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Ann Thorac Surg 2005;79:330-331
© 2005 The Society of Thoracic Surgeons

Case report

An Aberrant Donor Pulmonary Vein During Lung Transplant: A Surgical Challenge

Noman Hasan Khasati, MBBS, MS*,a, Ali MacHaal, MDb, Joyce Thekkudan, MBBS, FRCSb, Somnath Kumar, MBBS, MRCPc, Nizar Yonan, MBBS, FRCSb

a Departments of Cardiothoracic Surgery and Cardiology, Manchester, United Kingdom
b Transplant Unit, Manchester, United Kingdom
c Manchester, United Kingdom

Accepted for publication August 21, 2003.

* Address reprint requests to Dr Khasati, Department of Cardiothoracic Surgery, Wythenshawe Hospital, South Moor Rd, Wythenshawe, Manchester, UK
nkhasati{at}yahoo.com


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Aberrant pulmonary veins are uncommon. Anastomosis of such a vein during a lung transplant operation may provide a surgical challenge. We report the first case of an aberrant pulmonary vein anastomosed to the left atrial appendage during the implantation of the left lung.


   Introduction
Top
 Abstract
 Introduction
Comment
 References
 
Pulmonary venous anomalies are well described in the literature. There are only two reported cases in which a lung with abnormal venous drainage was used for transplantation. Prior knowledge of this aberration is vital to modify the surgical procedure. We present a case in which the venous anomaly was discovered late during the transplant operation, and we report a simple solution to overcome this problem.

A 23-year-old man with respiratory failure due to cystic fibrosis underwent a double lung transplant operation. The procedure was carried out through a clamshell incision using cardiopulmonary bypass. The right lung had normal anatomy and was transplanted in the conventional way.

Inspection of the left hilum revealed a single pulmonary vein, which was anastomosed to the left atrial venous confluence. On removal of the clamps to perfuse the left lung, significant bleeding was noted from the hilar region with no evidence of leakage from the anastomotic sites. A small bleeding vein was identified at the apex of the hilum above the pulmonary artery. This had not been identified by the retrieving surgeon and hence was not expected by the transplanting team. On gentle probing this vein was found to drain the left upper lobe; however it was too short to be anastomosed to the left atrium. Therefore we elected to proceed with end-to-end anastomosis of this vein to the left atrial appendage. The rest of the operation was uneventful.

An early postoperative transoesophageal echocardiogram confirmed a patent anastomosis of this aberrant vein to the left atrial appendage with good flow (Fig 1).



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  		Fig 1. Transesophageal echocardiogram. (LA = left atrium; LAA = left atrial appendage; LLPV = left inferior pulmonary vein; SPV = aberrant superior pulmonary vein).

 

   Comment
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 Abstract
 Introduction
 Comment
References
 
Pulmonary veins vary in number and size. Usually two veins from each lung open separately into the upper and posterior part of the left atrium. Occasionally the three right lobar pulmonary veins drain separately into the left atrium or the two left pulmonary veins join to form a single trunk, which was thought to be the case in this donor. At the root of the lung, the superior pulmonary vein lies in front of and a little below the pulmonary artery; the inferior is situated at the lowest part of the hilus of the lung and on a plane posterior to the upper vein [1]. Aberrant pulmonary veins may drain into the superior vena cava, azygos vein, or innominate vein. These pulmonary venous anomalies are well described in the literature [2].

During the harvesting procedure, the surgeon should carefully preserve an adequate donor left atrial cuff around the confluence of the superior and inferior pulmonary veins, thus providing for a single anastomosis with the left atrium of the recipient [3].

In our case the retrieving surgeon identified a single vein draining the left lung, rather than two veins, and confirmed the absence of a left superior vena cava. As the aberrant vein was not identified during the retrieval we cannot confirm the site of drainage of this vein in the donor.

Schmidt and colleagues [4] have reported two cases in which a donor lung with aberrant venous drainage was used for transplant operation. In one case the vein was bridged with a segment of the donor iliac vein, whereas in the other case the donor pericardium was used for the anastomosis to the left atrium.

The use of the left atrial appendage for pulmonary venous drainage as an alternative to conventional anastomosis in a case with difficult exposure of the anatomical confluence has been reported only once in the literature [5]. The left atrial appendage must be well developed with a wide waist to prevent narrowing and pulmonary venous congestion. This is the first case where an aberrant vein was anastomosed to the left atrial appendage. It exemplifies a simple way of overcoming a problem, which only became apparent late in the transplant operation.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Henry Gray. The pulmonary veins: anatomy of the human body (electronic version)
  2. Alpert JS, Dexter L, Vieweg WVR, Haynes FW, Dalen JE. Anomalous pulmonary venous return with intact atrial septum: diagnosis and pathophysiology. Circulation. 1977;56:870[Abstract/Free Full Text]
  3. UKT Cardiothoracic Advisory Group. Donor retrieval process for hearts and lungs: March 2002. Available at: http://www.uktransplant.org.uk/ukt/about_transplants/organ_allocation/cardiothoracic/national_protocols_and_standards/protocols_and_standards/retrieval_process.jsp. Accessed November 22, 2004.
  4. Schmidt F, McGiffin DC, Kirklin JK, et al. Management of congenital abnormalities of the donor lung. Ann Thorac Surg. 2001;72:935–937[Abstract/Free Full Text]
  5. Massad MG, Sirois C, Tripathy S, Jaffe HA, Snow N, Geha AS. Pulmonary venous drainage into the left atrial appendage facilitates transplantation of the left lung with difficult exposure. Ann Thorac Surg. 2001;71:1046–1047[Abstract/Free Full Text]



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This Article
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