SEARCH

SEARCH BY CITATION

American Journal of Transplantation Images in Transplantation — Continuing Medical Education (CME)

Each month, the American Journal of Transplantation will feature Images in Transplantation, a journal-based CME activity, chosen to educate participants on current developments in the science and imaging of transplantation. Participants can earn 1 AMA PRA Category 1 Credit™ per article at their own pace.

This month's feature article is titled: “A Laparoscopic Donor Nephrectomy in Patients With Anomalies of the Inferior Vena Cava.”

Accreditation and Designation Statement

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Blackwell Futura Media Services, the American Society of Transplant Surgeons and the American Society of Transplantation. Blackwell Futura Media Services is accredited by the ACCME to provide continuing medical education for physicians.

Blackwell Futura Media Services designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Statement of Need

Venous anomalies of the inferior vena cava (IVC) were once considered an incidental finding of trivial clinical significance, but the recent rise in living kidney donation has emphasized the importance of this irregularity. Moreover, this forthcoming discourse elucidates many important themes central to kidney donation and this variant venous anatomy.

Purpose of Activity

This activity is intended to:

  • Encourage the study of the embryologic origin of the IVC and its variant presentation, specifically duplication and left-sided positioning.
  • Enhance the understanding of the clinical and surgical implications of a duplicated and a left-sided IVC.
  • Ensure a safe strategy of living donor kidney procurement in patients with a duplicated or a left-sided IVC.

Identification of Practice Gap

Living donor kidney donation has arisen to address the tremendous need of patients with end-stage renal disease. As such, practitioners who screen potential donors should be mindful that IVC variation in presentation should not preclude donation.

Learning Objectives

Upon completion of this educational activity, participants will be able to:

  • Understand the embryologic mechanism of formation of a duplicated or left-sided IVC.
  • Recognize variant venous anatomy on axial imaging.
  • Learn that IVC variances should not preclude living donor nephrectomy.
  • Evaluate a safe preoperative strategy to perform living donor nephrectomies in patients with vascular anomalies.

Target Audience

This activity has been designed to meet the educational needs of physicians and surgeons in the field of transplantation.

Disclosures

No commercial support has been accepted related to the development or publication of this activity. Blackwell Futura Media Services has reviewed all disclosures and resolved or managed all identified conflicts of interest, as applicable. The following authors, editors, and staff reported no relevant financial relationships with respect to this activity.

Editor-in-Chief

Allan D. Kirk, MD, PhD, FACS

Editors

Sandy Feng, MD, PhD Douglas W. Hanto, MD, PhD Authors

Jay A. Graham, MD, and Lloyd E. Ratner, MD, MPH

ASTS Staff

Mina Behari, Director of Education

This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by the American Journal of Transplantation. The peer reviewers have no relevant financial relationships to disclose. The peer review process for the American Journal of Transplantation is blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review.

Instructions on Receiving CME Credit

This activity is designed to be completed within an hour. Physicians should claim only those credits that reflect the time actually spent in the activity. This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months.

Follow these steps to participate, answer the questions and claim your CME credit:

  • Log on to https://www.wileyhealthlearning.com/ajt
  • Read the learning objectives, target audience, and activity disclosures.
  • Read the article in print or online format.
  • Reflect on the article.
  • Access the CME Exam, and choose the best answer to each question.
  • Complete the required evaluation and print your CME certificate.

Continuing Medical Education

Images

in Transplantation

Look and Learn

A Laparoscopic Donor Nephrectomy in Patients With Anomalies of the Inferior Vena Cava

The first patient is a 34-year-old male who presented in a state of normal health wishing to donate his kidney to his mother. Preoperative imaging with a CT scan demonstrated a single left and right renal artery that measured 2.7 cm and 4.1 cm in length, respectively. Interestingly, while a single renal vein was seen draining each kidney, the left renal vein drained into a duplicated inferior vena cava (IVC) system (Figure 1A and 1B).

image

Figure 1. Serial coronal CT images demonstrate the normally positioned IVC (i), aorta (a) and left renal vein (star) extending from the duplicated IVC (di).

Download figure to PowerPoint

The second patient is a 52-year-old male who desired to donate to a friend. Again, preoperative imaging demonstrated an IVC variant, namely a left-sided IVC. Single right and left renal arteries were seen measuring 2.6 cm and 4 cm, respectively. Of note, while the left renal vein emanated from the left-sided IVC, the right renal vein originated superiorly as the IVC coursed into a more anatomically normal position (Figure 2A and 2B).

image

Figure 2. Serial coronal CT images demonstrate the aorta (a) and left renal vein (star) extending from the left-sided IVC (lsi). The right renal vein (arrow) emanates from the IVC as it moves into orthotopic position juxtaposed to the liver.

Download figure to PowerPoint

In the first patient, we procured the left kidney using a standardized laparoscopic approach. The duplicated IVC is not readily appreciated with the intraoperative imaging because the aorta dives underneath the left renal vein and duplicated IVC after the takeoff of the left renal artery (Figure 3A). Contrastingly, the right kidney was procured in the second patient because the left-sided IVC allowed easy access to the right renal vein as it was lying laterally to the origin of the right renal artery (Figure 3B).

image

Figure 3. A. Mobilized left kidney (K) in the patient with a duplicated IVC (di). Left renal artery takeoff from the aorta (*) is visualized as it dives underneath the duplicated IVC (di) as well as the left renal vein (star). B. Mobilized right kidney (K) with the left lobe of the liver (L) in the patient with a left-sided IVC (lsi). The right renal artery takeoff from the aorta (*) is visualized as well as the right renal vein (star).

Download figure to PowerPoint

Importantly, both donors had no untoward complications associated with the complexities of the vascular anomalies.

Questions

  1. Top of page
  2. Questions
  1. What embryological event can cause duplication and left-sided positioning of the IVC?
    1. Developmental failure of regression of the right subcardinal vein
    2. Developmental failure of regression of the left supracardinal vein
    3. Agenesis of the left iliac venous system
    4. Recanalization of the umbilical vein
    5. Duplication of the left gonadal vein
  2. During preoperative evaluation, your patient reports that she has had recurrent pulmonary embolisms despite an IVC filter placement previously. What congenital anomaly do you suspect?
    1. A retroaortic renal vein
    2. Circumaortic renal veins
    3. A retrocaval ureter
    4. A duplicated IVC
    5. A left-sided IVC
  3. Which of the following is TRUE? Preoperative recognition of a duplicated or left-sided IVC facilitates an operative plan that includes:
    1. Incomplete division of the duplicated or left-sided IVC to create a venous “cuff” or patch for the renal vein
    2. Complete division of the duplicated or left-sided IVC for added length of the renal vein, much in the way of standard deceased donor
    3. Division of the non-duplicated IVC as there is adequate venous outflow through the duplicated IVC
    4. Dividing the renal vein flush at the takeoff from the duplicated or left-sided IVC
    5. Canceling the procedure as patients with duplicated IVCs are not donor candidates
  4. Given the risk of venous thromboembolic events in donors with either a duplicated or left-sided IVC, what perioperative strategy would you employ for deep venous thrombosis (DVT) prophylaxis?
    1. Low-dose heparin sulfate drip (PTT 50-60) preoperatively and after the case
    2. High-dose heparin sulfate drip (PTT 70-90) preoperatively and after the case
    3. Heparin sulfate 5000 units subcutaneously before induction and twice a day thereafter
    4. Start the patient on Plavix 75 mg by mouth one week before the case
    5. No DVT prophylaxis should be given to donors
  5. Uncontrollable intraoperative hemorrhage during laparoscopic kidney procurement from the renal vein in patients with a duplicated or left-sided IVC mandates what action from the surgeon?
    1. Emergent conversion to open donor nephrectomy with a subcostal incision overlying the respective kidney
    2. Emergent conversion to open donor nephrectomy with a midline incision
    3. Laparoscopic insertion of gauze to apply pressure and tamponade the bleeding vessel
    4. Laparoscopic division of the IVC proximal and distal to the renal vein to gain control of the bleeding
    5. Laparoscopic division of the renal vein and continued mobilization of the kidney for removal

To complete this activity and earn credit, please go to https://www.wileyhealthlearning.com/ajt