Lower Extremity Transplantation: Concepts, Challenges, and Controversies

Gorantla, Vijay S.; Zor, Fatih; Nasır, Serdar; Breidenbach, Warren C.; Davis, Michael R.

doi:10.1007/978-1-4939-7247-0_11

Cited by 5 publications

(14 citation statements)

References 94 publications

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“…Until recently, four described attempts at combined VCA were unsuccessful because of patient death or graft failure and amputation. 69–72…”

Section: Discussionmentioning

confidence: 99%

“…Until recently, four described attempts at combined VCA were unsuccessful because of patient death or graft failure and amputation. [69][70][71][72] In August of 2020, the first successful face and bilateral hand transplant was performed at our institution. 3 Because of the high PRA profile in this 80% total body surface area burn patient, increasing the potential donor pool was necessary to find an appropriate immunologic match.…”

Section: Previous Kt and Lt Meta-analysesmentioning

confidence: 99%

See 1 more Smart Citation

Graft Survival and Acute Rejection in Cross-Sex Solid Organ Transplants: A Systematic Review and Meta-Analysis to Inform Vascularized Composite Allotransplantation Practice

Barrow

Diep

Berman

et al. 2023

Plastic &Amp; Reconstructive Surgery

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he advent of vascularized composite allotransplantation (VCA) provides a comprehensive reconstructive option for patients with extensive injuries. Since the first hand transplant in 1998 and first face transplant (FT) in 2005, medical technology, preoperative evaluation, operative technique, and posttransplant care have evolved considerably. For instance, the advent of calcineurin inhibitors, computerized surgical planning (CSP), and the inclusion of vascularized bone in FT have all played an important role in Background: Of nearly 90 hand and 50 face transplant recipients, only five have received a cross-sex vascularized composite allotransplantation (CS-VCA). CS-VCA has the potential to expand the donor pool and has been proven anatomically feasible and ethically acceptable in previous studies. However, there is a lack of immunologic data. This study evaluated the immunologic feasibility of CS-VCA through analysis of the solid organ transplant literature, given the paucity of CS-VCA data. The authors hypothesize that rates of acute rejection (AR) and graft survival (GS) in CS versus same-sex (SS) solid organ transplantation are similar. Methods: A systematic review and meta-analysis were performed. Studies comparing GS or AR episodes in CS and SS adult kidney (KT) and liver transplant (LT) populations were included. Odds ratios were calculated for overall GS and AR for all SS and CS transplant combinations [male-to-female (MTF), femaleto-male, and overall]. Results: A total of 693 articles were initially identified with 25 included in the meta-analysis. No significant difference in GS was noted between SS-KT versus CS-KT [OR, 1.04 (95% CI, 1.00 to 1.07); P = 0.07), SS-KT versus MTF-KT [OR, 0.97 (95% CI, 0.90 to 1.04); P = 0.41), and SS-LT versus MTF-LT [OR, 0.95 (95% CI, 0.91 to 1.00); P = 0.05). No significant difference in AR was noted between SS-KT versus MTF-KT [OR, 0.99 (95% CI, 0.96 to 1.02); P = 0.57), SS-LT versus CS-LT [OR, 0.78 (95% CI, 0.53 to 1.16); P = 0.22], or SS-LT versus female-to-male LT [OR, 1.03 (95% CI, 0.95 to 1.12); P = 0.47]. For the remaining pairings, GS was significantly increased and AR was significantly decreased in the SS transplants. Conclusions: Published data suggest immunologic feasibility of CS-KT and CS-LT with the potential for generalization to the VCA population. (Plast. Reconstr. Surg. 153: 839, 2024.) Clinical Relevance Statement: In theory, CS-VCA could expand the potential donor pool, ultimately leading to decreased wait times for recipients and improve the likelihood of establishing a immunologically favorable donorrecipient match.

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“…Until recently, four described attempts at combined VCA were unsuccessful because of patient death or graft failure and amputation. 69–72…”

Section: Discussionmentioning

confidence: 99%

Section: Previous Kt and Lt Meta-analysesmentioning

confidence: 99%

Graft Survival and Acute Rejection in Cross-Sex Solid Organ Transplants: A Systematic Review and Meta-Analysis to Inform Vascularized Composite Allotransplantation Practice

Barrow

Diep

Berman

et al. 2023

Plastic &Amp; Reconstructive Surgery

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“…66 Case 3: Concomitant Bilateral Upper Extremity and Unilateral Lower Extremity Transplantation-Ozkan et al (2012) In 2012, the world's first triple extremity transplant, which included transplantation of a lower extremity, and both the upper extremities, was performed by Ozkan et al in Turkey. 9,10,73 Even though this case has never been published in the literature, it was presented at scientific symposia, and there are quite a few media articles on this. The surgery was performed on a 34-year-old male recipient, who lost both arms and a leg due to electrocution injury during his childhood.…”

Section: Case 2: Bilateral Transfemoral-level Transplantation-cavadas...mentioning

confidence: 99%

“…[1][2][3][4] There is a growing interest in composite tissue allotransplantation in other anatomical regions. [5][6][7][8][9][10][11][12] This initial success of upper extremity and craniofacial VCA has pushed teams to pursue LET and push the limits in VCA procedures with combination composite transplants such as simultaneous upper extremity/lower extremity transplants. 13 The most common causes of lower extremity amputations in the United States include vascular, traumatic, neoplastic, and congenital issues.…”

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confidence: 99%

A World Update of Progress in Lower Extremity Transplantation

Kodali,

Janarthanan,

Sazoglu

et al. 2024

Ann Plast Surg

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The field of vascularized composite allotransplantation (VCA) is the new frontier of solid organ transplantation (SOT). VCA spans life-enhancing/life-changing procedures such as upper extremity, craniofacial (including eye), laryngeal, tracheal, abdominal wall, penis, and lower extremity transplants. VCAs such as uterus transplants are life giving unlike any other SOT. Of all VCAs that have shown successful intermediate- to long-term graft survival with functional and immunologic outcomes, lower extremity VCAs have remained largely underexplored. Lower extremity transplantation (LET) can offer patients with improved function compared to the use of conventional prostheses, reducing concerns of phantom limb pain and stump complications, and offer an option for eligible amputees that either fail prosthetic rehabilitation or do not adapt to prosthetics. Nevertheless, these benefits must be carefully weighed against the risks of VCA, which are not trivial, including the adverse effects of lifelong immunosuppression, extremely challenging perioperative care, and delayed nerve regeneration. There have been 5 lower extremity transplants to date, ranging from unilateral or bilateral to quadrimembral, progressively increasing in risk that resulted in fatalities in 3 of the 5 cases, emphasizing the inherent risks. The advantages of LET over prosthetics must be carefully weighed, demanding rigorous candidate selection for optimal outcomes.

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“…The lower extremity allograft was amputated by postoperative day 1 because of malperfusion, and the patient died 5 months later from disseminated aspergillosis and multiorgan failure. 14 Despite multiple successful bilateral hand transplants performed since, to our knowledge, there have been no further attempts at combined vascularized composite allotransplantation.…”

mentioning

confidence: 99%