Lung transplantation: how to perform the venous anastomosis when clamping is too distal

Report of the ISHLT Working Group on Primary Lung Graft Dysfunction Part IV: Recipient-Related Risk Factors and Markers

“…Hemodynamic instability may occur in severe cases. 93,96 Often a ventilation perfusion scan suggests the diagnosis, which is confirmed by a transesophageal echocardiography (TEE) or pulmonary angiogram. The left pulmonary arterial anastomosis is not always clearly visualized by TEE and, in these circumstances, a pulmonary angiogram is necessary.…”

“…The left pulmonary arterial anastomosis is not always clearly visualized by TEE and, in these circumstances, a pulmonary angiogram is necessary. [95][96][97] Surgical revision with hypothermic cardiopulmonary bypass to protect the graft, or endovascular balloon angioplasty and stenting (which may be combined with thrombolytic therapy in the presence of thrombus), are indicated to correct the stenosis. 93,95,98 -100 …”

Transesophageal Echocardiographic Visualization of Alternative Technique of Pulmonary Vein Anastomosis in Double Lung Transplantation

“…The velocities from these jets ideally should be <100 cm/s as an indication of unobstructed, lowgradient flow, minimizing the risks of venous congestion. 1,2 In the presented case, we visualized 2 PVs on the left side with a very unusual location on the postreperfusion examination and only 1 PV on the right side. The 2 jets arising from the posterior aspect of the left atrium (LA) correspond to the alternative anastomosis (Fig 2, A); the velocities from these jets reached up to 140 cm/s, and a turbulent flow also could be seen.…”

“…In a report by Robert et al the authors described the following 3 situations that can cause the clamp applied to PVs to be too distal on DLT recipient's atrium: (1) the heart does not tolerate the lateral atrial clamping (arrhythmias); (2) the clamp is no longer in the original intended position and cannot be repositioned; and (3) the venous section was too proximal in the donor lung hilum during harvesting, which interrupts the veins instead of the atrium. 1 Although Robert et al mentions that this situation is more common during the right side anastomosis because the distance from the right-sided PV to the right Fig 1. (A) The Satinsky clamp occludes both pulmonary veins, thus not allowing for the construction of the atrial cuff.…”

Separate pulmonary venous anastomoses using a left atrial appendage in a left single lung transplantation

“…Doing a single anastomosis (instead of 2 anastomoses on both veins) is easier and quicker, and minimizes the risks of stenosis and thus of thrombosis. 4 However, pulmonary venous anastomosis is occasionally technically challenging, as in the present case, and in such cases this surgical technique might be a useful option for thoracic surgeons. This technique could be used in other scenarios, such as difficulty in vein exposure owing to cardiac enlargement.…”