Ex vivo normothermic preservation of amputated limbs with a hemoglobin-based oxygen carrier perfusate

BACKGROUND Ex vivo normothermic limb perfusion (EVNLP) preserves amputated limbs under near-physiologic conditions. Perfusates containing red blood cells (RBCs) have shown to improve outcomes during ex vivo normothermic organ perfusion, when compared with acellular perfusates. To avoid limitations associated with the use of blood-based products, we evaluated the feasibility of EVNLP using a polymerized hemoglobin-based oxygen carrier-201 (HBOC-201). METHODS Twenty-four porcine forelimbs were procured from Yorkshire pigs. Six forelimbs underwent EVNLP with an HBOC-201-based perfusate, six with an RBC-based perfusate, and 12 served as static cold storage (SCS) controls. Ex vivo normothermic limb perfusion was terminated in the presence of systolic arterial pressure of 115 mm Hg or greater, fullness of compartments, or drop of tissue oxygen saturation by 20%. Limb contractility, weight change, compartment pressure, tissue oxygen saturation, oxygen uptake rates (OURs) were assessed. Perfusate fluid-dynamics, gases, electrolytes, metabolites, methemoglobin, creatine kinase, and myoglobin concentration were measured. Uniformity of skin perfusion was assessed with indocyanine green angiography and infrared thermography. RESULTS Warm ischemia time before EVNLP was 35.50 +/- 8.62 minutes (HBOC-201), 30.17 +/- 8.03 minutes (RBC) and 37.82 +/- 10.45 (SCS) (p = 0.09). Ex vivo normothermic limb perfusion duration was 22.5 +/- 1.7 hours (HBOC-201) and 28.2 +/- 7.3 hours (RBC) (p = 0.04). Vascular flow (325 +/- 25 mL center dot min(-1) vs. 444.7 +/- 50.6 mL center dot min(-1); p = 0.39), OUR (2.0 +/- 1.45 mL O-2 center dot min(-1)center dot g(-1) vs. 1.3 +/- 0.92 mL O-2 center dot min(-1)center dot g(-1) of tissue; p = 0.80), lactate (14.66 +/- 4.26 mmol center dot L-1 vs. 13.11 +/- 6.68 mmol center dot L-1; p = 0.32), perfusate pH (7.53 +/- 0.25 HBOC-201; 7.50 +/- 0.23 RBC; p = 0.82), flexor (28.3 +/- 22.0 vs. 27.5 +/- 10.6; p = 0.99), and extensor (31.5 +/- 22.9 vs. 28.8 +/- 14.5; p = 0.82) compartment pressures, and weight changes (23.1 +/- 3.0% vs. 13.2 +/- 22.7; p = 0.07) were not significantly different between HBOC-201 and RBC groups, respectively. In HBOC-201 perfused limbs, methemoglobin levels increased, reaching 47.8 +/- 12.1% at endpoint. Methemoglobin saturation did not affect OUR (rho = -0.15, r(2) = 0.022; p = 0.45). A significantly greater number of necrotic myocytes was found in the SCS group at endpoint (SCS, 127 +/- 17 cells; HBOC-201, 72 +/- 30 cells; RBC-based, 56 +/- 40 cells; vs. p = 0.003). CONCLUSION HBOC-201- and RBC-based perfusates similarly support isolated limb physiology, metabolism, and function.