Name: Lung Rapid Recovery Procurement Combined with Abdominal Normothermic Regional Perfusion in Controlled Donation after Circulatory Death (Video) | JoVE Journal
Uploaded: 2022-08-15T14:00:00.000+00:00
Duration: 9 min 54 s
Description: Learn lung rapid recovery procurement with abdominal normothermic regional perfusion for controlled donation after circulatory death. This technique minimizes ischemic injury and safely expands the donor pool for transplantation.

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5 minutes

The authors acknowledge all the members involved in the Lung Transplant Program at University Hospital Marqu&#233;s de Valdecilla.

These interventions are undertaken at the bedside in the intensive care unit (ICU). This protocol follows the guidelines of the University Hospital Marqu&#233;s de Valdecilla ethics committee and is in accordance with the Spanish legal framework regarding donation procedures. Informed consent was obtained from next of kin for video recording of the procedures for research. cDCD is considered in patients with catastrophic brain damage or a terminal heart or a neurodegenerative disease for whom the decision to withdraw life-sustaining therapy (WSLT) has been made. Exclusion criteria and lung evaluation are the same as with brain death donors (Table 1).
1. Premortem interventions in the donor
<ol>
	<li>Heparinization: administer intravenously a bolus of 300-500 UI/kg of heparin to the donor.</li>
	<li>Cannulation 
	NOTE: Cannulation is performed by the cardiovascular surgeon and is a sterile procedure.
	<ol>
		<li>Prepare a sterile instrumentation table, with all the equipment necessary (ECMO kit and surgical tools), as well as the electrocautery and suction system.</li>
		<li>Prepare a surgical field on the selected groin with disinfectant solution and sterile drapes.</li>
		<li>Make an 8-10 cm longitudinal incision with a no. 23 blade, controlling bleeding with electrocautery and Liga clips. Separate the wound edges with a retractor and proceed with dissection to expose the femoral artery and vein. Embrace both vessels with vessel loops for bleeding control.</li>
		<li>Select the appropriate cannula diameters according to the vessel sizes and large enough to provide a sufficient flow for organ perfusion and to prevent low-flow problems (usually 21 French).</li>
		<li>Cannulate the femoral vein, introducing first a metal wire as a guide, followed by progressive dilators to finally introduce the cannula. If bleeding is observed, perform a peri cannula 4-0 polypropylene purse string suture for control.</li>
		<li>Proceed in the same way with the femoral artery, using in this case a double lumen cannula.</li>
		<li>Cut off a 10 cm piece of the ECMO input line. Insert a straight connector with a Luer lock with a three-way stopcock assembled at one end of the piece and connect the other end of the piece to the arterial cannula (Figure 1).</li>
		<li>Purge the ECMO lines. Employ an irrigation pear with saline to fill the lines while connecting with cannulas. Connect the output ECMO line to the venous cannula and the input ECMO line to the straight connector with the three-way stopcock previously assembled to the arterial cannula. The three-way stopcock can be used for purging the system (Figure 2).</li>
		<li>Keep the ECMO lines clamped. Fix both cannulas to the groin with size 1 silk sutures to avoid displacement during transfer.</li>
		<li>Place a monitored pressure line in the femoral artery cannula and in donor&#39;s left radial artery.</li>
	</ol>
	</li>
	<li>Aortic occlusion balloon placement
	<ol>
		<li>Take, as a reference, the distance between the xiphoid process of the donor and the distal end of the arterial cannula and determine the length of the catheter to be inserted to reach the thoracic descending aorta. Set a reference mark in the balloon with a silk suture or a marker.</li>
		<li>Introduce a metal wire guide through the free lumen of the femoral artery cannula. Continue with the catheter in the same way, guided by the metal wire, and introduce it until the referenced mark.</li>
		<li>Confirm the correct position of the occlusion balloon with portable chest radiography or fluoroscopy (check radiopaque marks of the catheter above the diaphragm).</li>
		<li>Check the correct function of the occlusion balloon by filling it with a 50 cc cone syringe with saline just for 4-5 s, confirming that arterial pressure from the femoral cannula disappears while the pressure from the left radial artery is maintained (Figure 3).</li>
		<li>When the femoral pulse disappears, record the filling volume as the minimum volume to be used to block the thoracic aorta during ARNP. If flow is detected in the femoral cannula, check again for correct positioning or filling.</li>
	</ol>
	</li>
</ol>
2. Withdrawal of life-sustaining therapy (WLST) and declaration of death
<ol>
	<li>Transfer the donor connected to the ECMO system to the operation room. Prepare and drape the donor in a sterile fashion.</li>
	<li>Have the lung and abdominal preservation solutions and lines set and ready. Keep the surgical team scrubbed and sterile and ready in the adjacent operating room.</li>
	<li>Use a chronometer to register warm ischemic times. 
	NOTE: Functional warm ischemic time (FWIT), defined as the time from systolic blood pressure &#60;60 mmHg to ANRP is started for abdominal grafts and the administration of lung preservation solution through the pulmonary artery for lungs (5 min no-touch period is included). Upper limits of 30 min for the liver and pancreas and 60 min for the kidneys and lungs are considered.</li>
	<li>Allow relatives to be with their loved one during WLST until the declaration of death.</li>
	<li>Initiate WLST. Extubating is optional according to the relative&#39;s wishes. After the declaration of death, lead the relatives out from the surgical area.</li>
	<li>After the 5 min non-touch period, fill the aortic occlusion balloon with the previously determined minimum volume that ensures descending thoracic aortic block.</li>
	<li>If pressure from the left radial artery disappears, initiate ANRP. The pressure from the femoral cannula will turn into a continuous non-pulsatile flow provided by the ECMO.</li>
	<li>If flow in the radial line increases parallel to femoral pressure, stop ANRP and check the correct position and filling or clamp the thoracic aorta after another 5 min non-touch period before restoring ANRP. ANRP is not started until aortic occlusion is fully confirmed. 
	&#8203;NOTE: WLST can be performed in the operation room or in the ICU following the preference of relatives and loved ones. If it is performed in the ICU, after the 5 min no-touch period, the balloon is filled and function checked, ARNP is initiated, and the donor is transferred to the operation room where the surgical team is ready to start. If occlusion balloon malfunction is detected, ARNP is stopped until the thoracic aorta is clamped in the operation room.</li>
</ol>
3. Lung recovery and procurement technique
NOTE: Lung recovery and procurement techniques are performed by the thoracic surgeon and the&#160;transplant coordinator (Figure 4).
<ol>
	<li>Perform a medium sternotomy: proceed with a median vertical skin incision from the suprasternal notch to the tip of the xiphoid process. Extend the incision to the pectoral fascia and sternal periosteum using electrocautery.</li>
	<li>Divide the interclavicular ligament and create a plane by finger dissection behind the sternum, both at the level of the suprasternal notch and the xiphoid process. Divide the sternum with an electric saw. Place a sternal retractor and open carefully, releasing the pericardium from the posterior surface of the sternum. Control any bleeding point with electrocautery.</li>
	<li>At the same time, reintubate and ventilate the donor with 100% oxygen and a positive end-expiratory pressure of 5 cm H2O.</li>
	<li>If bronchoscopy was not performed during the donor&#39;s ICU stay as a critical patient management maneuver, it can be performed at this point by the second surgeon of the thoracic team. For the bronchoscopy, introduce a flexible bronchoscope through the endotracheal tube and evaluate the anatomy, mucosal appearance, and clear secretions.</li>
	<li>Open both the pleural cavities by longitudinal incisions in the mediastinal pleura.</li>
	<li>If there are doubts or problems about an adequate block of the supra-aortic vessels with the occlusion balloon, retract the left lung medially to expose and clamp the thoracic aorta as low as possible under direct vision.</li>
	<li>Examine the lungs performing visual and palpatory assessment. Inspect for bullae, contusion, atelectasis, pneumonia, and occult tumors. Deliver 1 L of 4 &#176;C saline in both pleural cavities.</li>
	<li>Reduce the inspired fraction of oxygen to 50%. Open the pericardium with an inverted T incision. Retract laterally the edges of the pericardium with 2-0 silk sutures fixed to the skin with mosquito forceps to expose the heart structures.</li>
	<li>Place a 4-0 polypropylene purse string suture on the main pulmonary artery below the bifurcation. Perform an arteriotomy with a no. 11 blade and dilate with curved mosquito forceps.</li>
	<li>Cannulate the pulmonary artery (PA) with a right-angled straight cannula clamped at the end. Connect the pulmonary artery cannula to the irrigation system line, assembling a straight connector with a Luer lock and a three-way stopcock. Connect the irrigation system to the lung preservation solution. Purge the lines.</li>
	<li>Start flushing 50-60 mL/kg of cold preservation solution in an antegrade fashion. Start flushing 500 &#181;g of prostaglandin diluted in 100 mL of saline at the same time through the three-way stopcock.</li>
	<li>Open the left atrial appendage or left atrium directly to allow free drainage. If areas of atelectasis are found, recruit them with short inspiratory holds at 25-30 cm H2O pressure.</li>
	<li>Once preservation is finished, remove the PA cannula. Announce to the rest of the team the intention to clamp the cava vein and start heart excision.</li>
	<li>Administer 1-1.2 L of saline solution to the donor before clamping the cava veins to avoid a decrease in pump flow due to the loss of blood venous return from the thorax.</li>
	<li>Place a cross-clamp in the inferior cava vein, making sure there is enough stump for the liver. Ligate and divide the inferior cava vein with no. 3 silk strand.</li>
	<li>Tie and divide the superior cava vein caudal to azygous with no. 3 silk strand. Secure the distal stump with a clamp.</li>
	<li>Leave the clamps remaining in the surgical field, being careful not to remove them by accident, as otherwise&#160;ANRP will be compromised. Excise the rest of the heart in a standard fashion.</li>
	<li>After heart excision, remove the lungs following the same procedure as with brain death donors, as described below.
	<ol>
		<li>Divide the inferior pulmonary ligaments, open the posterior pericardium, and expose the esophagus. Free the posterior mediastinal attachments of the lung with blunt dissection, ensuring cautious hemostasis.</li>
		<li>Dissect the pulmonary arteries away from the aorta. Isolate the trachea above the carina and pass a TA stapler around.</li>
		<li>Inflate the lungs to 50%-60% of tidal volume before withdrawing the endotracheal tube and divide the trachea. Remove any remaining attachment and extract the lung block from the donor.</li>
	</ol>
	</li>
	<li>Carefully check the thoracic cavity to detect any bleeding point, especially ligation of the azygos vein and cauterization of the vessels or capillaries from the posterior mediastinum, paratracheal structures, and surrounding tissues. Continuous blood loss may decrease the pump flow.</li>
	<li>Take the lung block to the back table and proceed with bench surgery. Separate the left and right lungs.</li>
	<li>With a Foley catheter with an inflated bulb at the tip, perform sequentially, through each pulmonary vein, a retrograde flush with 0.2-0.25 L of cold preservation solution.</li>
	<li>Pack each lung into a first sterile bag containing cold preservation solution only, surrounded by two other plastic bags, and store in a portable fridge containing ice-cold saline at 4 &#176;C.</li>
	<li>When an ex vivo lung perfusion system is indicated, follow the steps below for device connections to the pulmonary artery and trachea during lung procurement.
	<ol>
		<li>Preserve the main trunk of the pulmonary artery and not only its bifurcation during procurement.</li>
		<li>If it is not possible, take a 3-4 cm piece of the aorta to posteriorly suture it to the pulmonary artery bifurcation to replace the pulmonary artery trunk.</li>
		<li>Divide the trachea four to five rings above the carina to have enough length for intubation.</li>
		<li>Keep and store the lungs in block.</li>
	</ol>
	</li>
</ol>
4. Abdominal normothermic regional perfusion
<ol>
	<li>Initiate ANRP after filling the aortic occlusion balloon and checking for correct function.</li>
	<li>Set the following monitoring target points: pump flow = 2-2.5 L/min, continuous pressure of 60-65 mmHg in the femoral artery cannula, temperature = 37 &#176;C, pH = 7.35-7.45, hematocrit &#62;25%.</li>
	<li>Obtain blood samples from the femoral artery cannula with a 10 mL syringe after starting ANRP and every 30 min for hepatic and renal biochemistry analysis, serum lactate levels, blood arterial gas, and hematocrit values. Maintain ARNP for at least for 90-120 min.</li>
	<li>Discard the liver if alanine transaminase (ALT) or aspartate transaminase (AST) values are more than four times the upper normal limit during ANRP.</li>
</ol>
5. Liver and renal recovery
NOTE: Liver and renal recovery are performed by the hepatic surgeon and kidney surgeon, respectively.
<ol>
	<li>Perform medium laparotomy: proceed with a median vertical skin incision along the linea alba, from the xiphoid process (join to the previous sternotomy) to the pubis, curving the incision around the umbilicus. Use electrocautery to dissect the subcutaneous fat and superficial fascial layers down to the rectus sheath.</li>
	<li>Dissect through the anterior and posterior components of the rectus sheath and open the peritoneum to access the peritoneal cavity. Widen the incision by sticking the fingers into the hole created, taking care not to injure the underlying structures. Place retractors to have adequate exposure of the abdomen.</li>
	<li>Assess the macroscopic quality of the abdominal organs by performing visual and palpatory assessments. A liver biopsy can be taken if any concern is raised, as with brain death donors.</li>
	<li>If the chemistry values are correct and the macroscopic appearance is normal, validate the organs.</li>
	<li>Stop the ECMO device. Flush preservation solution for the abdominal organs via the femoral arterial cannula and use the femoral venous cannula for exsanguination.</li>
	<li>Procure abdominal organs suitable for transplantation in a standard fashion as in DBD27,28.</li>
</ol>

The authors declare there are no conflicts of interest.

Though the use of simultaneous lung cold perfusion with ARNP in cDCD was first published in 2014, very few experiences have been described for this25,26,29. Moreover, the utilization of cDCD lungs, regardless of the technique used, remains low in most countries.
The critical steps within this protocol are the use of premortem interventions; a specific methodology to ensure coronary and cerebral perfus...

Donation after circulatory death (DCD) started in Spain with uncontrolled donors. In 1996, the first national consensus document on DCD was published as a guide for the practice of uncontrolled donation after circulatory death1 (uDCD), also setting a moratorium on controlled donation after circulatory death (cDCD). In 2012, a new consensus emerged establishing the basis and the legislative framework for the practice of both uDCD and cDCD2. Currently, Spain is one of the most active countries in DCD, reaching the highest rate of donors after circulatory death in the world3. This type of donor represented nearly 35% of the total donors in 2021 in the country, with a marked decrease in uDCD and donors being exclusively cDCD4.
Organ procurement in cDCD is commonly performed using the super-rapid recovery technique5. After the declaration of death and when the non-touch period has elapsed, a rapid sternotomy and laparotomy is performed. The abdominal aorta and pulmonary artery are cannulated and flushed with cold perfusion solutions to preserve the abdominal and thoracic organs, plus topical cooling is conducted before retrieval6. In this situation, cDCD is characterized by the unpredictable consequences of warm ischemia,&#160;after the withdrawal of life-sustaining therapy. The ischemic damage during this period of agonic hypotension and progressive hypoxia, followed by the non-touch period after cardiac arrest, is further exacerbated by the later period of cold ischemia7. This combination of warm and cold ischemia seems to be detrimental, especially to abdominal grafts8,9,10,&#160;generating more reluctance among professionals in the use of these organs from cDCD donors.
To minimize these risks, an in situ preservation model, based on previous experiences from Spanish teams working in uCDC11,&#160;has been developed with growing interest. The use of extracorporeal membrane oxygenation (ECMO) systems to restore blood flow after death and before graft recovery can reverse the metabolic deviations resulting from ischemia and restore cellular physiology12. Abdominal normothermic regional perfusion (ANRP) can improve the quality of ischemic-damaged organs in cDCD13. Organ function can be assessed and improved, allowing a better selection of abdominal grafts for transplantation.
Recent international multicenter experiences provide evidence that ANRP versus the rapid recovery (RR) technique helps overcome traditional limitations in cDCD, reducing rates of post-transplant biliary complications, facilitating successful transplantation of older livers, and improving liver graft survival14,15. In kidneys, it seems to improve short-term outcomes with a lower delayed graft function and higher 1 year graft survival rates16. With this evidence, ANRP in cDCD has gained advantages over the rapid recovery technique for abdominal graft procurement and is now applied in several European countries and other parts of the world17,18.
The use of lungs from cDCD donors, however, was promptly adopted worldwide. A lung functional warm ischemic time of up to 60 min does not seem to affect survival19. In the last decade, several centers and multi-institutional experiences have reported outcomes after lung transplant from cDCD comparable to those from DBD20,21. The RR technique is the routine method for lung procurement: lungs are cooled topically and removed after being flushed with cold preservation solution22.
The first experiences combining ANRP and RR of lungs in cDCD were reported by two United Kingdom groups23,24. Years later, a variation of this technique adding premortem interventions was published25. Results present this dual procurement technique as safe and effective for both abdominal and thoracic grafts26. Obviously, the donation procedure becomes more complex. It requires technological and human resources, sufficient organizational capabilities, and has a higher economic cost. All of this may discourage professionals from starting a program. The aim of this study is to present a protocol especially focused on premortem interventions, cannulation, and aortic occlusion balloon placement, with tips and tricks learned from experience, and comment the different technical details to consider during lung retrieval when ARNP is used. At present, in the Center, cDCD donors have become the main source of grafts for thoracic and abdominal transplantation.

<table><tbody><tr><td>Vial 5 mL Heparin 1000 UI/mL</td><td>ROVI</td><td></td><td>For donor heparinization</td></tr><tr><td>&lt;strong&gt;ECMO KIT (MATERIALS FOR CANNULATION)&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Artery pressure lines</td><td>BEXEN MEDICAL</td><td>137.15</td><td>Artery pressure line por radial artery and femoral cannula</td></tr><tr><td>Bandage scissors</td><td>SURGIMEDIC</td><td>BC-881R</td><td>Shear to cut ECMO lines</td></tr><tr><td>Bio-medicus Venous cannula 21 Fr (7.0 mm) x 27.5 in (69.9 cm)</td><td>MEDTRONIC</td><td>96670-121</td><td>Venous cannula</td></tr><tr><td>Clhorhexidine solution 2%</td><td></td><td></td><td>Disinfectant solution</td></tr><tr><td>ECMO device Maquet Rotaflow</td><td>Maquet, Rasttat, Germany</td><td></td><td>ECMO system</td></tr><tr><td>Electrocautery handle</td><td>DEXTRO</td><td>SW12200</td><td></td></tr><tr><td>EndoReturn Arterial Cannula Kit&amp;nbsp; 21-23F</td><td>Edwards Lifesciences</td><td>ER21B, ER23B</td><td>Arterial cannula with a doble lumen to ECMO connection and to introduce aortic oclussion balloon</td></tr><tr><td>Ethicon LigaClip med/short 20 titanium medium</td><td>ETHICON</td><td>MCS30</td><td>Ligaclips for control bleeding during groin dissection</td></tr><tr><td>Ethicon LigaClip med/short 20 titanium small</td><td>ETHICON</td><td>MCS20</td><td>Ligaclips for control bleeding during groin dissection</td></tr><tr><td>Insertion Kit Bio-medicus 180cm</td><td>MEDTRONIC</td><td>96551</td><td>Insertion Kit for ECMO cannulas, with catheter, metal wire guide and dilators</td></tr><tr><td>Irrigation pear</td><td>MEDLINE</td><td>DYNDE 20125</td><td>Pear to be filled with saline and purge ECMO lines at the site of connection with cannulas</td></tr><tr><td>Luer cone syringe 50cc</td><td>CARDIONATUR</td><td>60ML</td><td>Syringe filled with saline to fill occlusion balloon</td></tr><tr><td>Mersilk no 1, LR-60 CONV , 75 cm</td><td>ETHICON</td><td>W562H</td><td>Silk curved suture for ECMO cannulas fixation</td></tr><tr><td>Prolene 4/0</td><td>ETHICON</td><td>W8355</td><td>polypropylene suture for purse string in femoral vessels or vascular suture</td></tr><tr><td>Prolene 5/0 , 60 cm</td><td>ETHICON</td><td>8325</td><td>polypropylene suture for vascular suture</td></tr><tr><td>Prolene 5/0, 90 cm</td><td>ETHICON</td><td>8720</td><td>polypropylene suture for vascular suture</td></tr><tr><td>Reliant Stent Graft Balloon Catheter&amp;nbsp;12F</td><td>Medtronic, Ireland</td><td>AB46</td><td>Aortic occlusion balloon introduced through femoral artery. It is used as an endoclamp</td></tr><tr><td>Scalpel blade no 11</td><td>INTRAVEN</td><td>150011</td><td></td></tr><tr><td>Scapel blade no 23</td><td>INTRAVEN</td><td>150023</td><td></td></tr><tr><td>Silicone tube</td><td>IBERHOSPITEX</td><td>0027224-P</td><td>Silicone tube to connect suction system</td></tr><tr><td>Sofsilk braided silk no 1 strands</td><td>COVIDIEN</td><td>L-12</td><td>Silk strand for ligation or bleeding control</td></tr><tr><td>Sofsilk braided silk no 3 strands</td><td>COVIDIEN</td><td>L-115</td><td>Silk strand for ligation or bleeding control</td></tr><tr><td>straight connector 3/8&quot;x3/8&quot; with Luer lock</td><td>ANDOCOR</td><td>04CS0022</td><td>Piece to connect arterial cannula with ECMO line and the three way stop-cock for pressure line and blood sampling</td></tr><tr><td>Surgical pads pack</td><td>TEXPOL</td><td>146500</td><td></td></tr><tr><td>Surgical stapler</td><td>COVIDIEN</td><td>8886803712</td><td>Stapler to close surgical wound</td></tr><tr><td>Three-way stopcock</td><td>BD CONNECTA</td><td>394501</td><td>Three way stop-cock to connect farterial cannula with pressure line</td></tr><tr><td>Vessel loop large</td><td>MEDLINE</td><td>VLMAXR</td><td>Vascular loop to embrace femoral artery and vein for bleeding control.</td></tr><tr><td>Vessel loop small</td><td>MEDLINE</td><td>VLMINR</td><td>Vascular loop to embrace femoral artery and vein for bleeding control.</td></tr><tr><td>Yankauer suction terminal 50 V</td><td>DEXTROMEDICA</td><td>349701</td><td>Suction terminal for suction while surgical dissection</td></tr><tr><td>&lt;strong&gt;SURGICAL TOOLS FOR CANNULATION&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Adson retractor 20 cm adn 33 cm</td><td></td><td></td><td></td></tr><tr><td>Aortic clamp</td><td></td><td></td><td></td></tr><tr><td>Boyd Scissors 18 cm</td><td></td><td></td><td></td></tr><tr><td>Dissection forceps without jaws 21 cm</td><td></td><td></td><td></td></tr><tr><td>Farabeuf retractor small</td><td></td><td></td><td></td></tr><tr><td>Mayo scissors straight 14 cm and 16 cm</td><td></td><td></td><td></td></tr><tr><td>Metzembaum scissors 18 cm, 20 cm and 23 cm</td><td></td><td></td><td></td></tr><tr><td>Mosquito forceps straigth and curved</td><td></td><td></td><td></td></tr><tr><td>Needle holder 18 cm and 23 cm</td><td></td><td></td><td></td></tr><tr><td>Russ dissection forceps 15 cm</td><td></td><td></td><td></td></tr><tr><td>Scalpel handle no 23 and no 21,&amp;nbsp; 21 cm</td><td></td><td></td><td></td></tr><tr><td>Surgical Dissector 23 cm</td><td></td><td></td><td></td></tr><tr><td>&lt;strong&gt;MATERIALS FOR LUNG PROCUREMENT&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>10 cc syringe</td><td>BD DISCARDIT</td><td>309110</td><td></td></tr><tr><td>Alprostadil 500 mcgs injectable solution</td><td>PFIZER</td><td></td><td>Prostaglandin injected with lung preservation solution</td></tr><tr><td>Disposable GIA cartridge Steril 6/Ca</td><td>MEDTRONIC</td><td>1141634</td><td></td></tr><tr><td>Disposable GIA stapler 60/3.8 3/Ca</td><td>MEDTRONIC</td><td>2802122</td><td>Stapler for trachea and bronquial division</td></tr><tr><td>Foley catheter 18 Ch Folysil</td><td>Folysil, Coloplast</td><td>AA6118</td><td>urinary catheter employed to canulated pulmonary veins for retrograde perfusion</td></tr><tr><td>Lung preservation solution Perfadex 1000 mL</td><td>Medisan, Uppsala, Sweeden</td><td>19811 ( box of 10 units)</td><td>Lung preservation solution</td></tr><tr><td>Mersilk no 1, LR-60 CONV , 75 cm</td><td>ETHICON</td><td>W562H</td><td>Silk curved suture for pericardium sutures</td></tr><tr><td>Paediatric Venous cannula</td><td>SORIN GROUP</td><td>V132-12</td><td>Cannula used for pulmonary artery cannulation</td></tr><tr><td>Prolene 4/0</td><td>ETHICON</td><td>W8355</td><td>polypropylene suture for purse string in pulmonary artery</td></tr><tr><td>Scalpel blade no 11</td><td>INTRAVEN</td><td>150011</td><td></td></tr><tr><td>Sofsilk braided silk no 1 strands</td><td>COVIDIEN</td><td>L-12</td><td>Silk strand to fix arterial cannula with the tourniquet</td></tr><tr><td>Sofsilk braided silk no 3 strands</td><td>COVIDIEN</td><td>L-115</td><td>Silk strand for vessel ligation</td></tr><tr><td>Sterile bags</td><td></td><td></td><td>To keep and store lungs.</td></tr><tr><td>Straigth connector 1,4&quot;/1,4&quot; with luer lock</td><td>ANDOCOR</td><td>04CS0032</td><td>Piece to connect pulmonary artery arterial cannula with preservation line and the three way stop-cock for prostaglandin</td></tr><tr><td>Three-way stopcock</td><td>BD CONNECTA</td><td>394501</td><td>Three way stop-cock to connect farterial cannula with pressure line</td></tr><tr><td>Uromatic set for irrigation double lead</td><td>MEDISAVE</td><td>TRC4007N</td><td>Irrigation system for lung preservation solution</td></tr><tr><td>Uromatic set for irrigation single lead</td><td>MEDISAVE</td><td>TRC4002</td><td>Irrigation system for lung preservation solution</td></tr><tr><td>&lt;strong&gt;SURGICAL TOOLS FOR LUNG PROCUREMENT&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Aortic cross- clamp</td><td></td><td></td><td></td></tr><tr><td>Battery-powered surgical saw</td><td></td><td></td><td></td></tr><tr><td>Cooley vascular clamp</td><td></td><td></td><td></td></tr><tr><td>Dissecting forceps 18 cm and 27,9 cm</td><td></td><td></td><td></td></tr><tr><td>Finochietto sternal retractor</td><td></td><td></td><td></td></tr><tr><td>Metzembaum scissors 20 cm and 23 cm</td><td></td><td></td><td></td></tr><tr><td>Mosquito forceps curved 12,5 cm</td><td></td><td></td><td></td></tr><tr><td>Vascular clamps</td><td></td><td></td><td></td></tr><tr><td>&lt;strong&gt;SURGICAL TOOLS FOR ABDOMINAL ORGAN PROCUREMENT&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Adson articulated retractors</td><td></td><td></td><td></td></tr><tr><td>Allis forceps 16 cm</td><td></td><td></td><td></td></tr><tr><td>Aortic cross-clamps</td><td></td><td></td><td></td></tr><tr><td>Boyd scissors 17 cm</td><td></td><td></td><td></td></tr><tr><td>Castroviejo needle holder</td><td></td><td></td><td></td></tr><tr><td>Cooley Vascular clamps</td><td></td><td></td><td></td></tr><tr><td>Crile forceps curved 18 cm</td><td></td><td></td><td></td></tr><tr><td>Davis retractor 24.5 cm</td><td></td><td></td><td></td></tr><tr><td>DeBakey dissecting forceps 19.7 cm adn 24.1 cm</td><td></td><td></td><td></td></tr><tr><td>DeBakey vascular clamps</td><td></td><td></td><td></td></tr><tr><td>Dissecting forceps 18 cm and 27.9 cm</td><td></td><td></td><td></td></tr><tr><td>Duval forceps 23 cm</td><td></td><td></td><td></td></tr><tr><td>Farabeuf retractors</td><td></td><td></td><td></td></tr><tr><td>Kidney Trays 300 cc and 500 cc</td><td></td><td></td><td></td></tr><tr><td>Kocher forceps straigth 18 cm</td><td></td><td></td><td></td></tr><tr><td>Langenbeck retractors 21 cm and 23 cm</td><td></td><td></td><td></td></tr><tr><td>Mayo scissors straigth and curved , 17 cm</td><td></td><td></td><td></td></tr><tr><td>Mosquito forceps straigth and curved, 12.5 cm</td><td></td><td></td><td></td></tr><tr><td>Needle holders 15 cm, 18 cm, 23 cm and 23 cm.</td><td></td><td></td><td></td></tr><tr><td>Pean forceps 16 cm</td><td></td><td></td><td></td></tr><tr><td>Potts scissors 19cm</td><td></td><td></td><td></td></tr><tr><td>Rochester forceps curved 24 cm</td><td></td><td></td><td></td></tr><tr><td>Rochester forceps straigth 24 cm</td><td></td><td></td><td></td></tr><tr><td>Russ dissection forceps 15 cm and 20 cm</td><td></td><td></td><td></td></tr><tr><td>Scalpel handles</td><td></td><td></td><td></td></tr><tr><td>Senn-mueller retractor 16 cm</td><td></td><td></td><td></td></tr></tbody></table>

lung rapid recovery procurement combined with abdominal normothermic regional perfusion in controlled donation after circulatory death

Lung Rapid Recovery Procurement Combined with Abdominal Normothermic Regional Perfusion in Controlled Donation after Circulatory Death

Controlled donation after circulatory death (cDCD) has contributed to increasing donor numbers all over the world. Experiences published in the last years confirm that the outcomes after lung transplantation from cDCD are similar to those from brain death donors; however, the utilization of lungs from asystole donors remains low. Several reasons may be involved: different legal frameworks among countries and centers with different premortem interventions, inadequate lung donor care before procurement, or even poor experience with cDCD procedures and protocols.
Initially, the rapid recovery technique was commonly employed for the procurement of thoracic and abdominal organs in cDCD, but, in the last decade, abdominal normothermic regional perfusion (ANRP) with extracorporeal membrane oxygenation devices has become a useful method to restore blood flow to abdominal organs, allowing their quality improvement and their functional assessment prior to transplantation. This makes the donation procedure more complex and generates doubts about injury to the grafts due to dual temperature.
The aim of this article is to describe a protocol based on a single center experience with Maastricht III donors combining lung cooling rapid recovery in the thorax and abdominal normothermic regional perfusion. Tips and tricks focused on premortem interventions and lung procurement procedure techniques are explained. This may help to minimize the reluctance among professionals to use this combined technique and encourage other donor centers to use it, despite the increased complexity of the procedure.

We performed a descriptive analysis of 30 lung transplants performed at University Hospital Marqués de Valdecilla with lungs obtained from cDCD donors in the last 2 years, 2020 and 2021. Donor and recipient demographic characteristics, technical data, postoperative outcomes, and short-term results are presented here. These results are presented as absolute numbers and percentages for categorical variables and as measures of central tendency and dispersion for continuous variables. The Kolmogorov-Smirnov test was used to ...

The protocol combines a lung cooling rapid recovery technique with abdominal normothermic regional perfusion for abdominal graft procurement in controlled asystole donors, which is a safe and useful method to expand the donor pool.

Controlled donation after circulatory death (cDCD) has contributed to increasing donor numbers all over the world. Experiences published in the last years ...

lung-rapid-recovery-procurement-combined-with-abdominal-normothermic

Research

JoVE Journal

Medicine

Marginal grafts, such as fatty livers, grafts from older donors, or livers retrieved after cardiac death (DCD) tolerate conventional, cold static storage only poorly. We developed a novel model of subnormothermic ex vivo liver perfusion for preservation, assessment, and repair of marginal liver grafts prior to transplantation.

Technique of Subnormothermic Ex Vivo Liver Perfusion for the Storage, Assessment, and Repair of Marginal Liver Grafts

We describe a method of ex vivo machine perfusion of human liver grafts at subnormothermic temperature (21 °C).

Functional Human Liver Preservation and Recovery by Means of Subnormothermic Machine Perfusion

This protocol shows a simple and flexible approach for the evaluation of new conditioning agents or strategies to increase the feasibility of cardiac donation after circulatory death.

Pre-clinical Model of Cardiac Donation after Circulatory Death

The protocol describes a large-animal (porcine) model of donation after circulatory death, followed by thoracoabdominal normothermic regional perfusion that closely simulates the clinical scenario in heart transplantation, and has the potential to facilitate therapeutic studies and strategies.

Large-Animal Model of Donation after Circulatory Death and Normothermic Regional Perfusion for Cardiac Assessment

In this protocol, a model of porcine orthotopic liver transplantation after static cold storage of donor organs for 20 h without the use of a veno-venous bypass during engraftment is described. The approach uses a simplified surgical technique with minimization of the anhepatic phase and sophisticated volume and vasopressor management.

Porcine Liver Transplantation Without Veno-Venous Bypass As an Extended Criteria Donor Model

Here, we present an assessment protocol of a heterotopically implanted heart after normothermic ex situ preservation in the rat model.

Rat Model of Normothermic Ex-Situ Perfused Heterotopic Heart Transplantation

This protocol outlines the methodology of establishing a porcine model utilizing variable temperature-controlled Machine Perfusion (MP) for the preservation of the donor liver, followed by orthotopic liver transplantation (OLTx). It aims to promote the success rate of OLTx using donor donation after circulatory death (DCD) liver and establish a stable model.

Preservation of Porcine Donation after Circulatory Death (DCD) Liver by Perfusion and Orthotopic Liver Transplantation

The objective is to develop a new ex vivo lung perfusion (EVLP) model in rats that can sustain consistent lung function for 4 h throughout EVLP and furnish the industry with implementation specifics that will offer a sturdy method for applying EVLP to rodent models.

Establishment of a Novel Ex Vivo Lung Perfusion System for Rat Lungs After Circulatory Death

The protocol here describes a high-fidelity porcine model of heart transplantation following donation after circulatory death utilizing ex vivo perfusion of the allograft.

A High-Fidelity Porcine Model of Orthotopic Heart Transplantation Following Donation after Circulatory Death

This protocol presents a rat ex-vivo lung perfusion model incorporating a transient exposure to a calibrated thermal stress, promoting endogenous protective mechanisms for the therapeutic reconditioning of damaged lung grafts. The approach is scalable and reproducible and supports the development of non-drug therapies to improve lung transplant success.

Thermal Preconditioning During Ex-vivo Lung Perfusion for the Rehabilitation of Damaged Lung Grafts before Transplantation

Learn lung rapid recovery procurement with abdominal normothermic regional perfusion for controlled donation after circulatory death. This technique minimizes ischemic injury and safely expands the donor pool for transplantation.

Lung Rapid Recovery Procurement Combined with Abdominal Normothermic Regional Perfusion in Controlled Donation after Circulatory Death (Video) | JoVE Journal

Lung Rapid Recovery Procurement Combined with Abdominal Normothermic Regional Perfusion in Controlled Donation after Circulatory Death

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