TITLE:
Reverse Spatulated Hybrid Technique of Arterial Anastomosis in Kidney Transplant
AUTHORS:
Martin Randriantsalama, Bhagwati Chandra Verma, Rajnish Kumar, Gaurav Faujdar, Deepak Kumar Rathi, Prasun Ghosh
KEYWORDS:
Kidney Transplantation, Vascular Anastomosis, Reverse Spatulation, Renal Allograft, Ischemia Time, Anastomotic Patency, Delayed Graft Function
JOURNAL NAME:
Open Journal of Organ Transplant Surgery,
Vol.13 No.1,
January
16,
2026
ABSTRACT: Introduction: Kidney transplant is the treatment of choice for end-stage renal disease. Vascular anastomosis remains a critical determinant of success, influencing graft perfusion, patency, and long-term function. Several techniques have been developed to minimize ischemia time and reduce vascular complications, particularly in arterial anastomoses. The reverse spatulated hybrid technique (RSHT) combines reverse spatulation of the donor renal artery with an oblique arteriotomy of the recipient internal iliac artery. To create a wide anastomosis and ensure that all sutures are taken under vision, thereby reducing the chances of TRAS to almost negligible levels. This study describes the RSHT and evaluates its clinical outcomes in renal transplantation. Objectıve: To evaluate the outcomes of the RSHT in kidney transplantation, focusing on vascular complications, ischemia times, and early graft function, including delayed graft function. Methods: In this single-center observational study, 101 kidney transplants were performed between October 2024 and February 2025. Eighty-six recipients with a single renal artery undergoing end-to-end anastomosis to the internal iliac artery using RSHT were included; 15 cases with multiple renal arteries, end-to-side anastomosis to the external iliac artery, cadaveric donors, or combined liver-kidney transplantation were excluded. The main point in RSHT is visualizing the lie of both RA and IIA and precisely spatulating both vessels in the reverse direction. Lie, and spatulation is a visual assessment made beforehand and is the key learning step in RSHT. The first suture is taken at the 6 o’clock position on both vessels, and the determination of this point and precise suturing is another key step. With both these maneuvers, we are able to create the widest possible anastomosis between RA and IIA and also maintain the final lie of the graft without kinking the anastomosis. Outcomes were assessed by Doppler ultrasonography and serum creatinine at predefined time points, and by clinical follow-up. Results: Eighty-six recipients were analyzed (mean age 36 years ± 13.2 years; range 9 - 66), of whom 64 (74.4%) were male, and 22 (25.6%) were female. Most donor nephrectomies were laparoscopic (82; 95.3%), with 4 (4.7%) open procedures; the graft renal artery was anastomosed to the right internal iliac artery in 84 cases (97.6%) and to the left in 2 (2.4%). Mean warm and cold ischemia times were 3.2 minutes (range 1 - 8) and 75.2 minutes (range 49 - 116), respectively; mean arterial and venous anastomosis times were 15.5 minutes (range 9 - 32) and 12.4 minutes (range 7 - 26). No vascular complications were observed in the early postoperative period: there were no cases of arterial or venous thrombosis or arterial stenosis on Doppler ultrasonography at days 1, 4, and 30. Mean serum creatinine values were 2.87 mg/dL on day 1, 1.3 mg/dL on day 3, and 1.2 mg/dL on days 30 and 90, and no delayed graft function occurred in this cohort. Two patients died from medical (non-surgical) complications. Conclusıon: The RSHT provides a favorable anastomotic geometry that may reduce flow turbulence and optimize vascular hemodynamics in renal transplantation. Although technically more complex and associated with a longer learning curve than conventional end-to-end anastomosis, the technique in this series was associated with acceptable ischemia and anastomosis times, absence of early vascular complications, and excellent early graft function without delayed graft function. The main limitations are the short mean follow-up and single-center design; larger multicenter studies with longer follow-up are needed to confirm the long-term patency and clinical impact of RSHT in kidney transplantation.