An Interview with Dr. Stephen Bartlett

Approximately one percent of donor kidneys contain three arteries that must be reconstructed before being transplanted into a potential recipient. Below, Dr. Stephen Bartlett, Peter Angelos Distinguished Professor and Chair of the Department of Surgery at the University of Maryland School of Medicine, discusses how he is able to reconstruct those donor kidneys that arrive with three arteries through the use of advanced vascular surgery techniques he has pioneered at the University of Maryland Medical Center.

What is a three-artery kidney transplant?

A three-artery kidney transplant occurs when the donor has three renal arteries attached to his/her kidney. This is an unusual situation as most individuals only have one artery and one vein coming off of each kidney. We always prefer to transplant the kidney with least amount of arteries, so if a person is born with more than one artery, it can be a challenge to donate.

How often does this condition occur?

About one percent of donor kidneys will have three or more arteries, and 14 percent of donor kidneys will have at least two arteries. Thus, what happens in many of these cases is that patients will be evaluated at other transplant centers and they will be told that they cannot donate their kidney because there are three arteries in both kidneys and there's too much risk associated with performing the surgery. The donor is just simply ruled out. However, at the University of Maryland Medical Center, we accept these types of donors because we have the expertise and surgical techniques to proceed with this type of case.

How is a three-artery kidney transplant performed?

To perform a three-artery kidney transplant, surgeons use the same technique that's employed in a renal artery bypass. The surgeon will take a piece of vein and connect it to the aorta, then re-route that vein into the kidney and bypass the blockage in the kidney.

Specifically, in a three-artery kidney transplant, the surgeon will take a piece of vein -- called the saphenous vein (the same vein used for heart bypass surgery) -- and use that vein to extend the artery, making the transplant much easier. Surgeons don't need to use much of that vein, and if he or she only uses four or five inches of that vein, a patient can still have a heart bypass in the future. This is the most common way we reconstruct kidneys that have three or more arteries, and it's often very successful.

Now, some people may ask, “If there's more than one artery, does that present any additional risk to the donor?” And, the answer is not really. We use a stapler to divide one artery and we can use that same stapler to divide three. It doesn't make a lot of difference. The burden is then upon the vascular surgeon to reconstruct the kidney.

Can you talk a little bit about a case in which you were involved that required a three-artery kidney transplant?

In one particular case, the donor had three arteries in her kidney and we needed to use some very special vascular surgical techniques in order to make the transplant work. The recipient, the donor's father, was a man who was undergoing his second kidney transplant. He had one transplant in the past, which lasted a bit more than a decade, but he needed a second transplant.

Initially, there was some concern about doing the transplant with a kidney that contained three arteries. However, we have had a lot of experience here at UMMC in performing these types of transplants, either by putting arteries directly in or using special vascular surgical techniques that we developed here to make the transplant work.

The donor and the recipient are both doing great. In the recipient, we were able to establish a very good anatomic connection with both arteries in his iliac artery. The kidney was 100 percent re-vascularized, and today he has a great creatinine level and normal kidney function. He's doing great. The donor is also doing very well.

Can you explain what makes UMMC qualified to handle this difficult procedure?

I think what makes our Transplant Center more uniquely qualified than others is that, due to my vascular surgery training, I was able to pioneer a unique way of managing these multiple arteries. Here at UMMC, we have done a lot of these procedures and have gained a lot of experience, which has led to very good results. We have also published articles about performing this type of procedure, explaining how to use these techniques to safely use kidneys with multiple arteries.

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