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Renal transplant is the most auspicious renal replacement therapy regarding prognosis and survival in patients with chronic kidney disease. The most common surgical technique for kidney graft placement is heterotopic transplant with graft renal artery anastomosis to the receptor's iliac artery, however, there are extraordinarily challenging cases that limit this technique. This case report’s objective is to detail an orthotopic renal transplant with end-to-end anastomosis of splenic artery in a patient with iliac artery thrombosis and exhaustion of vascular accesses.
Results
A normal vascular inflow and outflow was confirmed by means of follow-up ultrasound. Three days after transplant, a renal scintigraphy with m-mercaptoacetyltriglycine (MAG3) was performed, and it exposed total effective renal plasma flow in 87 ml/min.
Our patient presented the next biochemical evolution during his week of hospitalization and subsequently. (Figure 1) During the first 3 days after transplant, he presented increased pancreatic enzymes without severity.
Presented satisfactory evolution after transplant and normal kidney function.
In the face of a patient with impending lack of suitable venous access for hemodialysis, in which another location was inaccessible, renal transplant became (more than in a medium and long term plan), his only survival alternative.
Conventional heterotopic renal transplant wasn’t conceivable for him, because of open evidence of thrombosis of the inferior vena cava and iliac arteries, so an orthotopic transplant with anastomosis to splenic vessels was chosen; an unconventional, understudied alternative, that in this case, turned out prosperously.
Thus far, there are only 4 reported cases of this type of anastomosis after splenectomy (M Spaggiari-2018); concluding that this technique is appropriate and valuable in patients with iliocaval thrombosis. End-to-end anastomosis (compared to lateral-end anastomosis) provides a remarkable security profile regarding thrombotic implications or haemodynamic disturbances. In the other 4 cases reports; three of them used the left native ureter for urinary reconstruction and the fourth one, directly reach the bladder for the transplant ureteral anastomosis; in our center, left native pelvis was used for the urinary reconstruction (ureteropelvic anastomosis).
Orthotopic transplant with anastomosis to splenic vessels is an atypical transplant approach with scanty cases reported thus far. This case report could constitute a turning point to other renal transplant centers to consider it as a formidable alternative of anastomosis in cases that merit broader options.