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Renal transplantation usually is performed via transperitoneal approach and the graft is placed in iliac fossa. When iliac vessels are not appropriate for anastomosis, graft position can be changed. Here we report a Buerger disease patient who had successful orthotopic renal transplantation through native renal artery and splenic vein.The case is a 68 years old male patient with chronic renal failure due to Buerger disease. He suffered from Buerger disease for 30 years and he had aorta-bifemoral bypass. Preoperative evaluation revealed that both iliac arteries (external and internal iliac) were obliterated in both sites. Besides, right native renal artery was also thrombosed. So, we decided to perform orthotopic renal transplantation from a related living donor. In the same session we performed native nephrectomy and orthotopic renal transplantation. The artery of the graft was anastomosed to native renal artery through PTFE graft. In the first attempt the vein of the graft was anastomosed to renal vein but venous outflow was inadequate. So venous anastomosis is displaced to splenic vein and spleno-renal anastomosis was done through PTFE graft. At the 10th day of operation he was discharged from hospital with normal creatine value (0.6 mg/dL).In cases with lack of vascular access for renal transplantation splenic vein can be safely used for venous outflow of the graft.