Multiple Renal Arteries in Living-Related Kidney Transplantation: Surgical Approach and Clinical Outcomes

Background: The presence of multiple renal arteries in a kidney graft has traditionally been considered a factor increasing the technical complexity of living-related kidney transplantation. The main challenges are associated with detailed preoperative planning, selection of the nephrectomy technique, vascular reconstruction at the back-table, an increased number of arterial anastomoses, and a potential risk of vascular and ischemic complications. Current evidence suggests that, with adequate assessment of vascular anatomy and technically correct revascularization, grafts with multiple renal arteries can be successfully used without significant differences in early and one-year transplant outcomes. Objective: To evaluate the role of multislice computed tomography (MSCT) angiography, anatomical and surgical risk stratification, individualized selection of the revascularization method, and calculation of the equivalent diameter of a single arterial orifice in living-related kidney transplantation with multiple renal arteries. Material and methods: A retrospective analysis of 578 living-related kidney transplantations was performed. Based on the arterial anatomy of the graft, patients were divided into two groups: grafts with a single renal artery (471 cases) and grafts with two or more renal arteries (107 cases). All donors underwent preoperative MSCT angiography with 3D reconstruction. The surgical approach was determined by the number of renal arteries, minimum vessel diameter, the level of arterial bifurcation, the distance between arterial orifices, the presence of polar arteries, and feasibility of vascular reconstruction. When a single arterial orifice was created, the total luminal area and equivalent diameter were calculated using the formula: D eq =√(d 1 ²+d 2 ²). Revascularization modalities, as well as graft and recipient survival at 6 and 12 months, were evaluated. Results: Of 578 transplantations, 471 grafts had a graft with a single renal artery (81.5%), while 107 grafts had two or more renal arteries (18.5%). In cases with two arteries, separate revascularization using the 1+1 types was most commonly employed approach. In cases with three arteries, 2+1 and 1+1+1 configurations were used, while in cases with four arteries, paired arterial reconstruction using 2+2 configuration was performed. At 6 months, graft survival was 97.9% in the single-artery group and 97.2% in the group with two or more arteries (χ² = 0.184; p = 0.668). At 12 months, the rates were 96.2% and 96.3%, respectively (χ² = 0.002; p = 0.968). Recipient survival at 6 months was 96.8% and 96.3%, respectively (χ² = 0.084; p = 0.772), and at 12 months, 95.5% and 94.4% respectively (χ² = 0.258; p = 0.611). Conclusion: The presence of multiple renal arteries is not an absolute contraindication to living-related kidney transplantation. With careful preoperative planning, the use of MSCT angiography with 3D reconstruction, anatomical and surgical risk stratification, individualized selection of the revascularization technique, and calculation of the equivalent diameter of the reconstructed arterial orifice, transplant outcomes are comparable to those in kidney transplantation with standard single-artery anatomy.

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