Ann Thorac Surg 2000;70:2164-2165
© 2000 The Society of Thoracic Surgeons
How to do it
Lung transplantation: how to perform the venous anastomosis when clamping is too distal
John H. Robert, MDa,
Nicolas Murith, MDb,
Marc de Perrot, MDa,
Marek Bednarkiewicz, MDb,
Marc-Joseph Licker, MDc,
Anastase Spiliopoulos, MDa
a Unit of Thoracic Surgery, Geneva University Hospital, Geneva, Switzerland
b Clinic of Cardiovascular Surgery, Geneva University Hospital, Geneva, Switzerland
c Department of Anesthesiology, Geneva University Hospital, Geneva, Switzerland
Accepted for publication April 4, 2000.
Address reprint requests to Dr Robert, Unit of Thoracic Surgery, Geneva University Hospital, CH-1211 Geneva 14, Switzerland
e-mail: john.h.robert{at}hcuge.ch
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Abstract
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During lung transplantation, the venous anastomosis is performed between the atrial cuffs of the donor and the receiver. In certain rare circumstances, however, the surgeon may find two veins and no possibility to reposition the clamp more proximally. A simple technique can be used in this case: both veins are reunited and the venous anastomosis carried out as usual between two large lumens.
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Introduction
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In single or sequential lung transplantation, it is common practice to use the atrial cuffs of the donor and receiver to perform the venous anastomosis [1]. Doing a single anastomosis (instead of two on both veins) is easier and quicker, and minimizes the risks of stenosis and therefore thrombosis. Occasionally, however, the surgeon finds himself or herself with two veins (instead of the receiver atrial cuff). This situation occurred only once in our 7-year experience of 58 lung transplantations. This article describes a simple technique to circumvent this situation, when the Satinsky clamp cannot be repositioned more proximally.
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Technique
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Bronchial and arterial anastomoses have already been carried out, and the venous anastomosis is last (as we usually do). In the case described, given the position of the Satinsky clamp, which occludes both pulmonary veins, it is not possible to create an atrial cuff with an incision joining the superior and inferior pulmonary veins. A slit is cut on both pulmonary veins, each facing the other and of equal length. Both slits must stop before the clamp. Each side of both slits is sewn to the other using a running suture of polypropylene 7/0, thus creating a common ostium (Fig 1). Donor and receiver atria are then anastomosed one to the other in the usual fashion with two running sutures of 5/0 polypropylene (Fig 2). The two veins of the receiver should not be kept too long, to avoid kinking once the venous anastomosis is completed. The anastomosis is then washed out and the transplantation procedure completed as usual.
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Fig 1. Diagram showing the position of the clamp after removal of the lung, before performing the venous anastomosis (in finer lines, the position of the clamp before its displacement). Both pulmonary veins have been slitted and the side-to-side conjoining anastomosis is under way.
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Comment
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Three situations may lead to a clamp being too distal on the pulmonary veins of the receiver: (1) the heart does not tolerate lateral clamping of the left atrium, with atrial fibrillation being the commonest symptom; (2) the clamp has slipped from its initial position and cannot be replaced once the ties on the venous stumps have been removed; and (3) venous section was too proximal in the donor lung hilum during harvesting and has interrupted the veins instead of the atrium. This occurs when extraction of the heart in the donor removes too much of the left atrium [2]. This situation is more likely to occur on the right side, given the shorter distance between the pulmonary veins and the right atrium [1]. Cardiopulmonary bypass can obviate the inconvenients of cardiac arrhythmia, but is not routinely resorted to, and certainly not with the sole intent to circumvent the difficulties created by clamp slipping, as in the example given.
The type of enlarging reconstruction proposed in this paper bears some similarity with arterial profundaplasties performed on stenotic femoral bifurcations without extrinsic material; the inverted Y-shaped incision allows enlargement of both the superficial and deep branches of the femoral artery [3]. The analogy is even more striking in renal transplantation, when harvested kidneys present with multiple arteries [4]; in these cases, arterial (and occasionally venous) reconstruction is carried out extracorporeally.
Apart from simplicity, resistance to flow is also worth considering. Given the gain in cross-section, pulmonary venous outflow is facilitated with the angioplasty described. One may still object that in our model venous effluence must still take a double-lumen channel; this short segment, however, is devoid of any suture material and thus resistance to flow should still be lower than with two anastomoses and not unduly elevated. To date, the best method of quantifying blood flow in these circumstances (although not used in the present case) is with transesophageal echocardiography coupled with Doppler-flow measurements: increased velocities in a given pulmonary vein, for instance, suggest stenosis or partial obstruction of the venous anastomosis [5].
This situation occurred only once in 58 lung transplantations: in a 55-year old man with idiopathic pulmonary fibrosis, who underwent a double lung transplantation. He unfortunately died 6 months later of massive hemoptysis after routine lung biopsy. Autopsy did not reveal any thrombosis at the site or in the vicinity of the (left) venous anastomosis.
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References
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Cooper J.D., Pearson F.G., Patterson G.A., et al. Technique of successful lung transplantation in humans. J Thorac Cardiovasc Surg 1987;93:173-181.[Abstract]
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Todd T.R., Goldberg M., Koshal A., et al. Separate extraction of cardiac and pulmonary grafts from a single organ donor. Ann Thorac Surg 1988;46:356-359.[Abstract]
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Novick A.C., Magnusson M., Braun W.E. Multiple-artery transplantation: emphasis on extracorporeal methods of donor arterial reconstruction. J Urol 1979;122:731-735.[Medline]
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Michel-Cherqui M., Brusset A., Liu N., et al. Intraoperative transesophageal echocardiographic assessment of vascular anastomoses in lung transplantation. A report on 18 cases. Chest 1997;111:1229-1235.[Abstract/Free Full Text]
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Abstract
Introduction
