Development of a rat forelimb vascularized composite allograft (VCA) perfusion protocol

Vascular Microphysiological System for Investigating Endothelial Barrier Function During Organ Preservation and Reperfusion

Endothelial cell damage after cold preservation and reperfusion injury causes deterioration of the endothelial barrier and ultimately results in edema, leading to transplant failure. Here, a vascular microphysiological system (MPS) is introduced as a testbed to investigate the combinational effect of thermal and fluid perturbations (i.e., wall shear stress) on human endothelial barrier function. Two methods of organ storage are compared: isochoric supercooling (ISC) preservation, which prevents ice formation at subzero temperatures; and, the standard clinical protocol of static cold storage (SCS) at 4 °C. Integrating electrical impedance measurements on chip allow real-time monitoring and quantification of barrier function during preservation and reperfusion protocols. Isochoric supercooling preservation enables longer periods of preservation with superior recovery of barrier function during reperfusion, and has lower metabolic activities compared to static cold storage. Genomic analysis reveals injury and recovery mechanisms at the molecular level for the different preservation and reperfusion conditions. The multifunctional vascular microphysiological system provides a physiologically relevant in vitro model recapitulating ischemia-reperfusion injury to the endothelium. The vascular MPS has potential for optimizing organ preservation protocols, ultimately improving organ transplant viability.

A longitudinal rat forelimb model for assessing in vivo neuromuscular function following extremity reperfusion injury

Rhabdomyolysis following revascularization of the ischemic upper extremity can lead to life- & limb-threatening sequelae. In the context of replantations and vascularized composite allografting, a reconstructive procedure usually reserved for upper limb amputees, prolonged tissue ischemia is detrimental to extremity functional recovery. Currently, validated survival small animal models of extremity reperfusion injury that permit longitudinal assessment of limb function are lacking. To date, studies that evaluated reperfusion injury-induced neuromuscular impairment rely on terminal ex vivo procedures and do not provide clinically translatable measurements. Furthermore, it is unclear if upper extremity musculature exhibits a different ischemic threshold compared to the lower limb given the relatively rare incidence of upper limb ischemia. Here, we present a reliable rat model of extremity post-reperfusion syndrome (PRS) that comprehensively recapitulates the biochemical hallmarks of rhabdomyolysis secondary to upper extremity reperfusion injury and allows for monitoring in vivo upper limb function using clinically relevant electrodiagnostic and kinematic metrics. In addition to inducing severe metabolic derangements, our forelimb PRS provided insights on gross motor and electrophysiological alterations upper-extremity reperfusion injury. We identify gait coordination parameters such as stride frequency and forelimb-hindlimb coordination index and electrophysiological metrics including compound muscle action potential amplitude as objective, non-invasive outcome measures for limb function assessment in small animal models of extremity PRS. This comprehensive, validated functional model can serve as an invaluable tool to evaluate therapeutics or preconditioning regimens to attenuate PRS and mitigate resulting neuromuscular dysfunction.

A meta-analysis of perfusion parameters affecting weight gain in ex vivo perfusion

BACKGROUND

Ex vivo machine perfusion (EVMP) has been established to extend viability of donor organs. However, EVMP protocols are inconsistent. We hypothesize that there is a significant relationship between specific parameters during EVMP and perfusion outcomes.

METHODS

A meta-analysis of literature was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) Statement. The search encompassed articles published before July 25, 2023. PubMed, Embase, and CENTRAL databases were screened using search terms "ex-vivo," "ex-situ," "machine," and "perfusion." Weight gain, an indicator of organ viability, was chosen to compare outcomes. Extracted variables included perfused organ, warm and cold ischemia time before perfusion, perfusion duration, perfusate flow, pressure, temperature, perfusate composition (presence of cellular or acellular oxygen carrier, colloids, and other supplements) and percent weight change. Data were analyzed using SPSS statistical software.

RESULTS

Overall, 44 articles were included. Red blood cell-based perfusates resulted in significantly lower weight gain compared to acellular perfusates without oxygen carriers (11.3% vs. 27.0%, p < 0.001). Hemoglobin-based oxygen carriers resulted in significantly lower weight gain compared to acellular perfusates (16.5% vs. 27%, p = 0.006). Normothermic perfusion led to the least weight gain (14.6%), significantly different from hypothermic (24.3%) and subnormothermic (25.0%) conditions (p < 0.001), with no significant difference between hypothermic and subnormothermic groups (24.3% vs. 25.0%, p = 0.952). There was a positive correlation between flow rate and weight gain (ß = 13.1, R = 0.390, p < 0.001).

CONCLUSIONS

Oxygen carriers, low flow rates, and normothermic perfusate temperature appear to improve outcomes in EVMP. These findings offer opportunities for improving organ transplantation outcomes.

Successful Extension of Vascularized Composite Allograft Perfusion Cold Storage to 24 h in a Rat Hindlimb Transplant Model

Background

Vascularized composite allograft transplantation is a treatment option for complex tissue injuries; however, ischemia reperfusion injury and high acute rejection rates remain a challenge. Hypothermic machine perfusion using acellular storage perfusate is a potential solution. This study evaluated the University of Wisconsin Kidney Preservation Solution-1 (KPS-1) compared with normal saline (NS) for preservation of donor rat hindlimbs subjected to 24 h of ex vivo perfusion cold storage.

Methods

Hindlimbs were subjected to 24-h perfusion cold storage with heparinized KPS-1 (n = 6) or heparinized NS (n = 6). Flow, resistance, and pH were measured continuously. At the end of the 24-h period, tissue was collected for histological analysis of edema and apoptosis.

Results

KPS-1 perfused limbs showed significantly less edema than the NS group, as evidenced by lower limb weight gain (P < 0.001) and less interfascicular space (P < 0.001). KPS-perfused muscle had significantly less cell death than NS-perfused muscle based on terminal deoxynucleotidyl transferase dUTP nick-end labeling (P < 0.001) and cleaved caspase-3 staining (P = 0.045). During hypothermic machine perfusion, a significant decrease in pH over time was detected in both groups, with a significantly greater decline in pH in the KPS-1 group than in the NS group. There were no significant differences overall and over time in flow rate or vascular resistance between the KPS and NS groups.

Conclusions

Perfusion with KPS-1 can successfully extend vascularized composite allograft perfusion cold storage for 24 h in a rat hindlimb model without significant edema or cell death.

VCA supercooling in a swine partial hindlimb model

Vascularized composite allotransplantations are complex procedures with substantial functional impact on patients. Extended preservation of VCAs is of major importance in advancing this field. It would result in improved donor-recipient matching as well as the potential for ex vivo manipulation with gene and cell therapies. Moreover, it would make logistically feasible immune tolerance induction protocols through mixed chimerism. Supercooling techniques have shown promising results in multi-day liver preservation. It consists of reaching sub-zero temperatures while preventing ice formation within the graft by using various cryoprotective agents. By drastically decreasing the cell metabolism and need for oxygen and nutrients, supercooling allows extended preservation and recovery with lower ischemia-reperfusion injuries. This study is the first to demonstrate the supercooling of a large animal model of VCA. Porcine hindlimbs underwent 48 h of preservation at - 5 °C followed by recovery and normothermic machine perfusion assessment, with no issues in ice formation and favorable levels of injury markers. Our findings provide valuable preliminary results, suggesting a promising future for extended VCA preservation.

Review of machine perfusion studies in vascularized composite allotransplant preservation

The applications of Vascularized composite allotransplantation (VCA) are increasing since the first successful hand transplantation in 1998. However, the abundance of muscle tissue makes VCA's vulnerable to ischemia-reperfusion injury (IRI), which has detrimental effects on the outcome of the procedure, restricting allowable donor-to-recipient time and limiting its widespread use. The current clinical method is Static cold storage (SCS) and this allows only 6 h before irreversible damage occurs upon reperfusion. In order to overcome this obstacle, the focus of research has been shifted towards the prospect of ex-vivo perfusion preservation which already has an established clinical role in solid organ transplants especially in the last decade. In this comprehensive qualitative review, we compile the literature on all VCA machine perfusion models and we aim to highlight the essentials of an ex vivo perfusion set-up, the different strategies, and their associated outcomes.

Towards Optimizing Sub-Normothermic Machine Perfusion in Fasciocutaneous Flaps: A Large Animal Study

Machine perfusion has developed rapidly since its first use in solid organ transplantation. Likewise, reconstructive surgery has kept pace, and ex vivo perfusion appears as a new trend in vascularized composite allotransplants preservation. In autologous reconstruction, fasciocutaneous flaps are now the gold standard due to their low morbidity (muscle sparing) and favorable functional and cosmetic results. However, failures still occasionally arise due to difficulties encountered with the vessels during free flap transfer. The development of machine perfusion procedures would make it possible to temporarily substitute or even avoid microsurgical anastomoses in certain complex cases. We performed oxygenated acellular sub-normothermic perfusions of fasciocutaneous flaps for 24 and 48 h in a porcine model and compared continuous and intermittent perfusion regimens. The monitored metrics included vascular resistance, edema, arteriovenous oxygen gas differentials, and metabolic parameters. A final histological assessment was performed. Porcine flaps which underwent successful oxygenated perfusion showed minimal or no signs of cell necrosis at the end of the perfusion. Intermittent perfusion allowed overall better results to be obtained at 24 h and extended perfusion duration. This work provides a strong foundation for further research and could lead to new and reliable reconstructive techniques.