FEATURES OF PREPARATION AND SURGICAL TECHNIQUES IN KIDNEY TRANSPLANTATION WITH MULTIPLE RENAL ARTERIES

Abstract

Kidney transplantation is considered the most effective treatment for end-stage renal disease (ESRD), as it typically leads to better survival rates and quality of life than dialysis. However, anatomical variations such as multiple renal arteries (MRAs), observed in 18–35% of donors, introduce significant technical challenges during organ retrieval, vascular reconstruction, and anastomosis, increasing the risks of complications like thrombosis, stenosis, and delayed graft function (DGF). The aim of this review is to summarize and critically evaluate contemporary strategies for preoperative imaging, surgical preparation, operative reconstruction techniques, and postoperative outcomes in kidney transplantation involving MRAs. We conducted a structured narrative synthesis based on 27 recent peer-reviewed publications (2010–2024), including meta-analyses, clinical cohort studies, and guideline reviews. Data show that with accurate preoperative planning, especially using CT angiography and 3D reconstruction, MRAs can be reliably identified and classified. Surgical strategies vary from bench reconstruction of arterial confluences to separate multiple anastomoses depending on vessel diameter and orientation. Although transplant renal artery stenosis (TRAS) and DGF are statistically more frequent in MRA grafts compared to single-artery grafts [1, 5, 10, 14], long-term graft and patient survival rates are comparable [3, 6, 11, 22]. Emerging approaches, including computational hemodynamic modeling, endovascular therapies, and robotic-assisted transplantation, are broadening technical capabilities and minimizing risks. The review highlights the need for unified surgical guidelines and supports the feasibility and safety of MRA grafts when handled by experienced multidisciplinary teams. Limitations of existing literature include heterogeneity in reconstruction methods and underreporting of long-term vascular outcomes. Nonetheless, this review contributes by systematizing available knowledge and outlining evidence-based practical recommendations for surgical teams. It underscores the importance of integrating imaging technology, surgical innovation, and risk stratification in the management of anatomically complex kidney grafts.