Ann Thorac Surg 2009;88:1374-1376. doi:10.1016/j.athoracsur.2008.11.031
© 2009 The Society of Thoracic Surgeons
How To Do It
Alternative Technique for Salvage of Donor Lungs With Insufficient Atrial Cuffs
William M. Yarbrough, MD,
Michael J. Bates, MD,
Tobias Deuse, MD,
Daniel G. Tang, MD,
Robert C. Robbins, MD,
Bruce A. Reitz, MD,
Hari R. Mallidi, MD*
Department of Cardiothoracic Surgery, Stanford University Medical Center, Falk Cardiovascular Research Center, Stanford, California
Accepted for publication November 12, 2008.
* Address correspondence to Dr Mallidi, Department of Cardiothoracic Surgery, Stanford University Medical Center, Falk Cardiovascular Research Center, 300 Pasteur Dr, Stanford, CA 94305-5407 (Email: mallidi{at}stanford.edu).
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Abstract
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Inadequate left atrial cuff surrounding donor pulmonary veins may present a technical challenge for successful lung transplantation. A simple technique for construction of venous anastomoses during lung transplantation when donor atrial cuff is lacking involves circumferential incorporation of surrounding donor pericardium into the anastomosis without directly suturing or augmenting donor venous structures.
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Introduction
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Successful lung transplantation starts with appropriate donor and recipient selection, a technically successful operation, and close attention to detail in the postoperative and follow-up care of the transplant patient. The ability to perform a technically sound operation can not be overemphasized, nor can the fact that such success begins with adequate graft harvest. Thoracic organ procurement generally proceeds without event. However, when both heart and lungs are harvested, there may be occasional difficulty providing adequate donor left atrial tissue, irrespective of whether division is carried out in situ or on the back table. Upward retraction of the cardiac graft during separation permits visualization, but simultaneously obscures the orifice pulmonary veins and the left atrial-pulmonary vein confluence, misleading surgeons into occasionally dividing the intrapericardial portion of the pulmonary veins. Anatomic congestion, resulting from close proximity of the inferior vena cava to the right and left atriums and atrial septum makes the right inferior pulmonary vein particularly susceptible to harvest without an appropriate margin. Subsequent union of donor pulmonary grafts to the recipient left atrium, although not precluded, become more difficult as technical modifications may be required to avoid anastomotic stenosis, and the catastrophic clinical sequelae that may ensue [1]. Examples of such technical modifications have been previously described [2–5]. While they are successful and reproducible, each of these techniques requires sutures to be taken through donor pulmonary veins, either to unite them or to secure them to the surrounding pericardium, or both. Herein, we describe a simple technique for construction of venous anastomoses during lung transplantation when the donor atrial cuff is lacking. The technique involves circumferential incorporation of surrounding donor pericardium into the anastomosis, without directly suturing or augmenting donor venous structures, a technique analogous to the "sutureless" correction of recurrent pulmonary venous obstruction in the setting of total anomalous pulmonary venous connection [6].
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Technique
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Surgeons procuring lung blocs should invariably retrieve enough pericardium surrounding the pulmonary venous confluence to serve as an anastomotic component in the event that insufficient atrial cuff exists (Fig 1). Pericardium taken to the level of the phrenic nerve generally suffices. With the delivery of a pulmonary graft lacking atrial cuff, the recipient surgeon should tailor the donor pericardium into an appropriately sized circumferential "skirt," devoid of debris and adipose tissue (Fig 2). A pericardial-to-left atrial anastomosis is performed using 4-0 Prolene sutures (Ethicon Inc, Somerville, NJ) in a running fashion. No sutures are used to stabilize the retracting veins within the pericardial skirt. This technique achieves a generously sized, tension-free anastomosis. Benign prominence of the ipsilateral hilum may result and is visualized on a subsequent roentgenogram obtained during the immediate postoperative period (Fig 3). In the event that the posterior wall of the donor cuff exists, and the anterior, inferior, and superior walls are absent, the posterior atrial wall may be incorporated in the anastomosis. The suture line is then transitioned onto the surrounding pericardial skirt to complete the remaining majority of the anastomotic circumference.
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Fig 1. This photograph (left lung) demonstrates absence of an atrial cuff. The lung was harvested with a generous amount of surrounding pericardium.
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Fig 2. This photograph of the same lung demonstrates circumferential trimming of excessive pericardial tissue and creation of an appropriately sized pericardial cuff. Excess adipose tissue (arrow) and debris are cleared and the cuff is anastomosed to the recipient left atrium in a tension-free manner. No sutures are taken through the venous structures using this technique.
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Fig 3. This immediate postoperative roentgenogram obtained from a 28-year-old woman who underwent double-lung transplantation for bronchiectasis demonstrates fullness in the right hilum relative to the left. The right donor lung lacked an atrial cuff and was anastomosed to the recipient left atrium using the described technique. The right hilar fullness represents expected distension of the pericardial skirt. The patient recovered uneventfully.
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Comment
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The described technique is similar to those previously reported in that the donor pericardium is used in the venous anastomosis [2–5]. Although these techniques have been reported as effective, they involve circumferential suture stabilization of the venous structures to the surrounding pericardium, a step that may not only be unnecessary, but may predispose to anastomotic narrowing. When confronted with marginal or absent atrial cuffs, our institution has elected to refrain from placement of sutures through the donor venous structures, irrespective of whether the veins are returned in continuity. During the past year we have performed approximately 50 lung transplants, and we have used this technique in 3 separate patients. Thus far we have not identified any problems associated with retraction of venous structures that have not been sutured. Nor have we observed stenosis or thromboembolic complications when endothelium-to-endothelium anastomoses have not been feasible, and circumferential or near-circumferential incorporation of donor pericardium has been required (Fig 4).
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Fig 4. A noncontrasted computed tomographic scan obtained 6 months after transplant in the same patient reveals patent right superior (upper image) and inferior veins (lower image).
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References
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- Sarsam MA, Yonan NA, Beton D, McMaster D, Deiraniya AK. Early pulmonary vein thrombosis after single lung transplantation J Heart Lung Transplant 1993;12:17-19.[Medline]
- Casula RP, Stoica SC, Wallwork J, Dunning J. Pulmonary vein augmentation for single lung transplantation Ann Thorac Surg 2001;71:1373-137471.[Abstract/Free Full Text]
- Gamez P, Alvarez R, Hernandez H, Cordoba M, De Pablo A. Lung transplantation: how to do the venous anastomosis when the pulmonary graft has no auricular cuff J Heart Lung Transplant 2005;24:1123-11258.[Medline]
- Oto T, Rabinov M, Negri J, et al. Techniques of reconstruction for inadequate donor left atrial cuff in lung transplantation Ann Thorac Surg 2006;81:1199-1204.[Abstract/Free Full Text]
- Hammond GL, Franco KL, Baldwin JC. Method of single-lung transplantation in the absence of a left atrial cuff. Ann Thorac Surg 192;54:379–80.
- Najm HK, Caldarone CA, Smallhorn J, Coles JG. A sutureless technique for the relief of pulmonary vein stenosis with the use of in situ pericardium J Thorac Cardiovasc Surg 1998;115:468-470.[Free Full Text]
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Abstract
Introduction
