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Address for reprints: Bryan A. Whitson, MD, PhD, FACS, Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, N-816 Doan Hall, 410 W. 10th Ave, Columbus, OH 43210.
Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, Columbus, OhioThe Davis Heart and Lung Research Institute at The Ohio State University Wexner Medical, College of Medicine, Columbus, Ohio
An anomalous pulmonary vein found in a donor lung can be reconstructed on the back table, and the donor lung can still be used for lung transplantation.
Congenital pulmonary venous anomalies are rare, with a prevalence of 0.1%, but can complicate lung transplantation if they go unrecognized during the process of donor lung procurement.
This is a scenario we have encountered on less than a handful of occasions. We present an innovative reconstruction technique to help other surgeons who may find themselves facing a similar predicament. Per institution, Institutional Review Board approval and consent were not required.
The patient was a 53-year-old woman with nonspecific interstitial pneumonia thought to be secondary to mixed connective tissue disease who presented for lung transplantation. A donor after cardiac death (DCD) was identified, and the retrieval of the donor lungs was reported as uneventful. During our back-table dissection of the donor lungs to prepare them for implantation, an anomalous right superior pulmonary vein that had been draining into the superior vena cava was identified when it was inadvertently transected. After trimming redundant tissue, it was noted that the remaining cuff of native vein would be too short to reach the left atrial cuff without undue tension (Figure 1, B). The native donor carotid artery (which came with the specimen because donor was DCD and aortic arch was provided) was used as a conduit to bridge the anomalous right upper lobe vein into the left atrial cuff (Figure 1, C). The size and diameter of the conduit were estimated by visual inspection to be an appropriate size match. The native carotid artery conduit was anastomosed end-to-end to the anomalous donor right upper lobe vein using 4 continuous 6 to 0 monofilament sutures. Saline pressurization confirmed hemostasis (Figure 1, C). A linear incision was then created in the donor left atrial cuff, and the donor carotid conduit was trimmed into a tapered V-shape and brought into the linear incision of the donor left atrial cuff (Figure 1, D). An anastomosis was performed using 3 continuous 6 to 0 monofilament sutures.
Figure 1A, Cartoon representations of our right superior pulmonary vein reconstruction. B, Intraoperative picture of the distal end-to-end right superior pulmonary vein to carotid conduit anastomosis. As can be seen in the photograph, the cuff of the right superior pulmonary vein would have been too short to directly reach the left atrial cuff without undue tension. C, Saline pressurization to confirm hemostatic anastomosis. D, Intraoperative picture of the proximal anastomosis of the carotid conduit to the left atrial cuff.
The donor lungs were implanted into the recipient in standard fashion. The venous anastomosis was constructed and hemostatic. The implanted lungs were inflated without issue. Vein velocity on the right side was acceptable when visualized and measured via transesophageal echocardiography, which is our intraoperative process to assess pulmonary veins.
Comment
Partial anomalous pulmonary venous return (PAPVR) is a rare congenital phenomenon rarely reported in the lung transplantation literature. In the previously reported cases of donor PAPVR and lung transplantation, all anomalous veins have drained the upper lobe.
PAPVR typically goes undetected on preoperative imaging because studies are often inappropriately timed or contrasted. Furthermore, assessment for PAPVR is not part of the typical procurement routine. This holds particularly true if the heart is not also being procured, because the superior vena cava may not be completely dissected out, and in situations of DCDs as was the case presented. Findings of PAPVR intraoperatively can complicate an otherwise straightforward lung transplantation.
Anomalous veins can be bridged with autologous pericardial conduit, donor iliac vein, bovine pericardium, decellularized extracellular matrix conduit, or in cases of sufficient anomalous vessel length, reconstructed directly to the donor left atrial cuff (Figure 2), directly to the recipient left atrium (Figure 3) or the left atrial appendage.
The subtle but distinct difference between Figures 1, A and 2 is that in Figure 1, A, the interposition graft has 2 areas of anastomosis (distally to the inadvertently foreshortened anomalous pulmonary vein and proximally to the donor atrial cuff), whereas in Figure 2, there is no interposition graft. In Figure 2, the anomalous pulmonary vein (typically mobilized from the donor vena cava) is long enough that it does not require an interposition graft, and the cuff (typically donor vena cava) can be directly anastomosed to the donor left atrial cuff. Ours is the first to use the autologous donor carotid as a conduit (Figure 1).
Figure 2A, Cartoon representations of our right superior pulmonary vein reconstruction with direct implantation into the donor left atrial cuff and (B) intraoperative picture of the anastomosis.
Figure 3Cartoon representation of an anomalous right superior pulmonary vein directly anastomosed to the recipient left atrial cuff. This is an alternative technique from what we pursued that can be used if the anomalous pulmonary vein is long enough to reach the left atrial cuff without undue tension.
Unlike in many other previous reported cases in which the anomalous vessel was detected because of bleeding after crossclamp removal, our anomalous vessel was identified on the back table during donor lung preparation for implantation. Our construction of a vascular conduit from an autologous donor carotid artery is a quick and reliable method for reconstruction. By using continuous running monofilament after first tacking down all 4 quadrants, we limit the possibility of anastomotic stenosis and portend good long-term patency and function.
Conclusions
We report an alternative technique for anomalous pulmonary venous reconstruction encountered during lung transplantation. This is a useful technique for surgeons to have in their armamentarium to reconstruct and salvage donor allografts with anatomic variants. These lungs with PAPVR should not be excluded from transplantation outright.
References
Keshavamurthy S.
Dulam V.
Leung S.W.
Kashem M.A.
Toyoda Y.
Donor pulmonary vein anomalies: what's in your toolbox?.
B.A.W. is partially supported through National Institutes of Health National Heart Lung and Blood Institute Grant R01HL143000. This research was generously supported through The Jewel and Frank Benson Family Endowment and The Jewel and Frank Benson Research Professorship.
Disclosures: The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
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