Giant pulmonary artery aneurysm during lung transplantation.
Central Message.
Main pulmonary artery reconstruction using the donor pulmonary artery is feasible.
For pulmonary artery aneurysm (PAA), a life-threatening complication of pulmonary arterial hypertension (PAH),1,2 heart-lung transplantation has been the preferred treatment. Recent advances have shown that bilateral lung transplantation (LTx) can achieve favorable outcomes.2 Various procedures for pulmonary artery (PA) reconstruction, including the use of aortic or full-length PA grafts harvested from donors whose hearts were not procured,1,2 have been described. A case of bilateral deceased-donor LTx in a patient with PAH and giant PAA is reported, where PA reconstruction was performed using lung grafts from a deceased donor whose heart was procured and plicating the recipient trunk to enable a direct trunk-to-trunk anastomosis. This work received approval from the institutional review board (2406-(8), April 12th, 2023). Written informed consent for the publication was obtained from the patient.
Case Presentation
A 37-year-old woman with idiopathic PAH was referred for LTx. PAA was identified when the patient was in her late 20s and it had enlarged progressively. At listing, right heart catheterization showed severe PAH with a mean PA pressure of 59 mm Hg and a preserved cardiac index of 3.51 L/min/m2. Computed tomography of the chest revealed severe compression of the left main bronchus attributable to the giant PAA (Figure 1, A), and she developed desaturation, particularly in the supine position. She received a donor call at 41 years.
Figure 1.
A, Preoperative and (B) postoperative enhanced computed tomography of the chest.
Operative Technique
Because of the left main bronchus compression by the giant PAA, induction of general anesthesia in the supine position was considered high risk. With local anesthesia, venoarterial extracorporeal membrane oxygenation (VA-ECMO) was established through the right femoral artery and vein in a slightly head-up position. The patient was then positioned supine and intubated.
Clamshell thoracotomy was performed through the fourth intercostal space. There were no significant pleural adhesions, and the PAA was exposed (Figure 2 and Video 1). Cardiopulmonary bypass was established through cannulation of the superior vena cava (SVC) and arterial cannulation through a vascular graft sewn into the ascending aorta, allowing transition to postoperative VA-ECMO.3 The femoral venous cannula was connected to cardiopulmonary bypass, and the SVC and inferior vena cava were snared. A vent was then inserted into the PAA. The bilateral pulmonary veins were divided using staplers to reduce backflow. Accordingly, the right main PA was divided, whereas the left one was transected with scissors by incising into the PAA. After dividing the main bronchi bilaterally, bilateral pneumonectomy was performed. Because of marked calcification, the aneurysmal wall was resected while preserving the PA wall button around the ligamentum arteriosum to protect the recurrent nerve. A V-shaped wedge resection was made on the ventral aspect of the enlarged recipient PA trunk 2 cm above the pulmonary valve (Figure 3, A), and the defect was primarily closed to tailor the recipient PA trunk to the donor PA, while avoiding distortion of the valve (Figure 3, B).
Figure 2.
Intraoperative view of the giant pulmonary artery aneurysm. Ao, Aorta; PAA, pulmonary artery aneurysm; RA, right atrium.
Figure 3.
Imaging of the incision and primary closure plication of pulmonary artery trunk. A, V-shaped wedge resection on the ventral aspect incision of the enlarged recipient pulmonary artery trunk approximately 2 cm above the pulmonary valve. B, Appearance after the primary closure of pulmonary artery trunk, with reduction of the trunk diameter to match the donor pulmonary artery. Ao, Aorta; SGCath., Swan-Ganz Catheter.
The donor procurement was performed in a standard fashion for the heart and lungs, leaving approximately 1 cm of the PA trunk attached to the donor lungs. The donor PA was divided in the middle of the left main PA without further trimming. The right lung was implanted first; left atrial anastomosis of the right lung was performed, leaving the sutures untied for subsequent deairing during reperfusion. The donor PA segment (right PA + trunk + part of the left PA) was routed behind the SVC and aorta to reach the recipient's PA trunk and the right PA was clumped at the hilum to prevent spontaneous reperfusion (Figure 4, A). The left lung was implanted. The divided left donor PA was reconnected to the donor PA trunk and clumped at the hilum (Figure 4, B). After the Swan-Ganz catheter was directed toward the right PA and the vent removed, the donor and recipient PA trunks were anastomosed. Ventilation of the right lung was resumed immediately before completion of the anastomosis, and reperfusion was done thereafter. (Figure 4, C). Finally, left atrial anastomosis was completed, and left lung was reperfused. Warm ischemic time was 2 hours, 37 minutes (right) and 2 hours, 8 minutes (left), respectively. The SVC canula was removed and the remaining canulae (ascending aorta through vascular graft, femoral vein to inferior vena cava) were connected to the ECMO circuit. After obtaining adequate hemostasis, chest drains were placed and temporary closure with a Gore-Tex patch was performed.
Figure 4.
Schemas and intraoperative views during pulmonary artery (PA) trunk reconstruction. A, Donor PA segment is routed behind the aorta and superior vena cava, and right PA is clumped. B, Donor left PA and PA segment are anastomosed, and left PA is clumped. C, Donor PA trunk is anastomosed with recipient PA trunk, and right PA is declumped. Asterisk indicates donor PA trunk and arrowhead indicates recipient PA trunk. Ao, Aorta.
Postoperatively, VA-ECMO was maintained for 5 days as a planned protective strategy in recipients with PAH to allow gradual cardiopulmonary adaptation and reduce reperfusion-related stress.3 However, likely because of the patient's poor preoperative condition and the intraoperative use of cardiopulmonary bypass, prolonged central VA-ECMO support was required primarily for cardiac recovery rather than for the transplanted lungs, exceeding the median duration of 3.3 days reported in our previous PAH cohort.3 She required prolonged rehabilitation because of critical-illness neuropathy but remained off oxygen from postoperative day 39 and was discharged on postoperative day 196 with no rejection. At 1 year, she was ambulatory and living independently, with normal echocardiogram and no recurrence of PAA on computed tomography (Figure 1, B).
Comment
Schwarz and colleagues1 described reconstruction using a full-length PA harvested from donors without heart procurement. Notably, in our technique, recipient's PA trunk was plicated and anastomosed with donor's relatively short PA trunk, making the technique applicable for a donor with heart procurement. Reconstruction using aortic grafts has also been described2; however, potential drawbacks include the fact that the intercostal arteries that must be securely closed to prevent bleeding, uncertain long-term durability of aortic grafts in the low-pressure pulmonary circulation, and compliance mismatch between native PA and aortic graft that may cause flow disturbance and anastomotic complications.4 Our procedure is technically demanding—minimizing warm ischemic time through careful anastomotic sequencing, timely hilar clamping, and tailored plication of the recipient PA—yet it offers practical advantages by enabling the use of donor lungs procured with the heart and avoiding the potential risks associated with aortic grafts. In conclusion, main PA reconstruction using a donor PA may be feasible even when the donor heart is procured.
Conflict of Interest Statement
The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Supplementary Data
Pulmonary artery reconstruction during bilateral lung transplantation. Video available at: https://www.jtcvs.org/article/S2666-2507(26)00108-2/fulltext.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Pulmonary artery reconstruction during bilateral lung transplantation. Video available at: https://www.jtcvs.org/article/S2666-2507(26)00108-2/fulltext.