The landscape of vascularized composite allograft donation in the United States

Vascularized composite allograft deceased donation in the United States

Vascularized composite allograft (VCA) transplantation represents a significant advancement in reconstructive surgery and offers hope to individuals who experienced congenital disorders or severe tissue injuries to restore physical appearance, function, and enhance quality of life. VCA recovery introduces complexities to conventional solid organ recovery, and there remain concerns regarding the potential impact of VCA recovery on non-VCA organs for transplant. The current retrospective study examines deceased donor characteristics and observed-to-expected (O/E) organ yield ratios for 51 VCA donors recovered in the US between July 4, 2014 and March 31, 2024, compared with a contemporary cohort of non-VCA donors recovered in 2023. Among the VCA donors, 17 donated a uterus, 15 each donated head and neck and upper limbs, 4 were abdominal wall donors, and 2 donated external male genitalia. The findings indicate that VCA donors tended to be younger (18-34 years old), predominantly White, non-Hispanic, and had no history of diabetes, along with lower weight, lower kidney donor profile index, and lower ejection fraction. The analysis revealed that VCA donors had higher observed overall organ yield than expected (O/E: 1.24, 95% CI: 1.16-1.33), with better-than-expected organ yields across VCA types. The number of deceased VCA donors in the US is still relatively small compared to the overall donor population. As the field continues to evolve and more data becomes available, further analyses need to be conducted to understand the demographics of VCA donors and the potential impact of VCA donation within the donation and transplant system.

Tracheal Replacement: A Scoping Review

Objective  To summarize patient characteristics and outcomes for the historical and current methods of long-segment tracheal replacement in humans. Materials and Methods  A single reviewer screened the abstracts and full texts using Covidence for file management. Studies published in English that reported human subjects with circumferential or near-circumferential (>270 degrees) cervical tracheal replacements were included. Articles with subjects treated with primary anastomosis alone, retracted articles, abstracts, expert opinion articles, and conference presentations were excluded. Results  A total of 32 articles were included in the review reporting 156 cases of long-segment tracheal replacement including synthetic (alive at 1-8 years n  = 6/64), regenerative medicine (dead at 15 days-55 months n  = 4, not reported n  = 6), cadaveric tracheal allograft (alive at 5 months-10 years n  = 32/38), aortic allograft (alive at 6-85 months n  = 12/16), free tissue transfer (alive at 6-108 months n  = 13/21), allotransplantation (alive at 6-24 months n  = 5/8), and vascular composite allograft (VCA) (alive at 20 months n  = 1/1). Conclusion  Silicone and Marlex prostheses have poor long-term outcomes. The cadaveric tracheal allograft can only replace near-circumferential tracheal defects and is therefore limited to benign tracheal pathology. Inadequate structural support plagues the aortic allograft and often requires numerous invasive procedures and maintenance of an intraluminal stent. A lack of mucociliary clearance exists in all methods of tracheal replacement except cadaveric tracheal allograft and VCA and can cause fatal mucous plugging and chronic pulmonary infections. VCA and allotransplantation require long-term immunomodulation therapy.

Significantly Improved Cold Preservation of Rat Hind Limb Vascularized Composite Allografts Using the New PrC-210 Free Radical Scavenger

Vascularized composite allotransplantation (VCA) represents a promising reconstructive solution primarily conducted to improve quality of life. However, tissue damage caused by cold-ischemia (CI) storage prior to transplant represents a major factor limiting widespread application. This study investigates the addition of the novel free radical scavenger PrC-210 to UW Organ Preservation Solution (UW Solution) to suppress CI-induced skeletal muscle injury in a rat hind limb amputation model. Lewis rats received systemic perfusion of UW solution +/- PrC-210 (0 mM control, 10 mM, 20 mM, 30 mM, or 40 mM), followed by bilateral transfemoral amputation. Limbs were stored in 40 mL of the same perfusate at 4 °C for 48 h. Muscle punch biopsies were taken at set times over the 48 h cold-storage period and analyzed for caspase-3,7 activity, cytochrome C levels, and qualitative histology. A single 15 s perfusion of PrC-210-containing UW Solution conferred a dose-dependent reduction in CI-induced muscle cell death over 48 h. In the presence of PrC-210, muscle cell mitochondrial cytochrome C release was equivalent to 0 h controls, with profound reductions in the caspase-3,7 apoptotic marker that correlated with limb histology. PrC-210 conferred complete prevention of ROS-induced mitochondrial lysis in vitro, as measured by cytochrome C release. We conclude that the addition of 30 mM PrC210 to UW Solution conferred the most consistent reduction in CI limb damage, and it warrants further investigation for clinical application in the VCA setting.

Donor derived hematopoietic stem cell niche transplantation facilitates mixed chimerism mediated donor specific tolerance

Compelling experimental evidence confirms that the robustness and longevity of mixed chimerism (MC) relies on the persistence and availability of donor-derived hematopoietic stem cell (HSC) niches in recipients. Based on our prior work in rodent vascularized composite allotransplantation (VCA) models, we hypothesize that the vascularized bone components in VCA bearing donor HSC niches, thus may provide a unique biologic opportunity to facilitate stable MC and transplant tolerance. In this study, by utilizing a series of rodent VCA models we demonstrated that donor HSC niches in the vascularized bone facilitate persistent multilineage hematopoietic chimerism in transplant recipients and promote donor-specific tolerance without harsh myeloablation. In addition, the transplanted donor HSC niches in VCA facilitated the donor HSC niches seeding to the recipient bone marrow compartment and contributed to the maintenance and homeostasis of stable MC. Moreover, this study provided evidences that chimeric thymus plays a role in MC-mediated transplant tolerance through a mechanism of thymic central deletion. Mechanistic insights from our study could lead to the use of vascularized donor bone with pre-engrafted HSC niches as a safe, complementary strategy to induce robust and stable MC-mediated tolerance in VCA or solid organ transplantation recipients.

Policies and Price Tags: The Public's Perception of Face Transplantation and Its Funding

Study Design

Survey study.

Objective

Facial vascularized composite allotransplantation (FVCA) can cost over 1 million dollars per procedure and is usually not covered by insurance, yet this financial burden and public opinion surrounding this procedure are not well understood. This study is the first to evaluate the layperson's opinions on the allocation of financial responsibility for FVCA and its inclusion in organ donation registries.

Methods

Eight hundred and fifteen laypersons were surveyed through MTurk to assess their agreement with 11 statements about FVCA perceptions, funding, and inclusion on organ donation registries. Responses were analyzed with the Wilcoxon Signed-Rank test, the Kruskal-Wallis test, and the Dunn's test.

Results

The majority of respondents were supportive of FVCA in 10 out of 11 statements (P < 0.0001). They would be willing to undergo FVCA if they suffered from facial disfigurement; believe FVCA is as important as other organ transplants; believe faces should be included on the organ donation registry; support insurance companies providing coverage for FVCA regardless of trauma etiology; support tax dollars funding the procedure; and believe FVCA improves physical appearance and quality of life. Although respondents generally supported their tax dollars funding the procedure, fewer supported this for self-inflicted trauma (P > 0.01).

Conclusions

This study highlights a disconnect between public preference for insurance coverage of FVCA and current lack of coverage in practice. Respondents' acceptance of including faces in organ donation registries may help alleviate the issue of locating a donor, and increasing financial coverage may broaden this procedure's accessibility to a wider range of individuals.

Video Messaging to Increase Vascularized Composite Allograft Donation Willingness in United States Military Veterans

Expansion of vascularized composite allograft (VCA) transplantation depends on the public's willingness to donate VCA organs, including face, extremities, and genitourinary organs. This study evaluated the effectiveness of video messaging on VCA donation willingness in US military veterans, a key stakeholder in VCA transplantation.

Methods

Participants (n = 556) were randomized to 1 of 3 VCA video messaging interventions (informational, testimonial, or blended), a general (non-VCA) organ donation video message, or a control (nondonation) video message. Questionnaires were completed at pre- and postintervention and at 3-wk follow-up.

Results

Veterans exposed to any VCA video messaging were more likely to express VCA donation willingness (69%, n = 203/296) than those exposed to general donation messaging (53%, n = 47 of 89; P = 0.006) or No Donation Messaging (37%, n = 36 of 97; P < 0.001). A significantly higher proportion of participants who received Blended VCA Messaging were willing to be VCA donors, compared with the Informational VCA Messaging group (79% versus 61%, P = 0.006). Each VCA messaging video resulted in a significant pre- to postintervention increase in the proportion of participants willing to donate their own face, hands, and legs (P < 0.03).

Conclusions

Brief educational videos focused on VCA transplantation can have a demonstrable and verifiable impact on rates of VCA donation willingness in veterans.

Using team science in vascularized composite allotransplantation to improve team and patient outcomes

Reconstructive allografts using Vascularized Composite Allotransplantation (VCA) are providing individuals living with upper limb loss and facial disfigurement with new opportunities for a sensate, esthetically acceptable, and functional alternative to current treatment strategies. Important research attention is being paid to how best to assess and screen candidates for VCA, measure optimal patient outcomes, and support patient adherence to lifelong behaviors and medical regimens. Far less attention, however, has been dedicated to the team science required for these complex VCA teams to form, prepare, and provide the highest quality clinical and psychosocial care to those receiving VCA. VCA teams are unique in that they require specialized team members whose scope of practice may not otherwise overlap. The team also needs to constantly negotiate balancing patient safety with multiple risks throughout the transplant process. This study aimed to elucidate the team science needed for this highly innovative and complex area of medicine. Using in-depth qualitative interviews with 14 VCA team members and observations at team meetings, we found that careful consideration of team composition, team structure, and organizational commitment (e.g., local culture and team values; investment of resources) influences team performance and patient outcomes, but that to be efficient and truly effective, teams need to commit to developing processes that foster collaboration. These processes are action-oriented (e.g., communication, leadership), strategic (e.g., planning, training) and interpersonal (e.g., conflict management, trust building). Dedication and commitment to team science allows teams to manage conflict under stress and exercise ways to leverage strengths to provide optimal performance or patient psychosocial and clinical outcomes. This study can provide insight into quality improvement efforts for VCA teams and guidance for other transplant programs that wish to consider expansion into VCA.

Evaluation of an eLearning System to Train Health Professionals to Communicate about Vascularized Composite Allotransplantation with Donor Families

INTRODUCTION

Vascularized composite allotransplantation (VCA) donation relies on obtaining surrogate authorization. Yet, many donor professionals have limited experience discussing composite allograft donation. Using virtual and interactive elements, the eLearning program, Communicating Effectively about Donation for Vascularized Composite Allotransplantation (CEaD-VCA), was developed to enhance the quality of donor professionals' communication approach.

RESEARCH QUESTIONS

We tested the effectiveness of the eLearning program in improving donor professionals' knowledge, preparedness, and confidence leading discussions with families.

DESIGN

Donor professionals who primarily obtain family authorization for solid organ and tissue donation were recruited from 2 regional Organ Procurement Organizations. The training was evaluated using a nonrandomized pre-post design. Participants completed an online survey with items assessing their knowledge, preparedness, and confidence for donation discussions. Pre- and post-training responses were compared using paired sample t-tests.

RESULTS

The sample included 42 donor professionals. The majority (71.4%) had at least 3 years of work experience, and over half (52.4%) had no experience discussing VCA donation with families. Post-training, significant increases in mean knowledge scores (6.4 pre to 7.0 post, P < 0.01) and mean self-reported preparation (6.6 pre to 7.9 post, P < 0.0001) were observed. There were significant increases in mean confidence scores for discussing face (6.2 pre to 7.9 post, P < 0.0001) and hand (6.2 pre to 8.0 post, P < 0.0001) transplants.

CONCLUSION

The CEaD-VCA program was effective in increasing donor professionals' knowledge, preparation, and confidence when discussing donation, and holds potential for improving donor professional communication during donation discussions.

Bionic Prostheses: The Emerging Alternative to Vascularised Composite Allotransplantation of the Limb

Twenty years have surpassed since the first vascularised composite allotransplantation (VCA) of the upper limb. This is an opportunity to reflect on the position of VCA as the gold standard in limb reconstruction. The paucity of recipients, tentative clinical outcomes, and insufficient scientific progress question whether VCA will remain a viable treatment option for the growing numbers of amputees. Bionic technology is advancing at a rapid pace. The prospect of widely available, affordable, safely applied prostheses with long-standing functional benefit is appealing. Progress in the field stems from the contributions made by engineering, electronic, computing and material science research groups. This review will address the ongoing reservations surrounding VCA whilst acknowledging the future impact of bionic technology as a realistic alternative for limb reconstruction.

Attitudes Toward Organ, Tissue, and Vascularized Composite Allograft (VCA) Donation and Transplantation: A Survey of United States Military Veterans

BACKGROUND

There are 20 million living US armed forces veterans; however, the organ donation attitudes of veterans have not been examined.

METHODS

Over a 17-month period, a convenience sample of 1517 veterans in New England completed a survey to assess attitudes about organ, tissue, and vascularized composite allograft (VCA) donation.

RESULTS

Most veterans (96%) supported the donation of organs and tissue for transplantation, and 59% were registered as an organ and tissue donor. Being younger (adjusted odds ratio [aOR]: 0.960.970.98; P = 0.01), female (aOR: 1.061.462.03; P = 0.02), non-Hispanic white (aOR: 1.302.073.30; P = 0.01), Hispanic (aOR: 1.282.434.61; P = 0.01), and having more trust that the transplant process is fair and equal (aOR: 1.191.401.65; P = 0.01) were predictive of donor registration. Also, most veterans were willing to donate their face (57%), hands/arms (81%), legs (81%), penis (men: 61%), and uterus (women: 76%) at time of death; donation willingness was higher for upper and lower limbs than for face or genitourinary organs (P < 0.001). Those unwilling to donate VCA organs expressed concerns about identity loss, psychological discomfort of self and others, body integrity, funeral presentation, and religious beliefs. Most (54%) felt that VCA donation should require permission of legal next-of-kin at the time of one's death, even if the decedent was a registered donor.

CONCLUSIONS

There is a high level of support for organ, tissue, and VCA transplantation and donation among veterans, despite limited educational campaigns targeting this population. There is high potential among veterans to further increase donor registry enrollment and raise awareness about VCA benefits for severely injured service members.