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Volume: 19 Issue: 12 December 2021

FULL TEXT

LETTER TO EDITOR
An Alternative Approach to Supraceliac Aortic Control in Donation After Circulatory Death Donors

Dear Editor:

Safe and expeditious retrieval of donor organs is crucial to the success of organ transplant. Although improved outcomes have increased demand for solid-organ transplant, the supply of deceased donor organs has remained relatively stable.1 Efforts to expand the donor pool have included donation after cardiac death (DCD).2 The circumstances specific to the DCD setting require rapid cannulation techniques to ensure short duration of warm ischemia. Most centers use some variation of the super-rapid technique described initially by the Pittsburgh group.3 Principles of this approach emphasize sharp dissection with expeditious cannulation of the abdominal aorta to facilitate flush of the abdominal viscera with the preservation solution. After the inferior vena cava has been vented, the next critical step is to clamp the supraceliac aorta to prevent the extravasation of preservation solution into the thoracic cavity. The technique to expose the supraceliac aorta requires access into the left-side pleural cavity through a median sternotomy.4 After the pleural space has been entered from the left side, the inferior pulmonary ligament is freed to allow medial rotation of the lung to expose the descending thoracic aorta underneath. Super-rapid procurement techniques in DCD donors have allowed successful and invaluable expansion of the donor pool with additional organs suitable for transplant. Although the anatomy of most donors allows for exposure of the descending thoracic aorta after medial rotation of the left lung, there are circumstances for which this approach may not be possible. One such scenario is a hostile thoracic cavity. This scenario is characterized by com-plications such as adhesions secondary to previous inflammation or infection or surgical exposure, such that the left lung parenchyma is in apposition to the parietal pleura and thereby prevents the release of the inferior pulmonary ligament with subsequent medial rotation of the lung. When we have encountered such unfavorable donor thoracic anatomy, our preference has been to enter the pleural space from the left side (after cold perfusion) via a median sternotomy in the usual fashion. Then, while the left lung remains undisturbed in situ, the heart is rotated anteriorly so that the underlying posterior pericardium is exposed. Incision of the posterior pericardium provides direct exposure of the underlying descending thoracic aorta, which is then occluded with a large vascular clamp. Supraceliac control prevents further loss of preservation solution into the thoracic cavity, and then the subsequent steps of the rapid organ procurement may proceed in the usual fashion. The descending thoracic aorta can be approached directly posterior to the posterior mediastinum, at the level of the heart (Figure 1).5 This anatomic relationship is constant, and exposure is not altered by any underlying inflammatory processes in the thoracic cavity. The aorta is fixed at this point, which allows placement of a partial cross-clamp. Additionally, identification of the nasogastric tube in the esophagus helps differentiate it from the aorta. Our experience has shown this method to be faster and more accurate versus an approach to the supraceliac aorta through the left-sided pleural space.

Review of the current literature did not reveal any technique for organ procurement similar to the method we have described in this letter; however, we did discover a published description of a similar technique to access the descending aorta via the posterior pericardium in open repair of descending thoracic aortic pathologies.5 Desai and colleagues have described a modified technique for supraceliac aortic control for obese and/or pediatric donors via a left-side intra-abdominal approach; however, these procurements were not from DCD donors, where rapid supraceliac control is desired.6 Hollingshead and colleagues have described a rapid external clamp technique for use in the DCD setting, but for their technique the procuring surgeon is required to mobilize the left lung to the right side.7 In contrast, our technique provides the benefit of rapid access to the descending thoracic aorta without the need to mobilize the left lung. Therefore, our technique could substantially reduce the procedure time in the case of an impediment to mobilization of the left lung, eg, by preexisting scar tissue. As a rule, DCD procedures require rapid completion, which generally disallows the usual surgery below the diaphragm as performed in donation after brain death, a dissection that requires division of the diaphragmatic crus by electrocautery technique in advance of the cross-clamp placement. In contrast, all dissection elements of the DCD procedure are done sharply.3

This technique for supraceliac aortic control in the DCD setting has become our routine alternative approach for selected cases with hostile chest. We hope dissemination of the details of this method will prove beneficial to transplant teams as a reliable backup strategy in the setting of an unfavorable thoracic anatomy.


References:


  1. Israni AK, Zaun D, Hadley N, et al. OPTN/SRTR 2018 Annual Data Report: deceased organ donation. Am J Transplant. 2020;20 Suppl s1:509-541. doi:10.1111/ajt.15678
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  2. Nostedt JJ, Shapiro J, Freed DH, Bigam DL. Addressing organ shortages: progress in donation after circulatory death for liver transplantation. Can J Surg. 2020;63(2):E135-E141. doi:10.1503/cjs.005519
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  3. Casavilla A, Ramirez C, Shapiro R, et al. Experience with liver and kidney allografts from non-heart-beating donors. Transplantation. 1995;59(2):197-203. doi:10.1097/00007890-199501000-00008
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  4. Olson L, Davi R, Barnhart J, et al. Non-heart-beating cadaver donor hepatectomy ‘the operative procedure’. Clin Transplant. 1999;13(1 Pt 2):98-103. doi:10.1034/j.1399-0012.1999.130106.x
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  5. Cavozza C, Campanella A, Audo A. One-stage transmediastinal surgical approach for extensive aortic pathology. Multimed Man Cardiothorac Surg. 2018. doi:10.1510/mmcts.2018.049
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  6. Desai CS, Girlanda R, Hawksworth J, Fishbein TM. Modified technique for aortic cross-clamping during liver donor procurement. Clin Transplant. 2014;28(5):611-615. doi:10.1111/ctr.12360
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  7. Hollingshead J, Solomon H. A new technique for cannulation and external ‘clamping’ in the difficult DCD donor. Transplantation. July 1, 2018;102:S388.
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Volume : 19
Issue : 12
Pages : 1356 - 1357
DOI : 10.6002/ect.2021.0310


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From the 1Division of Kidney and Pancreas Transplantation, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee; and the 2Comprehensive Transplant Center, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
Acknowledgements: The authors have not received any funding or grants in support of the presented research or for the preparation of this work and have no declarations of potential conflicts of interest.
Corresponding author: Bernard J. Dubray, Assistant Professor of Surgery, Vanderbilt University Medical Center, Division of Kidney and Pancreas Transplantation, Section of Surgical Sciences, 912 Oxford House, 1313 21st Ave. South, Nashville, TN 37232-4750
E-mail: bernard.j.dubray@vumc.org