Various techniques for anastomosis of pulmonary arteries with size mismatch during lung transplantation

Abstract

Video clip is available online. Vessels of different calibers are often encountered when anastomosing pulmonary arteries (PAs) during lung transplantation. In living-donor lobar lung transplantation (LDLLT), grafts are taken from the donor's lower lobes, and pulmonary anastomosis sometimes requires adjustment of the caliber of the blood vessels due to mismatch between the donor's and the recipient's PAs. Among the solutions to this problem, as we previously reported, is donor graft PA plasty using an autopericardial patch to preserve the donor's lingular branch if the graft's PA has a diagonal cut line. 1,2 Other surgical techniques include using a tack suture or direct plication of the recipient's large PA. In cadaveric lung transplantation (CLT), a PA size mismatch could also be encountered because a giant PA can be seen in a recipient with idiopathic pulmonary hypertension. 3 Herein, we reviewed the surgical techniques used in our institution along with some new surgical techniques.

Anastomotic complications after lung transplantation

“…The incidence of anastomotic pulmonary artery stenosis is less than 2%, and it is considered when the anastomotic diameter is less than 75% compared to the neighbouring vessels. Mild stenoses are commonly seen secondary to donor-recipient size discrepancies, but these are not associatend to hemodynamic impairment (44).…”

“…The pulmonary artery is divided on both the recipient and donor in an extent to avoid excessive lengh and kinking. The pulmonary venous anastomosis utilizes a standard left atrial cuff technique to create a wider venous confluent and to facilitate the appropriate orientation of the vascular edges to be anastomosed, to reduce the formation of thrombi (44).…”

Technical Aspects of Lung Transplantation: General Considerations

“…A brief declamping of the proximal pulmonary artery while the distal pulmonary artery is clamped enables the identification of significant anastomotic disruption. To compensate for size mismatch during anastomosis, direct replication, tack sutures, stapling, and auto-pericardial patching can be used [ 15 ]. If the size discrepancy is large, the anastomosis can be made just distal to the first branch rather than the main pulmonary artery of the recipient.…”

REPLY: Reply to Kumar and colleagues

“…In their recent letter to the Editor, Kumar and colleagues 1 provided an important suggestion for additional evaluation of the pulmonary artery anastomosis after lung transplantation with transesophageal echocardiography (TEE) in the operating room. We thank Yokoyama and colleagues 2 for their previous article on anastomotic techniques that again highlight the importance of a technically optimal operation, which includes an unobstructed pulmonary artery anastomosis. The routine nature of thoracic transplantation might allow a suboptimal pulmonary artery anastomosis after heart or lung transplantation to go undetected as a potential cause of pulmonary graft dysfunction or donor heart right ventricular dysfunction.…”