Salvaging unexpected vascular challenges in renal transplant: two case reports.

Objective: Kidney transplantation remains the optimal treatment for end-stage renal disease (ESRD). The disparity between organ demand and supply persists. Vascular complications can challenge graft viability. Given the dependence on living donors, marginal donors with vascular anomalies present significant surgical challenges, necessitating meticulous preoperative planning and intraoperative adaptability. We report two cases, one involving an upper segmental artery injury detected during bench dissection and the second featured multiple renal arteries with unexpected anatomical variations. Presentation of case: Case 1 involved a marginal donor with an unexpected tunica adventitia and media disruption in an upper segmental artery detected during bench dissection. A 1.75 mm coronary shunt was used for precise end-to-end arterial reconstruction. Case 2 required intricate vascular reconstruction due to multiple renal arteries, managed by a pantaloon technique to create a single wide ostium, optimizing anastomosis. Results: Both grafts demonstrated excellent perfusion and function, with primary outcomes showing patent vasculature and stable renal function over 1-year follow-up. Conclusion: Bench dissection is an important step to detect vascular anomalies and guiding surgical decision-making. Creating a single wide ostium for multiple arteries enhances transplant success by reducing warm ischemia and anastomotic complications. Surgeons must anticipate vascular challenges and refine reconstruction techniques to optimize long-term outcomes in living donor kidney transplant/transplantation.