Direct revascularization of bronchial arteries for lung transplantation: An anatomical study

doi:10.1016/0003-4975(90)90355-A

The Annals of Thoracic Surgery

Volume 49, Issue 1, January 1990, Pages 44-54

https://doi.org/10.1016/0003-4975(90)90355-A Get rights and content

Abstract

Direct revascularization of the bronchial arteries for both single-lung and double-lung transplantation would improve airway healing and reduce airway complications after transplantation. We studied the anatomical pattern of bronchial arteries in 30 autopsy cases. In 28 of 30 cases (93.3%), at least one left bronchial artery arose directly from the anterior wall of the descending thoracic aorta. In 25 of the 30 cases (83.3%), at least one right bronchial artery was related to the first right intercostal artery. Injection studies showed that this right intercostobronchial artery supplies the proximal left main bronchus and carina as well as the right bronchus. We developed a technique for extracting the lungs along with the right intercostobronchial artery and a patch of aorta at its origin and applied it to 19 of the dissections. In 17 of the 19 cases studied (89.4%), the right intercostobronchial artery pedicle obtained had a length varying from 6.5 to 8.5 cm, sufficient for attachment of its origin to the ascending aorta of the recipient after double-lung transplantation. The right intercostobronchial artery pedicle provides the possibility for direct bronchial revascularization in right single-lung, double-lung, and lung-heart transplantation. A similar technique, utilizing the left bronchial artery, can be used to revascularize a left lung transplant.

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The lungs are dually perfused by the pulmonary artery and the bronchial arteries. This study aimed to test the feasibility of dual-perfusion techniques with the bronchial artery circulation and pulmonary artery circulation synchronously perfused using ex vivo lung perfusion (EVLP) and evaluate the effects of dual-perfusion on posttransplant lung graft function. Using rat heart-lung blocks, we developed a dual-perfusion EVLP circuit (dual-EVLP), and compared cellular metabolism, expression of inflammatory mediators, and posttransplant graft function in lung allografts maintained with dual-EVLP, standard-EVLP, or cold static preservation. The microvasculature in lung grafts after transplant was objectively evaluated using microcomputed tomography angiography. Lung grafts subjected to dual-EVLP exhibited significantly better lung graft function with reduced proinflammatory profiles and more mitochondrial biogenesis, leading to better posttransplant function and compliance, as compared with standard-EVLP or static cold preservation. Interestingly, lung grafts maintained on dual-EVLP exhibited remarkably increased microvasculature and perfusion as compared with lungs maintained on standard-EVLP. Our results suggest that lung grafts can be perfused and preserved using dual-perfusion EVLP techniques that contribute to better graft function by reducing proinflammatory profiles and activating mitochondrial respiration. Dual-EVLP also yields better posttransplant graft function through increased microvasculature and better perfusion of the lung grafts after transplantation.
The Role of Bronchial Artery Revascularization in Lung Transplantation
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The anatomy of the BA is quite varied. Variations in bronchial arterial origin and course were well studied by Schreinemakers and colleagues25 and have been confirmed by the authors’ clinical experience with BAR.26 The BAs, 1 to 4 in number, arise from the descending aorta and are among or medial to the upper right intercostal arteries (Fig. 1).
Airway Complications After Lung Transplantation
2015, Thoracic Surgery Clinics
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The internal thoracic artery is then anastomosed to at least 1 bronchial artery ostia in the donor descending aorta. Single-lung transplantation is not performed on CPB and the bronchial anastomosis occurs at the secondary carina, as in non-BAR transplants, and is the final anastomosis after giving 10,000 IU of heparin and pulmonary artery reperfusion.115,116,121–126 This technique was recently readdressed at the authors’ institution.
Comparative study of bronchial artery revascularization in lung transplantation
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Donor lungs for BAR are procured en bloc with the esophagus and descending aorta to secure inclusion of the retroesophageal right intercostobronchial artery. Lung transplants with BAR are performed according to techniques previously described.9-15 One internal thoracic artery is harvested.
Restoring dual blood supply to transplanted lungs by bronchial artery revascularization (BAR) remains controversial. We compared outcomes after lung transplantation performed with and without BAR.
From December 2007 to July 2010, 283 patients underwent transplantation; 187 were 18 years or older, without previous or concomitant cardiac surgery. Of these patients, 27 underwent BAR in a pilot study to test success, safety, effectiveness, and teachability. A propensity score was generated to match BAR patients and 54 routine non-BAR patients. Follow-up was 1.3 ± 0.68 years.
BAR was angiographically successful in 26 (96%) of 27 patients. BAR and non-BAR patients had similar skin-to-skin time (P = .07) and postoperative hospital stays (P = .2), but more reoperations for bleeding (P = .002). Tracheostomy was performed in 9 (33%) of 27 BAR and 10 (19%) of 54 non-BAR patients (P = .2, log-rank). One BAR (3.7%) and 4 non-BAR (7.4%) patients required extracorporeal membrane oxygenation (P = .7). Airway ischemia was observed in 1 BAR (3.7%) versus 12 non-BAR (22%) patients (P = .03); anastomotic intervention was required in no BAR versus 8 non-BAR (15%) patients (P = .04). Hospital mortality was 1 of 27 versus 2 of 54 (P = .9). BAR patients had lower early biopsy tissue rejection grades (P = .008) and fewer pulmonary (P < .04) and bloodstream (P < .02) infections. Forced 1-second expiratory volume was similar (P > .2); 3 BAR versus 9 non-BAR patients developed bronchiolitis obliterans syndrome (BOS) (P = .14, log-rank). During follow-up, 4 BAR and 8 non-BAR patients died (P = .6, log-rank).
BAR is safe, with comparable early outcomes. Benefits of BAR include reduced airway ischemia and complications, lower biopsy tissue grades, fewer infections, and delay of BOS. A multicenter study is needed to establish these benefits.
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When bronchial artery revascularization is necessary during lung transplantation, this anatomy necessitates extraction of the lung bloc in toto with the thoracic aorta, esophagus, part of the right sided pleural covering the azygos vein, and all the posterior mediastinal fatty tissue immediately anterior to the vertebral bodies in which the artery is embedded [18]. The length of the course of the right bronchial artery has been estimated to vary from 6.5 to 8.5 cm by Shreinmakers [18] and from 5 to 8 cm by Carles [15]. The right bronchial artery gives branches to the midportion of the esophagus, the trachea, the pericardium and left atrium, the mediastinal lymph nodes, the vessels, and the nerves (especially the vagus nerve, which it crosses and with the branches of which it often intermingles).

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^☆: Presented at the Twenty-fifth Anniversary Meeting of The Society of Thoracic Surgeons, Baltimore, MD, Sep 11–13, 1989.

^☆☆: This work was supported by a grant from the Cystic Fibrosis Foundation.

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Original articleDirect revascularization of bronchial arteries for lung transplantation: An anatomical study☆,☆☆

Abstract

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thoracic Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Original article
Direct revascularization of bronchial arteries for lung transplantation: An anatomical study☆,☆☆