Current Status of Vascularized Composite Allotransplantation

Abstract

The field of vascularized composite allotransplantation (VCA) has moved from a highly experimental procedure to, at least for some patients, one of the best treatment alternatives for catastrophic tissue loss or dysfunction. Although the worldwide experience is still limited, progress has been made in translation to the clinic, and hand transplantation was recently designated standard of care and is now covered in full by the British Health System. This progress is tempered by the long-term challenges of systemic immunosuppression, and the rapidly evolving indications for VCA such as urogenital transplantation. This update will cover the state of and recent changes in the field, and an update of the Louisville VCA program as our initial recipient, the first person to receive a hand transplant in the United States celebrates the 20th anniversary of his transplant. The achievements and complications encountered over the last two decades will be reviewed. In addition, potential directions for research and collaboration as well as practical issues of how third party payers and funding are affecting growth of the field are presented.

Machine preservation of extremities

“…Upper extremity transplantation has progressed from a research project to a controversial procedure and finally to a widely accepted field with promising results . Not only is this treatment option considered ethical and beneficial, but also many countries around the word (Britain, France, Spain) designated upper extremity transplantation as standard of care . However, in the USA, almost all extremity transplants have been covered by grants or institutional funding with significant waiving of surgical and physical therapy fees .…”

“…Not only is this treatment option considered ethical and beneficial, but also many countries around the word (Britain, France, Spain) designated upper extremity transplantation as standard of care . However, in the USA, almost all extremity transplants have been covered by grants or institutional funding with significant waiving of surgical and physical therapy fees . This lack of insurers has definitely had a major limiting impact on the widespread use of this modality.…”

“…In addition to a substantial effect on the quality of life, lifetime healthcare costs associated with limb loss are $509 275 compared to $361 200 without limb loss per person . Despite good outcomes of extremity transplantation surgery, only about 150 transplants have been performed since 1998 . Ischemia time and optimal extremity selection and preservation following procurement are among the factors limiting the increase of the numbers of extremity transplants.…”

Extended ex vivo normothermic perfusion for preservation of vascularized composite allografts

“…To date, more than 120 cases of upper extremity transplantation (UET) have been reported worldwide with a graft survival rate of 90.4% at 1 year and 86.6% at 5 and 10 years. 1,2 Currently, there are about 2 million people living with limb loss in the United States; 185 000 amputations are performed annually with 83 000 amputations due to trauma alone that could potentially benefit from UET. 3 Requirement for lifelong immunosuppression is a major factor limiting the widespread adoption of vascularized composite allotransplantation, as the complications outweigh benefits of life-enhancing rather than life-saving treatment.…”

Evaluation of PLGA microspheres with triple regimen on long‐term survival of vascularized composite allograft – an experimental study

“…Vascularized composite allotransplantation (VCA) is a promising option for severe injuries and defects involving multilayered functional tissues, which cannot be repaired to the level of fine aesthetic and functional recovery through conventional reconstruction with autologous tissues or prostheses . However, since VCA consists of complex tissue types such as skin, muscle, bone, nerves, and blood vessels, severe immunological rejection occurs after transplantation.…”