112: Management of Surgical Complications of Lung Transplantation

Introduction

Recipients of lung transplantation are surviving longer. As a consequence, complications secondary to the procedure (surgical) or resulting from mandatory lifelong immunosuppression (medical) are becoming increasingly evident. These events can lead to significant morbidity and potential mortality if not managed appropriately and in a timely fashion. This chapter focuses on the common surgical complications of lung transplantation.

Technical Complications

Transplant operations of all types require at minimum two separate surgical procedures: retrieval of the organ from the donor and implantation of the organ into the recipient. Thus technical complications can occur during any phase of either operation. Pitfalls of donor procurement include inadequate harvest of the atrial cuff or iatrogenic injury to the pulmonary artery, pulmonary veins, bronchus, and lung parenchyma. Complications secondary to lung implantation include phrenic nerve injury, hemorrhage, and pulmonary hypertension/hypoxemia.

Complications Related to Suboptimal Donor Procurement

Atrial Cuff and Pulmonary Vein Orifices

Donor procurement is always performed on an emergent basis. Consequently, despite the best efforts of both the heart and lung procurement teams to equitably divide the left atrial cuff and preserve the pulmonary vein orifices, the donor lungs occasionally arrive at the recipient OR in less than optimal condition, with either insufficient left atrial cuff or lacerated pulmonary vein orifices (in particular, the right inferior pulmonary vein). These injuries usually occur as a result of poor visibility or undue haste during division of the left atrial cuff. Laceration of the pulmonary vein orifice is repaired simply by dividing the pericardium overlying the vein and exposing the vessel to the point where it disappears into the lung parenchyma. Small branches of the vein also may require repair if the vein orifice was entered during procurement. These branches should be identified and oversewn to prevent troublesome bleeding after reperfusion.

Casula et al.¹ have described a useful technique for augmenting the pulmonary veins with donor pericardium when the left atrial cuff is found to be inadequate. This method can be used to create a cuff even when the superior and inferior pulmonary veins are completely separated. A running 5-0 polypropylene suture is placed around each vein orifice to tack the intima to the pericardium, thereby creating a “neoatrial cuff.” Scissors are used to trim the newly created pericardial cuff and separate it from the other hilar structures. This pericardial cuff substitutes for donor atrium in the atrial anastomosis. Alternatively, donor superior vena cava or redundant donor pulmonary artery can be used for the reconstruction if there is inadequate pericardial tissue.

Pulmonary Artery Injury

The bifurcation of the pulmonary artery always should be taken with the lung graft at the time of procurement. Even when a heart transplant is planned from the same donor, dividing the pulmonary artery at the distal extent of the main trunk ...