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Lung transplantation has evolved greatly over the last decade. Improvements in donor management, recipient selection, donor and recipient surgical techniques, and postoperative management have resulted in a significant increase in the number of patients being considered for lung transplantation. This, in turn, has resulted in an expansion of both donor and recipient criteria. Consequently, the technical challenges of the surgical procedure and subsequent medical management of pulmonary allografts are becoming increasingly evident. These events can lead to significant morbidity and potential mortality if not managed in an appropriate and timely fashion. This chapter focuses on the common surgical complications of lung transplantation.
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TECHNICAL COMPLICATIONS
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Technical considerations of lung transplantation can be divided into three phases: retrieval of the organ from the donor, explantation of the recipient native lung or lungs, and implantation of the allograft into the recipient. Thus, technical complications can occur during any phase. 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 native lung explantation include phrenic nerve injury, hemorrhage, and pulmonary hypertension/hypoxemia.
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Complications Related to Suboptimal Donor Procurement
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A number of technical steps can be taken to avoid injury to the donor organ during retrieval.
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Left Atrial Cuff and Pulmonary Vein Orifices
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Complications relating to the left atrial cuff and the vein orifices usually occur during donor cardiectomy, after the cross clamp has been applied and the lungs have been flushed with preservative solution. Although they occur more commonly during concomitant procurement of both the heart and lungs for separate recipients, they can certainly arise in the setting where only the lungs are being procured and the heart will be discarded. 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 operating room 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 because of poor visibility or undue haste during division of the left atrial cuff.
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Prevention of such injuries is ideal. Taking certain precautionary steps during the donor procurement can help mitigate the risk of having a short atrial cuff and/or pulmonary vein injury. These include the following:
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Both the lung and heart procurement teams should engage in a conversation about the conduct of the procurement, with special attention to how to handle the left atrial cuff. This should include a discussion about the most suitable site for venting of the left atrium, the sequence of vessels transected during the donor cardiectomy, and even specifics about where the left atriotomy will be created and in which direction ...