosed with the aorta. The ureter was placed with a reversed
U shape and anastomosed with the native ureter.
Occlusion of Inferior Vena Cava
Some children with Wilms tumor, neuroblastoma,
hepatoblastoma, or previous transplant procedures
have partially or totally thrombosed IVC. The venous
anastomosis site of an allograft renal vein should be
evaluated by reviewing 3D-CT venography image
results. In 13 pediatric kidney transplants in children
with occlusion of IVC at our center, 7 grafts were
placed on the left and 6 grafts were placed on the
right side. A patent segment of IVC, the left original
renal vein, an ascending lumbar vein, an azygos vein,
the first graft renal vein, and a portal vein were used
16 Atsushi Aikawa et al/Experimental and Clinical Transplantation (2018) Suppl 1: 14-19 Exp Clin Transplant

for venous anastomosis in 6, 2, 2, 1, 1, and 1 recipient, internal iliac arteries. In addition, the IVC was mostly
respectively (Table 1). One child had graft loss due to occluded, although partial patentcy was shown
renal vein thrombosis, and one child died of around the junction of the left original renal vein to
hemorrhage immediately posttransplant. Three the IVC (Figure 3). Therefore, we decided that a third
children had long-term graft function, but grafts graft could be placed in the left side with a transverse
were lost due to chronic allograft nephropathy 100, incision and intraperitoneal approach. The renal vein
122, and 137 months posttransplant. However, 8 was extended so that it could be anastomosed with
recipients have shown graft function for 6 to 138 the junction of the left original renal vein using the
months since transplant (Table 2). venous graft, which was modified by the donor’s left
ovarian and right saphenous veins (Figure 4). The
Table 1. Kidney Transplant in Children with Inferior Vena Cava Occlusion renal artery was anastomosed with the aorta. Blood
Patient Age at Donor Graft Arterial Venous
Transplant, Placement Anastomosis Anastomosis
flow was observed at 3 months posttransplant from
y Location the renal vein to the central IVC through the venous
1 7.4 Living Right Ao Left renal vein graft, which crossed over the aorta (Figure 5).
2 2.8 Living Right Ao Patent segment of IVC
3 (2-2) 6.4 Deceased Left Ao Patent segment of IVC
4 4.7 Living Right Ao Left renal vein Figure 3. 3-Dimensional Computed Tomographic Venography Images of
5 (4-2) 14.9 Deceased Left Ao Patent segment of IVC Occlusion in Case A
6 4.5 Deceased Right Ao Azygos vein
7 (6-2) 15.9 Living Right Ao First graft vein
8 6.8 Living Right Ao Patent segment of IVC
9 10.3 Living Left Ao Ascending lumber vein
10 9.0 Living Left Ao Ascending lumber vein
11 4.9 Deceased Left Ao Patent segment of IVC
12 11.3 Living Left Ao Patent segment of IVC
13 5.9 Living Left Ao Portal vein
Abbreviations: Ao, aorta; IVC, inferior vena cava

Table 2. Outcomes of Kidney Transplant in Children with Inferior Vena Cava

Occlusion
Patient Serum Serum CCr, mL/min/ Outcome Posttransplant,
Creatinine Creatinine 1.73 m2 mo
(3 mo), mg/dL (1 y), mg/dL
1 0.56 0.7 77 Graft loss 100
2 ND Graft loss 0
3 (2-2) 0.65 0.78 72.2 Graft survival 138
4 0.54 0.58 107.7 Graft loss 122
5 (4-2) 1.55 1.76 56.5 Graft survival 29
6 0.98 0.92 64.2 Graft loss 137
7 (6-2) ND Graft survival 12 Images show occlusion of the inferior vena cava and dilated ascending
8 ND Death 0 lumbar vein. The inferior vena cava was partially patent around the junction
9 0.84 1.27 55.4 Graft survival 78 of the native renal vein to the inferior vena cava (arrows).
10 0.57 0.84 71.6 Graft survival 60
11 0.62 0.57 94.2 Graft survival 28
12 0.37 0.61 Graft survival 14 Figure 4. Venous Graft Procedure in Case A
13 0.12 Graft survival 6
OV SV
Abbreviations: CCr, creatinine clearance; ND, not determined

Case Presentation

Case A
Case A was an 11-year-old boy (patient 12; Table 1)
who had previous kidney transplant twice in the
right side of the pelvic space. The second graft had
been replaced using an intra-abdominal approach
after the first graft was removed; however, this graft
showed primary graft nonfunction and was removed
9 days after transplant. Before a third kidney Left ovarian vein (OV) and right saphenous vein (SV) were retrieved from
the donor and joined into a single vein. The venous graft was connected to
transplant was planned, a 3D-CT angiography
the transplant renal vein (RV). Images were modified from Figure 3 in
showed absence of the right common, external, and Muramatsu and associates.14
 Atsushi Aikawa et al/Experimental and Clinical Transplantation (2018) Suppl 1: 14-19 17

Figure 5. 3-Dimensional Computed Tomographic Venography Image at 3 anastomose. We implemented a transverse incision
Months Posttransplant in Case A
with intraperitoneal approach in the upper abdomen.
IVC a venous graft The graft was placed upside down in the left renal
cross over fossa after left nephrectomy. The renal vein was
aorta to IVC
extended by the venous graft, which consisted of the
donor’s retrieved left ovarian and left saphenous
veins. The venous graft was anastomosed with the
portal vein as a bypass from the graft renal vein
(Figure 7, left). The renal artery was anastomosed
with the aorta. Renal venous flow was observed 3
months posttransplant from the renal vein to the
portal vein through the venous graft, which crossed
over the aorta (Figure 7, right).

Case C
Case C was a 10-year-old boy (patient 9; Table 1) in
Anastomosis whom the IVC was totally occluded after
beteen the renal hepatoblastoma surgery (Figure 8, left). The donor’s
artery and aorta
ovarian vein was retrieved, replacing the upper site
The renal vein flow to the inferior vena cava (IVC) through a venous graft was
confirmed. Images were modified from Figure 4 in Muramatsu and
of the graft renal vein with side-to-end anastomosis
associates.14 (Figure 8, right; Figure 9, left). The ovarian vein graft
was anastomosed with the splenic vein after
splenectomy (Figure 9, left). The renal vein was
Case B
anastomosed with the junction of the left original
Case B was a 5-year-old girl (patient 13; Table 1) in
renal vein to the left testicular vein (Figure 8, right;
whom the IVC was mostly occluded because of
congenital nephrotic syndrome. A small part of the
Figure 7. Venous Graft Consisted of Donor’s Right Ovarian and Right Saphenous
IVC in the central area was patent; however, it was Veins and Used as Extended Renal Vein to the Portal Vein in Case B
not an appropriate anastomosis site (Figure 6). Other
veins such as the left original renal vein, ascending
lumbar vein, and azygos vein were also too small to

Figure 6. 3-Dimensional Computed Tomographic Venography Image Showing

Inferior Vena Cava Occlusion and Dilated Ascending Lumbar Vein in Case B

Graft renal vein flow to the portal vein thorough the venous graft was confirmed
at 3 months posttransplant.

Figure 8. 3-Dimensional Computed Tomographic Venography Image Showing

Inferior Vena Cava Occlusion With Dilated Testicular Vein and Ascending
Lumbar Vein in Case C

Patent part of the inferior vena cava (IVC) was not appropriate for venous
anastomosis.
18 Atsushi Aikawa et al/Experimental and Clinical Transplantation (2018) Suppl 1: 14-19
Figure 9, left). The renal artery was anastomosed
with the aorta. Blood flow was observed at 3 months
posttransplant from the renal vein to the portal vein
through the ovarian vein graft and the splenic vein,
as shown by 3D-CT venography (Figure 9, right).
Figure 9. Ovarian Vein Used as Venous Graft Between the Renal Vein and the
Splenic Vein in Case C
(Left) Ovarian vein used as venous graft between the renal vein and the
splenic vein. This figure was modified from Shishido and associates.5
(Right) 3-dimension computed tomographic venography at 3 months
posttransplant. The ovarian vein was used as a bypass between the renal
vein and the splenic vein.
Discussion
An intraperitoneal approach is the easier operative
procedure to expose the operating field and perform
vascular anastomosis than the extraperitoneal
approach. However, an adhesive intestinal ileus
occasionally occurs in the intraperitoneal approach.
The extraperitoneal approach is preferred in children
who are more than 12 kg body weight. Heap and
associates1 demonstrated that between days 2 and 14
postoperatively, an extraperitoneal renal transplant
in patients less than 6 years of age resulted in a
transient improvement in early graft function;
however, there were no significant differences in the
number of complications between intra- and
extraperitoneal approaches.
In children with renal double arteries, the
conjoined method or end-to-side anastomosis
between the small artery and the main artery is
preferred. The preferred choice is dependent on the
size and position of the double arteries. It is necessary
to avoid multiple anastomoses between the renal
arteries and aorta. Multiple anastomoses with aortas
increase the risk of long ischemic time in the pelvic
organs and legs and can result in massive bleeding.
Intravenous blood pressure should be below
25 mm Hg10; otherwise, renal vein thrombosis
frequently occurs. A venous anastomosis should be
Exp Clin Transplant
considered for small children with a defect of the IVC.
If the IVC cannot be used for venous anastomosis,
the native renal vein,5 the gonadal vein,5-7 or the
ascending lumbar vein5 could be options. When
these veins are too small to keep venous flow and to
avoid high venous pressure, a splenic vein5 after
splenectomy, an inferior mesenteric vein,10 a superior
mesenteric vein,11 or a portal vein12 can be
anastomosed with the renal vein.
A pediatric kidney transplant surgeon should
master good vascular surgical techniques; however,
it is also important to identify the suitable arterial
and venous anastomosis sites. Particularly for
children with thrombosed IVC, the inferior and the
superior mesenteric veins, the splenic vein, or the
portal vein could be indicated for venous
anastomosis with a renal vein.
Kidney transplant in children with thrombosed
IVC was previously not performed because of
difficulty with vascular anastomosis. However,
successful kidney transplant can result in no dialysis,
normal growth, and normal child life. To achieve
good quality of life for children with end-stage renal
disease, a pediatric transplant surgeon should master
vascular anastomosis techniques to allow these
children a chance for transplant. Despite the surgical
challenges in children with a compromised vascular
system, kidney transplant is beneficial.
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