Bronchial Artery Revascularization: Surgical Technique

The lung transplant community has long ignored the importance of bronchial arterial blood supply. We review relevant history, published articles addressing post-transplant ischemia, and single-center reports with artery revascularization (BAR), followed by details surgical technique. In our experience, although BAR requires cardiopulmonary bypass (CPB) there is increased risk bleeding, ischemic time was shorter length ICU hospital stays were similar. Technical success achieved in > 95% cases, which guarantees normal airway healing. Lung safe, reproducible, may provide benefits beyond healing, potential for decreasing BOS/CLAD improving long-term survival. Multicenter study follow-up are needed. Central MessageBronchial a safe reproducible technique that Bronchial Lungs have dual supply from 1) pulmonary trunk 2) arteries (BAs). Approximately 50% total comes BAs poorly oxygenated circulation.1Barman SA Ardell JL Parker JC et al.Pulmonary systemic flow contributions to upper airways canine lungs.Am J Physiol Heart Circ Physiol. 255, 1988; : 1130-1135Crossref Google Scholar extrapulmonic airways, main bronchi trachea, depend more or entirely on BAs, collaterals coronaries, other mediastinal tracheal arteries. While BA circulation represents only 3%-5% cardiac output, can enlarge response inflammation also compensatory gas exchange when fails elsewhere any region lung.2Deffebach ME Charan NB Lakshminarayan S al.The circulation. Small, but vital attribute lung.Am Rev Respir Dis. 1987; 135: 463-481PubMed originate primarily proximal descending aorta, because they source veins (via vasa vasorum), local nerves, lymph nodes, play an important role defense, fluid balance, metabolism.2Deffebach Scholar, 3Pump KK. Distribution human lung.Chest. 1972; 62: 447-451Abstract Full Text PDF PubMed Scopus (119) 4Wagner EM Blosser Mitzner W vascular contribution flow.J Appl (1985). 1998; 85: 2190-2195Crossref (33) 5Wagner Foster WM. Importance particle clearance lung.J 1996; 81: 1878-1883Crossref (31) During transplant, however, routinely sacrificed due perceived technical complexity (BAR). therefore solid-organ all major allograft not reconnected. A controversial comment Dr. Francis Robicsek illustrates issue: “…it makes as much sense lungs without hearts coronary arteries.”6Schreinemakers HH Weder Miyoshi al.Direct transplantation: An anatomical study.Ann Thorac Surg. 1990; 49: 44-53Abstract (67) Although this be overstatement, many describe outcomes after transplantation good even excellent, certainly spectacular nor solid organs. initial goal improve Since 1990s, prevalence ischemia decreased improved techniques utilizing bi-bronchial anastomosis better management immunosuppression, resulting lack enthusiasm pursue greater community. However, continues perioperative issue, estimated recent ranging 2% 11%.7Yserbyt Dooms C Vos R al.Anastomotic complications Risk factors, treatment modalities outcome—a single-centre experience.Eur Cardio-Thorac 2016; e1-e8Crossref (59) 8van Berkel V Guthrie TJ Puri al.Impact anastomotic transplant.Ann 2011; 92: 316-320Abstract (37) 9Fitzsullivan E Gries CJ Phelan P al.Reduction novel technique.Ann 309-315Abstract (34) particular, patients who anatomically candidates will require en-bloc double reported very high complications, up 40%.10Patterson GA Todd TR Cooper JD al.Airway transplantation. Toronto Transplant Group.J Cardiovasc 99: 14-20Abstract addition, mounting evidence compromised microvasculature, suboptimal perfusion, hypoxemia transplanted contribute bronchiolitis obliterans syndrome/obliterative (BOS/OB) chronic dysfunction (CLAD).11Jiang X Khan MA Tian al.Adenovirus-mediated HIF-1α gene transfer promotes repair mouse microvasculature attenuates rejection.J Clin Invest. 121: 2336-2349Crossref (89) 12Pettersson GB Karam K Thuita L al.Comparative transplantation.J 2013; 146: 894-900e3Abstract (32) 13Pasnupneti Nicolls MR. Airway hypoxia transplantation.Curr Opin 2019; 7: 21-26Crossref (8) lower issues CLAD/BOS heart-lung suggested preserved collaterals.14Shumway SJ Hertz MI Maynard Kshettry VR transplantation.Transplant Proc. 1993; 25: 1165-1166PubMed Scholar,15Kitai T Okamoto Miyakoshi combined heart syndrome, vasculopathy, survival.J Transplant. 38: 1170-1177Abstract (6) likely contributes several factors limit survival still far worse than transplants. literature demonstrating summarized below.16Dhillon GS Zamora MR Roos JE al.Lung hypoxia: diathesis fibrosis?.Am Crit Care Med. 2010; 182: 230-236Crossref largest series date demonstrates underwent double-lung BAR, 69% 5-year survival, exceeding bilateral sequential (57%).17Burton CM Milman N Carlsen Copenhagen National Group: Survival single lung, 2005; 24: 1834-1843Abstract (105) As presented at 2013 International Society Transplantation (ISHLT) meeting, 20-year had University Hospital better-than-expected survival.18Perch MAN M. Møller C.J. J. al.Long-Term Outcome Artery Revascularization Study. ISHLT, Montreal, QC, Canada2013Google report, we summarize (Table 116Dhillon Scholar), experimental clinical pertaining detailed illustrations key steps BAR.Table 1How Could Improve TransplantationReprinted permission American Thoracic Society. Copyright © 2022 All rights reserved. Cite: Dhillon GS, MR, JE, Sheahan D, Sista RR, Van der Starre P, al. 2010. fibrosis?/Am 182(2):230–6. Open table new tab dogs described Metras 1950s.19Metras H. Note préliminaire sur la greffe totale du poumon chez le chien.C Acad Sci (Paris). 1950; 231: 1176-1178Google He sewed donor aortic button recipient aorta. Animal experiments Mills confirmed healing.20Mills NL Boyd AD Gheranpong C. significance 1970; 60: 866-878Abstract Using Metras’ technique, first technically successful Haglin 1973.21Haglin JJ RE Baker RC Anderson WR Histologic studies allotransplantation.in: W. Morphology S. Karger, Basel, Switzerland1973Google patient left right BAR. died 11 days autopsy performed within hours he expired showed revascularized viable whereas bronchus extensive necrosis layers. early centers promising results (summary below). Subsequently, Pettersson 106 transplants 1994, worldwide. Between 1990 18 using saphenous vein graft conduit off ascending 22 69 months.22Baudet Dromer Dubrez al.Intermediate-term en bloc revascularization.J 112: 1292-1300Abstract (36) surgery 30-40 minutes, reduced compared transplant. There no intraoperative deaths bleeding related 3 in-hospital (2 urgently ventilator dependent) 5 late OB). Fourteen arteriogram, patent 11. Normal healing observed 1 patient, limited focal subsequently healed further intervention. Five failed developed OB. authors concluded could protect against BOS/OB. This 9 internal thoracic (ITA) conduit. cohort, 2 reoperations tissue severe intracranial hemorrhage. chest wall adhesions ITA-bronchial anastomosis. One 6 weeks postop infection acute respiratory distress syndrome. Twenty-nine 31 angiograms, 29 BAs. Only visible ulceration anastomosis, resolved intervention, others healing.25Daly Tadjkarimi Khaghani Banner NR al.Successful direct revascularization.Ann 56: 885-892Abstract (58) Daly McGregor 10 1994. death dysfunction. Seven survivors postoperative angiogram. noted, median 13 months.28Daly CG. Routine immediate single-lung transplantation.Ann 1994; 57: 1446-1452Abstract (43) 1992 1995, 48 heart-lung, performed, ITA conduit, similar Yacoub.25Daly added 20-45 minutes procedure organ procurement, identification, revascularization. Early approximately hour. required reoperation Thirty-day mortality 2.1% (1 patient), 0%, 20% respectively, seen 43 patients. Angiography 53 (43/48 6/9 4/6 lung), 50 (94%). Two left-sided pneumonectomy. 2-year patency 100%. overall 63%. later expanded 68 lungs, 27 experience world. colleagues including comparison cases 1:2 propensity-matching. Twenty-seven (20 7 single). Patent angiography 26/27 case occurred transplant; central mucosal sloughing areas deep seen, eventually non-BAR groups operative times stay, (P<0.002). These Mortality 3.7% both groups. McKenzie Texas Children's pediatric 88 between 2005 2014. Recipient age ranged months 20 years. Surgical involved sewing origins group, unrelated ischemia. Ischemic time, stay less frequent (16% vs 57%). freedom BOS years superior cohort (77% 61%, 94% 71%, respectively). illustrated Figures 1-10 figure legends.Figure 2Donor retrieval preparation.Show full captionThe procurement team needs familiar anatomy avoid injury. removed esophagus, aorta order preserve intercostobronchial (RICBA), courses behind esophagus. trachea esophagus stapled divided well above level azygos vein. proximally arch distally diaphragm. distal just block dissected out, staying hard posterior vertebral column remove paraspinal block. Usually, been before retrieved, hopefully leaving atrial cuffs bilaterally piece trunk. prefer valve. After arrival operating room, held upright cranial traction Careful sharp dissection surrounding carried out caudally, close esophageal adventitial layer RICBA removed, tissue, arteries, remains, creating “tunnel.”View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Opening aorta.Show opened vertically midline its pleura-covered surface (see 1). Orifices intercostal become visible, divided.View 4Typical location subcarinal artery, RICBA, LBAs.Show typical orifices illustrated. upper-right branch ostium usually most RICBA. identified 90% specimens according Schreinemakers al,6 about 75% 80%. found medial caudally Often orifice artery.View 5Identification arteries.Show inspection gentle probing 1-mm probe. “tunnel” where gently stretched index middle fingers inserted into tunnel injury artery. enables passing probe safely identify course. taking 1-2 cm must clipped bleeding.When trimming excess great care taken injure peribronchial pericarinal intact jeopardizing carina. one ring carina.One large enough complete If convincing ones damaged, often should done fashion anastomoses BAR.View 6Recipient opening harvest.Show captionBefore sternotomy harvested skeletonized facilitate anastomoses. continuity until heparinized.View 7Cannulation removal.Show captionCardiopulmonary mandatory surgeon cannot commit examined least usable identified. Once acceptable identified, cannulated (ascending bicaval cannulation required) initiated. excised distally. decision made proceed back Hemostasis mediastinum particularly important. Irrigated bipolar radiofrequency cautery (Aquamantys; Medtronic Inc, Minneapolis, MN, USA) proven useful achieving hemostasis prior implant.View 8Inserting pleural cavities.Show pericardium sufficient extent allow introduced minimal trauma. through pericardial openings cavities. lifted upward passed windows created sides phrenic nerves. pushed their respective space. Because leading spaces size (particularly right), attention paid torsion, proper orientation carefully checked.View 9Exposure anastomosis(-es).Show captionAfter inserted, completed. rotated toward over heart. patch pulled positioned almost anterior heart, inside outside depending exposure.View 10Bronchial if sequentially.Show anastomosed either (if present) multiple ostia fashion. running 7-0 monofilament sutures. Successful immediately release clamp observing assessed open, thereby reperfusing reducing warm time. When allowing fall chest, lie ITA, checked ensure favorable kinking ITA.Finally, cuff completed usual 4-0 sutures.View (PPT) “tunnel.” divided. bleeding. Before heparinized. Cardiopulmonary implant. checked. exposure. ITA. Finally, collective world limited, suggests feasible 90%. With success, serious 3%. present prevents ensures extend Nobody questions restoring beneficial Patterson wrote editorial Annals Surgery 1993 entitled “Airway revascularization: Is it necessary?”37Patterson GA. necessary?.Ann 807-808Abstract (35) able convince isn't necessary. good, ask ourselves justify ignoring obvious possibility outcomes. his “To fully define value multicenter follow required.” 30 later, come perform study.