Management of donor partial anomalous pulmonary veins during lung transplantation.

Central MessageAn 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. 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.1Keshavamurthy S. Dulam V. Leung S.W. Kashem M.A. Toyoda Y. Donor pulmonary vein anomalies: what's in your toolbox?.Ann Thorac Surg. 2021; 112: e369-e371Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,2Ho M.L. Bhalla S. Bierhals A. Gutierrez F. MDCT of partial anomalous pulmonary venous return (PAPVR) in adults.J Thorac Imaging. 2009; 24: 89-95Crossref PubMed Scopus (93) Google Scholar 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. 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. 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.3Nykanen A.I. Raivio P. Reconstruction of donor anomalous pulmonary vein during lung transplantation.Ann Thorac Surg. 2022; 114: e83-e84Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar 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.4Oto T. Rabinov M. Negri J. Marasco S. Rowland M. Pick A. et al.Techniques of reconstruction for inadequate donor left atrial cuff in lung transplantation.Ann Thorac Surg. 2006; 81: 1199-1204Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar 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.3Nykanen A.I. Raivio P. Reconstruction of donor anomalous pulmonary vein during lung transplantation.Ann Thorac Surg. 2022; 114: e83-e84Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,5Schmidt F. McGiffin D.C. Zorn G. Young K.R. Weill D. Kirklin J.K. Management of congenital abnormalities of the donor lung.Ann Thorac Surg. 2001; 72: 935-937Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar 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 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.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Our case further confirms the predominant location of the aberrant pulmonary vein in the upper lobe.3Nykanen A.I. Raivio P. Reconstruction of donor anomalous pulmonary vein during lung transplantation.Ann Thorac Surg. 2022; 114: e83-e84Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar 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. 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.