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Kumar N, Hussain N, Kumar J, Essandoh MK, Bhatt AM, Awad H, Perez WJ, Whitson BA, Ganapathi AM, Mokadam NA, Gorelik L, Turner K, Iyer MH. Evaluating the Impact of Pulmonary Artery Obstruction After Lung Transplant Surgery: A Systematic Review and Meta-analysis. Transplantation 2021; 105:711-722. [PMID: 33760790 DOI: 10.1097/tp.0000000000003407] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pulmonary artery obstruction is an uncommon but significant complication after lung transplantation. Although numerous reports have documented its occurrence, the hemodynamic parameters associated with its presentation and diagnostic considerations remain ill-defined. This systematic review summarizes evidence in the literature surrounding pulmonary artery obstruction after lung transplantation surgery. METHODS Databases were searched for all articles and abstracts reporting on pulmonary artery obstruction. Data collected included the number of patients studied, patient characteristics, incidences of pulmonary artery obstruction, and timing and imaging modality used for diagnosis. RESULTS Thirty-four full-text citations were included in this review. The point prevalence of pulmonary artery obstruction was 3.66%. The peak pulmonary artery velocity associated with obstruction was found to be 2.60 ± 0.58 m/s. The diameter of the obstructed pulmonary artery predictive of poor outcomes was noted to be 0.78 ± 0.40 cm. The majority of diagnoses were made in the late postoperative period using pulmonary angiogram and transesophageal echocardiography. Overall, 76% of patients (47 of 62) required emergent procedural reintervention, and 23% of patients (14 of 62) diagnosed with pulmonary artery obstruction died during their hospital stay. CONCLUSIONS This systematic review underscores the importance of identifying pulmonary artery obstruction immediately after lung transplant surgery. The clinical implications of these results warrant the development of identification and management strategies for early detection of irregularities in pulmonary artery anastomosis in lung transplant patients.
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Affiliation(s)
- Nicolas Kumar
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Nasir Hussain
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Julia Kumar
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Michael K Essandoh
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Amar M Bhatt
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Hamdy Awad
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - William J Perez
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Bryan A Whitson
- Division of Cardiac Surgery, Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Asvin M Ganapathi
- Division of Cardiac Surgery, Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Nahush A Mokadam
- Division of Cardiac Surgery, Department of Surgery, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Leonid Gorelik
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Katja Turner
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH
| | - Manoj H Iyer
- Department of Anesthesiology, Wexner Medical Center, The Ohio State University, Columbus, OH
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Successful angioplasties using high pressure large balloons in a patient with severe anastomotic pulmonary artery stenosis soon after single-lung transplantation. J Cardiol Cases 2020; 22:22-25. [PMID: 32636964 DOI: 10.1016/j.jccase.2020.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 03/06/2020] [Accepted: 03/30/2020] [Indexed: 11/21/2022] Open
Abstract
A 59-year-old man received a single-lung transplantation due to interstitial pneumonitis. Severe anastomotic pulmonary artery stenosis (PAS) resulting in hypoxia and respiratory symptoms was found in the immediate postoperative period. A scintigraphy showed severe hypoperfusion of the left transplanted lung with 7% of the total pulmonary blood flow. On postoperative days (POD) 29 and 64, the patient underwent serial balloon angioplasties without any complications. Based on the balloon selection criteria for PAS after heart surgery in children, a high-pressure large balloon was used with resultant improvement in respiratory signs and symptoms without any complications. The patient was discharged on POD 92. A follow-up scintigraphy on POD 169 revealed 58% of blood distribution to the left lung. The patient has been doing clinically well and remained asymptomatic one year after the transplantation. Balloon angioplasty with a high-pressure large balloon without stent implantation during an early postoperative period may be a safe and effective strategy. The balloon selecting criteria used in pediatric patients may be applied in the adult lung transplant recipients. <Learning objective: Anastomotic pulmonary artery stenosis (PAS) in a single-lung transplant recipient is a critical complication. A balloon angioplasty with a high-pressure large balloon should be a first choice for anastomotic PAS, because it is safer than stent implantation especially for transplant recipients. And the balloon selecting criteria used in children with congenital heart disease may be applied in the adult lung transplant recipients.>.
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Batra K, Chamarthy MR, Reddick M, Roda MS, Wait M, Kalva SP. Diagnosis and interventions of vascular complications in lung transplant. Cardiovasc Diagn Ther 2018; 8:378-386. [PMID: 30057884 DOI: 10.21037/cdt.2018.03.05] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Though rare, pulmonary vascular complications after lung transplantation carry high morbidity and mortality. Knowledge of the normal and abnormal appearance of lung transplant vasculature is essential for timely and appropriate diagnosis and management of complications. Appropriate selection of surgical and endovascular treatments depend on the availability of expertise and requires a multidisciplinary approach to ensure the best outcomes.
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Affiliation(s)
- Kiran Batra
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Murthy R Chamarthy
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mark Reddick
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Manohar S Roda
- Department of Radiology, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Michael Wait
- Department of Cardiothoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sanjeeva P Kalva
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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4
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Long B, Koyfman A. The emergency medicine approach to transplant complications. Am J Emerg Med 2016; 34:2200-2208. [DOI: 10.1016/j.ajem.2016.08.049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 08/18/2016] [Accepted: 08/20/2016] [Indexed: 02/07/2023] Open
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Copelan A, George D, Kapoor B, Nghiem HV, Lorenz JM, Erly B, Wang W. Iatrogenic-related transplant injuries: the role of the interventional radiologist. Semin Intervent Radiol 2015; 32:133-55. [PMID: 26038621 DOI: 10.1055/s-0035-1549842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
As advances in surgical techniques and postoperative care continue to improve outcomes, the use of solid organ transplants as a treatment for end-stage organ disease is increasing. With the growing population of transplant patients, there is an increasing need for radiologic diagnosis and minimally invasive procedures for the management of posttransplant complications. Typical complications may be vascular or nonvascular. Vascular complications include arterial stenosis, graft thrombosis, and development of fistulae. Common nonvascular complications consist of leaks, abscess formation, and stricture development. The use of interventional radiology in the management of these problems has led to better graft survival and lower patient morbidity and mortality. An understanding of surgical techniques, postoperative anatomy, radiologic findings, and management options for complications is critical for proficient management of complex transplant cases. This article reviews these factors for kidney, liver, pancreas, islet cell, lung, and small bowel transplants.
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Affiliation(s)
- Alexander Copelan
- Department of Diagnostic Radiology, William Beaumont Hospital, Royal Oak, Michigan
| | - Daniel George
- Department of Diagnostic Radiology, William Beaumont Hospital, Royal Oak, Michigan
| | - Baljendra Kapoor
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | - Hahn Vu Nghiem
- Department of Diagnostic Radiology, William Beaumont Hospital, Royal Oak, Michigan
| | - Jonathan M Lorenz
- Section of Interventional Radiology, The University of Chicago, Chicago, Illinois
| | - Brian Erly
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio ; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Weiping Wang
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
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Anaya-Ayala JE, Loebe M, Davies MG. Endovascular management of early lung transplant-related anastomotic pulmonary artery stenosis. J Vasc Interv Radiol 2015; 26:878-82. [PMID: 25851200 DOI: 10.1016/j.jvir.2015.02.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Revised: 02/16/2015] [Accepted: 02/18/2015] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To report the safety and short-term efficacy of endovascular interventions for symptomatic lung transplant-related anastomotic pulmonary artery stenosis (PAS). MATERIALS AND METHODS From February 2008 to December 2011, 354 lung transplants were performed. Pulmonary arteriography was performed in 19 patients (63% men; age, 57 y ± 21, mean ± SD; seven double-lung transplants) because of respiratory decompensation (mean 6.7 mo after transplant). Seven arteriograms were normal, and 12 showed significant PAS. One patient (5%) underwent angioplasty alone, and 11 patients (57%) underwent stent placement. RESULTS All patients underwent general anesthesia, and femoral access was used for the intervention. Technical success was 100% in the 12 patients treated. Symptoms improved in all patients who underwent intervention, with resolution in 11 of 12 (92%). There were no major or minor complications. Three patients (16%) had recurrent symptoms after discharge secondary to chronic rejection or pneumonia. Two patients died as a result of sepsis and multiorgan failure at 2 days and 14 days, respectively, after undergoing only pulmonary arteriography. In-stent stenosis occurred in 1 (9%) patient who required additional stent placement. During a mean follow-up period of 11 months, the remaining stents were patent, and the patients were asymptomatic. CONCLUSIONS Endovascular stent placement provides an alternative to open repair for transplant-related anastomotic PAS. It has low mortality and morbidity rates, and it has shown excellent short-term functional and anatomic outcomes.
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Affiliation(s)
- Javier E Anaya-Ayala
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX 77030..
| | - Matthias Loebe
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX 77030
| | - Mark G Davies
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX 77030
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Grubstein A, Atar E, Litvin S, Belenky A, Knizhnik M, Medalion B, Raviv Y, Kramer MR, Fox BD. Angioplasty Using Covered Stents in Five Patients With Symptomatic Pulmonary Artery Stenosis After Single-Lung Transplantation. Cardiovasc Intervent Radiol 2014; 37:686-90. [DOI: 10.1007/s00270-013-0758-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 09/06/2013] [Indexed: 11/30/2022]
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Abdulaziz S, Al-Shahid M, Al-Thenayan E. A 49-year-old man with acute pulmonary hypertension post lung transplantation. Chest 2014; 144:704-707. [PMID: 23918117 DOI: 10.1378/chest.12-2811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Salman Abdulaziz
- Department of Adult Critical Care Medicine, Riyadh, Kingdom of Saudi Arabia.
| | - Maie Al-Shahid
- King Faisal Heart Institute, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Eyad Al-Thenayan
- Department of Adult Critical Care Medicine, Riyadh, Kingdom of Saudi Arabia
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9
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Siddique A, Bose AK, Özalp F, Butt TA, Muse H, Morley KE, Dark JH, Parry G, Clark SC. Vascular anastomotic complications in lung transplantation: a single institution's experience. Interact Cardiovasc Thorac Surg 2013; 17:625-31. [PMID: 23788195 DOI: 10.1093/icvts/ivt266] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Lung transplant recipients were reviewed to compare our early and current experience of vascular complications. Since 1995, we have had a policy of early identification and intervention. METHODS We undertook a retrospective review of all adult lung transplants performed at our centre. Patients with pulmonary vascular complications before and after 1995 were identified and reviewed to determine changes in management and outcome. RESULTS We identified a total of 13 patients with either pulmonary artery or venous obstruction out of a total of 720 adult lung transplants (1.8%). There were 9 females and 4 males with an age range of 25-64 years. Complications were more common in patients with fibrotic lung disease and involved 15 vascular anastomoses, most commonly the pulmonary arterial anastomosis. Prior to 1995, 5 cases were identified, all postoperatively. In this group, the mean time for identification of the complication was 9.4 (range 4-14) days. Only 1 patient survived to discharge. After 1995, vascular complications were identified intraoperatively in 4 cases and corrected immediately. Four cases were identified postoperatively (at <1-17 days) by a computed tomography pulmonary angiogram. Three were treated surgically within 24 h of diagnosis (using cardiopulmonary bypass with cold preservation). One patient was managed conservatively. Among patients identified after 1995, 5 survived to discharge. CONCLUSIONS Though rare, pulmonary vascular complications after lung transplantation carry high mortality. In our opinion, early identification and intervention improves outcome. Intraoperative assessment by pressure gradient measurement and transoesophageal echocardiography is recommended. Despite this, mortality remains high and prevention is better than cure.
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Affiliation(s)
- Aleem Siddique
- Department of Cardiothoracic Transplantation and Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Chen F, Tazaki J, Shibata T, Miwa S, Yamazaki K, Ishii H, Shoji T, Fujinaga T, Bando T, Date H. Stent angioplasty for a kink in the pulmonary artery anastomosis soon after living-donor lobar lung transplantation. Ann Thorac Surg 2011; 92:e105-6. [PMID: 22051314 DOI: 10.1016/j.athoracsur.2011.05.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2011] [Revised: 05/03/2011] [Accepted: 05/13/2011] [Indexed: 11/26/2022]
Abstract
Herein, we report a case of stent angioplasty for a kink in the pulmonary artery (PA) anastomosis soon after living-donor lobar lung transplantation (LDLLT). A 64-year-old man with idiopathic pulmonary fibrosis underwent bilateral LDLLT with lung donations from his daughters. After reperfusion, the left PA anastomosis showed a kink, which could not be corrected completely during surgery. Due to the kink in the left PA, and the relatively small donor grafts, the patient required extracorporeal membrane oxygenation) after LDLLT. Approximately 24 hours after reperfusion, stent angioplasty was performed, resulting in the patient being successfully weaned from extracorporeal membrane oxygenation on postoperative day 4.
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Affiliation(s)
- Fengshi Chen
- Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
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Amesur NB, Orons PD, Iacono AT. Interventional techniques in the management of airway complications following lung transplantation. Semin Intervent Radiol 2011; 21:283-95. [PMID: 21331140 DOI: 10.1055/s-2004-861563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The last four decades have seen tremendous advances in the field of pulmonary transplantation. Vast improvements in the areas of surgical transplantation techniques, immunosuppressive agents, and postoperative care have all contributed to improved survival of patients. Advances in noninvasive imaging and bronchoscopy have allowed the pulmonary transplant team to intervene early in patients presenting with airway complications, often using minimally invasive procedures such as endobronchial balloon dilation or stent placement, or both. Stent technology itself has also improved and stents may sometimes be customized for treatment of short airway lesions or to optimize continued airflow through the sides of stents by creating openings using balloons or bronchoscopically directed laser. Preliminary work with brachytherapy may be decreasing the need for secondary reinterventions. The authors present an overview of some of these conventional and novel approaches to the treatment of airway complications after lung transplantation.
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Affiliation(s)
- Nikhil B Amesur
- Assistant Professor of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Lumsden AB, Anaya-Ayala JE, Birnbaum I, Davies MG, Bismuth J, Cheema ZF, El Sayed HF, Seethamraju H, Loebe M, Valderrabano M. Robot-assisted stenting of a high-grade anastomotic pulmonary artery stenosis following single lung transplantation. J Endovasc Ther 2011; 17:612-6. [PMID: 20939718 DOI: 10.1583/10-3208r.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To report robot-assisted stenting of a stenosis at the pulmonary artery anastomosis following lung transplantation, a rare complication that conveys poor prognosis even after surgical correction. TECHNIQUE The technique is illustrated in a 72-year-old man with end-stage lung disease who received a left single lung transplant. On postoperative day 54, he was evaluated for recurrent dyspnea on exertion that was due to a severe stenosis at the site of the pulmonary artery anastomosis. Balloon angioplasty was performed, and a 10-mm stent was deployed, with marked clinical improvement. Fourteen months later, he presented with recurrent symptoms due to in-stent restenosis. Multiple attempts at catheterization and balloon angioplasty of the stent failed. Due to the technical difficulty involved in maneuvering the balloon while maintaining stability, it was decided to repeat the angioplasty with the assistance of a Hansen Sensei remote robotic navigation system. The robotic arm markedly enhanced stability and facilitated successful navigation of the stented site. A 16-mm-diameter Wallstent was placed through the previously placed balloon-expandable stent and postdilated. CONCLUSION A remote robotic catheter navigation system was able to assist stenting of an anastomotic pulmonary artery stenosis following failure of conventional interventional techniques.
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Affiliation(s)
- Alan B Lumsden
- Methodist DeBakey Heart & Vascular Center, Department of Cardiovascular Surgery, The Methodist Hospital, Houston, Texas 77030, USA.
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Abstract
This article reviews several important noninfectious pulmonary complications that threaten survival, pulmonary function, and quality of life after lung transplantation. Topics reviewed include primary graft dysfunction (PGD), native lung hyperinflation, anastomotic complications, phrenic nerve injury, pleural complications, lung cancer, pulmonary toxicity associated with immunosuppressive medications, and exercise limitation.
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Affiliation(s)
- Vivek N Ahya
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Van Raemdonck D, Klepetko W, Verleden GM, Daenen W, Coosemans W, Decker G, De Leyn P, Nafteux P, Lerut T. [Surgical aspects of (cardio) pulmonary transplantation]. Rev Mal Respir 2005; 22:785-95. [PMID: 16272981 DOI: 10.1016/s0761-8425(05)85636-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
UNLABELLED INTRODUCTION AND STATE OF THE ART: Both short and long-term outcomes following lung transplantation have improved substantially in recent years as a result of advances in the selection and management of donors, organ preservation, immunosuppressive therapy, and the treatment of infectious and malignant complications. In addition surgical techniques have evolved over time and have contributed to this increase in success rates. PERSPECTIVES AND CONCLUSIONS This review outlines surgical aspects of lung transplantation including a historical note, techniques of lung harvesting, some anaesthetic considerations, the different transplant types and incisions, as well as anastomotic techniques and their pitfalls.
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Affiliation(s)
- D Van Raemdonck
- Département de Chirurgie Thoracique, Hôpital Universitaire de Leuven, Belgique.
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