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Ann Thorac Surg 1999;67:1787-1789
© 1999 The Society of Thoracic Surgeons

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Case Reports

Pulmonary thromboembolectomy of donor lungs prior to lung transplantation

^a Division of Cardiovascular and Thoracic Surgery, University of Minnesota Hospital and Clinic, Minneapolis, Minnesota, USA

Accepted for publication November 7, 1998.

Address reprint requests to Dr Park, Division of Cardiovascular and Thoracic Surgery, University of Minnesota, Box 207, 420 Delaware St SE, Minneapolis, MN 55455
e-mail: parkx021{at}maroon.tc.umn.edu

	Abstract

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Successful bilateral single-lung transplantation was performed after pulmonary thromboembolectomy of the donor lungs. The donor lungs were not thought to contain large amounts of pulmonary thromboemboli because they satisfied all the donor selection criteria. This case reinforces the need of not only meticulous inspection of the donor lungs prior to implantation but also the productive use of available donor organs.

	Introduction

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Lung transplantation is a successful and accepted treatment of several types of end-stage lung disease. Stringent donor selection criteria have been used in lung transplantation to ensure quality donor organs, although some transplant centers have progressed to using "marginal" donor lungs because of the current shortage of suitable donors [1]. Occasionally, however, the selection criteria fail to identify donor lungs with a major pathologic process. We present a case where the donor lungs satisfied all the selection criteria for transplantation but were found after procurement to contain large amounts of pulmonary thromboemboli, necessitating pulmonary thromboembolectomy prior to implantation.

A 47-year-old man with a 5-year history of ₁-antitrypsin deficiency was admitted for bilateral single-lung transplantation. The donor was a 45-year-old man with a history of a grade II oligoastrocytoma. He had undergone five cycles of chemotherapy and gamma-knife radiation for this tumor. One month prior to admission, recurrence of the cancer was demonstrated. He subsequently underwent two more cycles of chemotherapy, with the most recent course of therapy completed 5 days before admission. The patient sought medical attention because of an altered mental status. A magnetic resonance imaging study revealed massive sagittal sinus thrombosis, and he died of brainstem herniation.

The donor remained on mechanical ventilation for approximately 24 hours. He was ventilated at a tidal volume of 10 mL/kg and at a positive end-expiratory pressure of 5 cm H₂O. Arterial blood gas analysis 4 hours before organ procurement revealed a carbon dioxide tension of 31 mm Hg and an oxygen tension of 493 mm Hg at an inspired oxygen fraction of 1.00. Peak airway pressure was about 20 cm H₂O. Chest radiography demonstrated only a minor density at the left lung base, which had resolved on a subsequent study. Gram’s staining of sputum showed mixed bacterial flora with few leukocytes. On direct examination during organ procurement, the donor lungs appeared well inflated and without gross evidence of injury. Heparin sodium (375 U/kg) was administered prior to placement of an aortic cross-clamp. Five liters of Euro-Collins solution was infused in antegrade fashion. No evidence of maldistribution of the preservation solution was noted during flushing.

Prior to implantation, the donor lungs were carefully examined. The pulmonary arteries of both lungs were found to contain organized thromboemboli (Fig 1). These thromboemboli were easily extracted from the first and second lobar pulmonary artery branches of each lung. A Fogarty catheter was inserted into the distal pulmonary arteries, but no further thromboembolus was recovered. Pathologic examination revealed that the specimens were organized thrombi. The source of the clots, whether thrombotic or embolic, could not be ascertained.

View larger version (173K): [in this window] [in a new window]   Fig 1. Thromboemboli (arrows) in pulmonary artery of donor lung.

The patient is currently alive and well 5 months after transplantation. Pulmonary function tests 2 months postoperatively demonstrated a forced expiratory volume in 1 second of 2.6 L (61% predicted) and a forced vital capacity of 2.8 L (53% predicted). These values are comparable to those of patients who underwent bilateral single-lung transplantation with donor lungs that did not have pulmonary thromboemboli [2]. These results also represent a substantial improvement compared with values before transplantation: forced expiratory volume in 1 second of 0.44 L (10% predicted) and forced vital capacity of 1.6 L (30% predicted).

	Comment

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Pulmonary embolism affects approximately 23 per 100,000 hospitalized patients in the United States [3]. However, the exact incidence of pulmonary embolism in the potential lung donor population is unknown. The vast majority of potential organ donors die of cranio–nervous system disease or motor vehicle accident associated with multiple trauma [4]. Within the trauma population, for instance, the incidence of pulmonary embolism, although higher than that in the general hospitalized population, is only 0.4% [5]. The infrequent occurrence of pulmonary emboli in the donor population along with the application of the rigorous donor selection criteria may explain the rare finding of large pulmonary thromboemboli in donor lungs.

One previous report [6] of donor lung thromboembolectomy prior to transplantation has been published. The donor died of head trauma 8 days after a motor vehicle accident. The donor lungs met all selection criteria for transplantation. The donor did not manifest any clinical evidence of pulmonary embolism. The only clue to any abnormality of the donor lungs was the unequal distribution of the hypothermic preservation solution during flushing. During preparation of the donor lungs, nonadherent thromboembolus was found in lower lobar pulmonary artery branches of both lungs. After pulmonary thromboembolectomy of the donor lungs, single-lung transplantation was performed in 2 patients. One survived, and 1 died 3 weeks after transplantation of a nonrespiratory cause.

In contrast to that case report [6], there was no evidence of maldistribution of the lung preservation solution during flushing of the pulmonary artery in our donor. Despite the extensive nature of the thromboemboli, our donor did not manifest any clinical evidence of pulmonary embolism during the hospital course. He had a few risk factors for venous thromboembolic disease, including age greater than 40 years, an immobile state, and presence of a central venous catheter. He also had received recent chemotherapy. Chemotherapeutic agents have been described to have thrombogenic effects [7].

The presence of these risk factors did little to heighten our suspicion for pulmonary embolism in these donor lungs. Is there thus a role for the use of screening pulmonary angiograms or ventilation/perfusion scans to evaluate donor patients who have an increased risk for venous thromboembolism? More importantly, if the pulmonary thromboemboli had been diagnosed prior to procurement, would the donor lungs have been used for transplantation? Some centers advocate a combination of both retrograde and antegrade flushing of the preservation solution, and such technique reportedly may facilitate the removal of fibrin debris from both pulmonary and bronchial vascular networks [8]. However, on the basis of our clinical experience, antegrade perfusion of lung preservation solution is simple and effective and provides adequate lung protection even in the presence of pulmonary thromboemboli, as demonstrated by the case of our patient. In the event that antegrade perfusion is suboptimal, the retrograde approach can be considered.

With the current shortage of donor lungs, it is obligatory that available donor organs be used efficiently. Although there were large amounts of pulmonary thromboemboli in the donor lungs, there was no evidence of tissue infarction. In addition, the donor lungs had satisfied all of the selection criteria. Consequently, we proceeded with pulmonary thromboembolectomy and subsequent transplantation of the donor lungs.

The presence of large amounts of thromboemboli in the donor lungs that meet all donor selection criteria is a rare occurrence. Nevertheless, had the thromboemboli not been recognized and removed at the time of transplantation, they could have caused disastrous complications for the recipient. When found at the time of transplantation, however, a satisfactory outcome can be achieved after thromboembolectomy of the donor lungs. Meticulous inspection of the donor lungs for potential pulmonary thromboemboli during procurement and implantation is imperative.

	References

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1. Sundaresan S., Semenkovich J., Ochoa L., et al. Successful outcome of lung transplantation is not compromised by the use of marginal donor lungs. J Thorac Cardiovasc Surg 1995;109:1075-1080.
2. Bavaria J.E., Kotloff R., Palevsky H., et al. Bilateral versus single lung transplantation for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1997;113:520-528.[Abstract/Free Full Text]
3. Anderson F.A., Wheeler B., Goldberg R.J., et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. Arch Intern Med 1991;151:933-938.[Abstract/Free Full Text]
4. Frost A.E. Donor criteria and evaluation. Clin Chest Med 1997;18:231-237.[Medline]
5. Winchell R.J., Hoyt D.B., Walsh J.C., Simons R.K., Eastman A.B. Risk factors associated with pulmonary embolism despite routine prophylaxis: implications for improved protection. J Trauma 1994;37:600-606.[Medline]
6. Smith J.A., Mohajeri M., Rabinov M., Esmore D.S. Maldistribution of pneumoplegia in pulmonary allografts secondary to post-traumatic pulmonary thromboembolism. J Heart Lung Transplant 1996;15:324-325.[Medline]
7. Levine M.N., Gent M., Hirsh J., et al. The thrombogenic effect of anticancer drug therapy in women with stage II breast cancer. N Engl J Med 1988;318:404-407.[Abstract]
8. Varela A., Cordoba M., Serrano-Fiz S., et al. Early lung allograft function after retrograde and antegrade preservation. J Thorac Cardiovasc Surg 1997;114:1119-1120.[Free Full Text]

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