Introduction: Refinements of the conventional kidney transplant technique have been developed to reduce the incidence of post-transplant surgical complications.
Methods: 707 consecutive recipients of a kidney-alone transplant were performed at our center using the renal artery anastomosis first approach.The technique included clamping the external(or common)iliac artery and the external iliac vein while performing the renal artery anastamosis first.The iliac artery was incised and extended with medial and lateral sutures being placed to keep the two arterial walls apart.The lateral side of the renal anastomosis was performed first by continuous suture.The kidney allograft was then flipped to its lateral side and was placed on the psoas muscle.The medial side of the renal arterial anastomosis was performed in a continuous manner.Next, the external iliac vein was incised, extended, and anastomosed by placing two corner proximal and distal sutures.A stay suture was placed through the middle of the medial wall to keep the external iliac vein open.The lateral side of the renal vein anastomosis was performed first from inside of the lumen and finishing at the distal corner, being tied with the distal corner suture.The medial side of the renal vein anastomosis was performed next, outside of the renal vein, with corner sutures being used in a continuous manner, finishing at the middle of the renal vein anastomosis and being tied.The medial stay suture was removed, once one of the corners got to the middle of the medial wall.This step avoids the flip-flop maneuver as well as avoids the need of retracting the renal vein while performing the arterial anastomosis. 
Results: 19/707 patients developed a vascular complication during the first 12mo post-transplant.2 patients experienced transplant renal artery stenosis(RAS) at the anastomosis level: one received a living donor(LD) kidney and was treated with stent placement, and the other received a deceased donor(DD) kidney with 2 renal arteries without a carrel patch(both renal arteries were anastomosed together side-to-side), with the superior renal artery developing stenosis, which was treated with balloon angioplasty.10/19 patients had proximal RAS with patent renal artery anastomosis.2 patients had kinking of one of the branches of the main renal artery;3 patients had stenosis of one of the branches of the main renal artery.Balloon angioplasty and/or stent placement was successfully performed in all 15/19 cases.1/19 patient experienced both renal artery and renal vein thrombosis along with simultaneous graft failure at 9 days post-transplant.In 2/19 cases, a thrombectomy was performed.One additional patient who developed renal vein thrombosis and abdominal compartment syndrome at day1 post-transplant had surgical repair.
Conclusions: Performing these modifications to the conventional kidney transplant technique may be associated with a reduced risk of developing vascular complications post-transplant.