Adaptation over a wide range of donor graft lung size discrepancies in living-donor lobar lung transplantation.

Living-donor lobar lung transplantation (LDLLT), unlike deceased donor lung transplantation, often involves a wide range of size discrepancies between donors and recipients. The aim of this study was to evaluate the function of donor lung grafts in the recipient thorax in 14 cases of bilateral LDLLT involving 28 successfully transplanted lower-lobe grafts. Pulmonary function tests and three-dimensional computed tomography (3D-CT) volumetry were performed perioperatively. According to 3D-CT size matching, donor graft volumes ranged from 40% to 161% of the hemilateral thoracic volumes of the recipients. Graft forced vital capacity (FVC) values increased over time, reaching 102 ± 39% of preoperatively estimated values at 12 months postoperatively. Graft volumes also increased over time, reaching 120 ± 38% of the original values at 12 months postoperatively. Undersized donor grafts expanded more after LDLLT than oversized donor grafts, producing greater FVC values than those estimated preoperatively, whereas oversized donor grafts became inflated to their original size and maintained FVC values that approached the preoperative estimates. Thus, donor grafts were found to overinflate or underinflate to the extent that they could preserve their native function in the new recipient's environment.

Thin-section computed tomography findings before and after azithromycin treatment of neutrophilic reversible lung allograft dysfunction.

OBJECTIVES: Recently a novel subgroup of bronchiolitis obliterans syndrome (BOS) has been described in patients after lung transplantation with high neutrophil counts in broncho-alveolar lavage and recovery of lung functional decline with azithromycin treatment. We aimed to describe the thin-section computed tomography (CT) findings of these neutrophilic reversible allograft dysfunction (NRAD) patients before and after azithromycin. METHODS: A cohort of 100 lung transplant recipients with BOS were treated with azithromycin and underwent lung function testing, broncho-alveolar lavage and CT before azithromycin treatment and during follow-up. The 200 CT data sets were scored for bronchial dilatation, mucus plugging, centrilobular abnormalities, airway wall thickening, consolidation, ground glass and end-expiratory air trapping. RESULTS: NRAD was characterized by more centrilobular abnormalities on CT (p = 0.03 for prevalence and p = 0.06 for severity) compared to non-responders. At follow-up NRAD patients showed improvement in all CT abnormalities including air trapping, but the degree of improvement in all CT abnormalities was significantly different between responders and non-responders (who showed progression of bronchus dilatation, consolidation and air trapping). CONCLUSIONS: Within BOS patients those with NRAD differ from azithromycin non-responders by more centrilobular abnormalities on CT before azithromycin and improvement in bronchus dilatation, consolidation and air trapping during treatment.

Medication-induced periostitis in lung transplant patients: periostitis deformans revisited.

We report five cases of diffuse periostitis resembling hypertrophic osteoarthropathy and perostitis deformans in lung transplantation patients on chronic voriconazole, a fluoride-containing compound. Although drug-related periostitis has long been known, the association of lung transplant medication with periostitis was only recently introduced in the literature. To our knowledge, imaging findings have not been fully characterized in the radiology literature. Imaging features along with clinical history help to distinguish this benign condition from other disease entities. In this article, we review the current literature and illustrate the variety of imaging characteristics of this entity so that interpreting radiologists can make accurate diagnoses and avoid unnecessary work up.

Preoperative graft volume assessment with 3D-CT volumetry in living-donor lobar lung transplantations.

To determine the effectiveness of living-donor lobar lung transplantation (LDLLT), it is necessary to predict the recipient's postoperative lung function. Traditionally, Date's formula, also called the segmental ratio, has used the number of lung segments to estimate the forced vital capacity (FVC) of grafts in LDLLT. To provide a more precise estimate of graft FVC, we calculated the volumes of the lower lobe and total lung using three-dimensional computed tomography (3D-CT) and the volume ratio between them. We calculated the volume ratio in 52 donors and tested the difference between the segmental volume ratios with a one-tailed t-test. We also calculated the predicted graft FVC in 21 LDLLTs using the segmental ratio pFVC(c) and the volume ratio pFVC(v), and then found the Pearson's correlation coefficients for both pFVC(c) and pFVC(v) with the recipients' actual FVC (rFVC) measured spirometrically 6 months after surgery. Significant differences were found between the segmental ratio and the average volume ratio for both sides (right, p＝0.03;left, p＝0.0003). Both pFVC(c) and pFVC(v) correlated significantly with rFVC at 6 months after surgery (p＝0.007 and 0.006). Both the conventional and the volumetric methods provided FVC predictions that correlated significantly with measured postoperative FVC.

Radiopharmaceutical considerations for using Tc-99m MAA in lung transplant patients.

OBJECTIVES: To elucidate radiopharmaceutical considerations for using technetium Tc-99m albumin aggregated (Tc-99m MAA) in lung transplant patients and to establish an appropriate routine dose and preparation procedure. SETTING: Tertiary care academic hospital during May 2007 to May 2009. PRACTICE DESCRIPTION: Nuclear pharmacist working in nuclear medicine department. PRACTICE INNOVATION: Radiopharmaceutical considerations deemed important for the use of Tc-99m MAA in lung transplant patients included radioactivity dose, particulate dose, rate of the radiolabeling reaction (preparation time), and final radiochemical purity. Evaluation of our initial 12-month experience, published literature, and professional practice guidelines provided the basis for establishing an appropriate dose and preparation procedure of Tc-99m MAA for use in lung transplant patients. MAIN OUTCOME MEASURES: Radiochemical purity at typical incubation times and image quality in subsequent lung transplant patients imaged during the next 12 months. RESULTS: Based on considerations of radioactivity dose, particulate dose, rate of the radiolabeling reaction (preparation time), and final radiochemical purity, a routine dose consisting of 3 mCi (111 MBq) and 100,000 particles of Tc-99m MAA for planar perfusion lung imaging of adult lung transplant patients was established as reasonable and appropriate. MAA kits were prepared with a more reasonable amount of Tc-99m and yielded high radiochemical purity values in typical incubation times. Images have continued to be of high diagnostic quality. CONCLUSION: Tc-99m MAA used for lung transplant imaging can be readily prepared with high radiochemical purity to provide a dose of 3 mCi (111 GBq)/100,000 particles, which provides images of high diagnostic quality.

Imaging of lung transplantation: review.

OBJECTIVE Lung transplantation is an established treatment for end-stage pulmonary disease. Complications of lung transplantation include airway stenosis and dehiscence, reimplantation response, acute rejection, infection, posttransplantation lymphoproliferative disorder, and bronchiolitis obliterans syndrome. The incidence of graft rejection and airway anastomosis experienced in the early years of lung transplantation have been significantly reduced by advances in immunosuppression and surgical techniques. Infection is currently the most common cause of mortality during the first 6 months after transplantation, whereas chronic rejection or obliterative bronchiolitis is the most common cause of mortality thereafter. This article reviews the radiologic findings of different surgical techniques as well as the common early and late complications of lung transplantation. CONCLUSION Radiology plays a pivotal role in the diagnosis and management of complications of lung transplantation. Advancements in surgical technique and medical therapy influence the spectrum of expected radiologic findings. Familiarity with the radiologic appearances of common surgical techniques and complications of lung transplantation is important.

Pseudallescheria boydii (Scedosporium species) in 3 lung transplant recipients: computed tomography findings and literature review.

OBJECTIVE: The objective of our study was to evaluate chest computed tomography (CT) findings in 3 lung transplant recipients infected with Pseudallescheria boydii complex or its asexual anamorph, Scedosporium apiospermum, 2 after double-lung transplant and 1 after single-lung transplantation. Awareness and early diagnosis of this rare but potentially lethal infection are important, as it is largely refractory to treatment with the antifungal agents of choice used for the more common Aspergillus species. Computed tomography investigation focused on the location, quality, and appearance of the various pulmonary lesions as well as the presence of cavitation, mediastinal lymphadenopathy, and pleural effusions. A literature review of previous lung and other solid organ transplant recipients infected with pulmonary Pseudallescheria boydii was also conducted and compared with our findings. CONCLUSION: While the high-resolution CT findings of pulmonary P. boydii infection are nonspecific and markedly similar to the manifestations of the more common Aspergillus species, awareness of this rare opportunist is important, given the high mortality associated with disseminated infection and the relative success possible with timely and appropriate treatment. The most common CT abnormalities present in our 3 patients included hilar and paratracheal adenopathy, noncavitary tree-in-bud nodules surrounded by ground-glass opacities, and airway thickening.

Assessment of mean transit time in the engrafted lung with 133Xe lung ventilation scintigraphy improves diagnosis of bronchiolitis obliterans syndrome in living-donor lobar lung transplant recipients.

OBJECTIVE: Staging of bronchiolitis obliterans syndrome (BOS) following lung transplantation is based on declines in forced expiratory volume in 1 s (FEV(1)). The aim of this study was to evaluate the usefulness of (133)Xe ventilation scintigraphy in the early detection of BOS following living-donor lobar lung transplantation (LDLLT), to compare (133)Xe washout imaging with computed tomography (CT) findings for early detection of BOS following LDLLT, and to evaluate (133)Xe washout imaging by quantitative analyses. METHODS: Subjects comprised 30 double-lung recipients and 1 single-lung recipient, who had undergone LDLLT at our institution and survived more than 1 year. Clinically diagnosed BOS developed in six recipients. Declines in graft function were evaluated using a combination of three methods, namely, dynamic spirometry, high-resolution CT (HRCT), and (133)Xe ventilation scintigraphy. Findings for all transplanted lungs were compared between CT and (133)Xe washout imaging. (133)Xe washout imaging was assessed using mean transit time (MTT) of bi-and unilateral lungs. Correlations between MTT of bilateral lungs and FEV(1)% were evaluated. Differences in MTT between BOS and non-BOS lungs, and between non-BOS and donor lungs were also evaluated on unilateral lungs. Appropriate cut-off values of MTT of unilateral lungs were set for the diagnosis of BOS. RESULTS: In all six BOS cases, prolonged-washout images of engrafted lungs revealed early-phase BOS with declines from baseline FEV(1), whereas only one BOS case could be detected using early CT findings of BO (bronchodilatation, decrease in number and size of pulmonary vessels, thickening of septal lines, and volume reduction). A significant correlation was identified between MTT and FEV(1)% (r = -0.346, P < 0.0001). MTT of unilateral lungs was significantly longer in BOS lungs than in non-BOS lungs (P < 0.0001). The cut-off MTT of unilateral lungs for the diagnosis of BOS was set at 64.77 s. CONCLUSIONS: Our data show that (133)Xe washout imaging offers excellent potential for early detection of BOS compared with early CT findings. Using (133)Xe washout imaging and MTT with radioactive tracer offers a noninvasive indication of selective ventilatory function in engrafted lungs following LDLLT. MTT appears useful for identifying BOS following LDLLT and allows quantitative evaluation of graft function in unilateral lungs.

Postoperative complications of lung transplantation: radiologic findings along a time continuum.

In the past decade, lung transplantation has become established as an accepted therapy for end-stage pulmonary disease. Complications of lung transplantation that may occur in the immediate or longer postoperative term include mechanical problems due to a size mismatch between the donor lung and the recipient thoracic cage; malposition of monitoring tubes and lines; injuries from ischemia and reperfusion; acute pleural events; hyperacute, acute, and chronic rejection; pulmonary infections; bronchial anastomotic complications; pulmonary thromboembolism; upper-lobe fibrosis; primary disease recurrence; posttransplantation lymphoproliferative disorder; and native lung complications such as hyperinflation, malignancy, and infection. Radiologic imaging--particularly chest radiography, computed tomography (CT), and high-resolution CT--is critical for the early detection, evaluation, and diagnosis of complications after lung transplantation. To enable the selection of an effective and relevant course of therapy and, ultimately, to decrease morbidity and mortality among lung transplant recipients, radiologists at all levels of experience must be able to recognize and understand the imaging manifestations of posttransplantation complications.

[Visual assessment of functional lungs parenchyma on HRCT and (3)He-MRI in patients after single lung transplantation: comparison with quantitative volumetric results]. / Visuelle Abschätzung der funktionellen Lungenanteile in der HRCT und (3)He-MRT bei Patienten nach Einzel-Lungentransplantation: Vergleich mit der absoluten Volumetrie.

PURPOSE: Visual assessment of the ventilation using HRCT and (3)He-MRI in patients after single lung transplantation (SLTX). Analysis of specific ventilation defects found with (3)He-MRI and morphological changes found with HRCT. MATERIALS AND METHODS: We evaluated 8male patients (54 +/- 6 years) suffering from emphysema and six patients (3males and 3 females, 58 +/- 9.5 years) suffering from idiopathic pulmonary fibrosis (IPF) after SLTX. The morphological changes at HRCT were classified and localized. In (3)He-MRI (2D FLASH), 10 to 14 slices (slice thickness 10 mm, gap 5 mm) were acquired in coronal orientation to cover the whole lung. Ventilation defects were localized and characterized. The visually estimated ventilation was recorded on a 5-point scoring system. A double threshold technique was applied to volumetric quantification in (3)He-MRI to serve as internal reference. RESULTS: We found no correlation between morphological changes in HRCT and ventilation defects in (3)He-MRI. The visual assessment of ventilation in (3)He-MRI was sufficient in patients with emphysema, but this was not confirmed in patients with IPF. The visual assessment in HRCT did not correlate with the volumetric evaluation in both conditions. CONCLUSION: The various ventilation defects were not linked to specific morphological changes. For the visually assessed ventilation in patients with emphysema, (3)He-MRI is superior to HRCT.

Bronchial artery perfusion scintigraphy to assess bronchial artery blood flow after lung transplantation.

UNLABELLED: The bronchial arterial system is inevitably interrupted in transplanted lungs when removing the organs from the donor, but it can be reestablished by direct bronchial artery revascularization (BAR) during implantation. The purpose of this study was to visualize and quantify the distribution of bronchial artery perfusion after en bloc double lung transplantation with BAR, by injecting radiolabeled macroaggregated albumin directly into the bronchial artery system. METHODS: BAR was performed using the internal mammary artery as conduit. Patients were imaged 1 mo (n = 13) or 2 y (n = 9) after en bloc double lung transplantation with BAR. Immediately after bronchial arteriography, 100 MBq macroaggregated albumin (45,000 particles) were injected through the arteriographic catheter. Gamma camera studies were then acquired in the anterior position. At the end of imaging, with the patient remaining in exactly the same position, 81mKr-ventilation scintigraphy or conventional intravenous pulmonary perfusion scintigraphy or both were performed. Images were evaluated by visual analysis, and a semiquantitative assessment of the bronchial arterial supply to the peripheral parts of the lungs was obtained with conventional pulmonary scintigraphy. RESULTS: The bronchial artery scintigraphic images showed that the major part of the bronchial arterial flow supplied central thoracic structures, but bronchial artery perfusion could also be demonstrated in the peripheral parts of the lungs when compared with conventional pulmonary scintigraphy. There were no differences between scintigrams obtained from patients studied 1 mo and 2 y post-transplantation. CONCLUSION: Total distribution of bronchial artery supply to the human lung has been visualized in lung transplant patients. This study demonstrates that this nutritive flow reaches even the most peripheral parts of the lungs and is present 1 mo as well as 2 y after lung transplantation. The results suggest that bronchial artery revascularization may be of significance for the long-term status of the lung transplant.

Usefulness of bronchoalveolar cell profile in early detection of canine lung allograft rejection.

To evaluate the value of a bronchoalveolar cell profile in the early detection of canine lung allograft rejection, bronchoalveolar lavages were done serially in mongrel dogs before and after single lung transplantation. The dogs were divided into 3 groups. In group 1, neither donor nor recipient dogs were treated with cyclosporine. In group 2, only donors were treated with cyclosporine, orally at a single dose of 20 mg/kg/day for 3 days prior to single lung transplantation. In group 3, only recipients were treated with cyclosporine (20 mg/kg/day) for 9 days after single lung transplantation. A marked increase in the number of bronchoalveolar cells and their cell differentials, and of major histocompatibility complex (MHC) class II-positive cells obtained from the grafted lungs after lung transplantation, was seen in groups 1 and 2. The changes in bronchoalveolar cell profile obtained from the rejecting grafted lungs were significantly different from those obtained from the normal and native lungs (P less than 0.05). In group 3, the bronchoalveolar cell profile obtained from the grafted lungs did not significantly differ from those present in normal and native lungs during the period of cyclosporine treatment after lung transplantation. On various days after withdrawal of cyclosporine treatment, bronchoalveolar cell profiles obtained from the grafted lungs showed similar changes to those observed in groups 1 and 2. Abnormal changes in bronchoalveolar cell profiles obtained from the grafted lungs heralded the appearance of abnormalities detected by chest X-ray films. Our results indicate that serial measurements of bronchoalveolar cell profile may serve as a useful means for early detection of canine lung allograft rejection.

Reestablishment of lymphatic drainage after canine lung transplantation.

The technique of pulmonary lymphoscintigraphy was used to evaluate pulmonary lymphatic flow and to assess reestablishment of lymphatic drainage after lung transplantation. A first group of six control dogs underwent percutaneous transthoracic injection of a radiocolloid into the periphery of the left upper and lower lobes. Radiocolloids are large molecules tagged with radioisotopes that are absorbed only through lymph and are concentrated in tributary lymph nodes. Twenty-four hours after injection the dogs underwent scintigraphic studies of the chest and upper part of the abdomen. Mediastinal lymph nodes were visualized in all animals. A second group of four dogs underwent partial reimplantation of the native left lung, with interruption of all lymphatic connections between the lung and mediastinum. Lymphoscintigraphic studies of the left lung were obtained on the third postoperative day and then weekly for 4 weeks. Three of the four dogs in this group did not have visible mediastinal nodes 3 days after the operation. Nodes were visualized in all animals at 1 week and at all following studies. A third group of five dogs were subjected to left lung allotransplantation by means of standard surgical techniques, as well as immunosuppression. The animals were studied with radiocolloid injections and lung lymphoscintigraphy at weekly intervals for 6 weeks. Mediastinal nodes were visualized for the first time 2 to 4 weeks after the operation and at every subsequent study. We conclude that lung lymphoscintigraphy is a reliable technique for the study of pulmonary lymphatic flow. This experiment demonstrates that lymphatic drainage after lung transplantation is reestablished as early as the second postoperative week.

The donor lung: infectious and pathologic factors affecting outcome in lung transplantation.

The prevalence of posttransplantation pulmonary infection and the importance of this complication with respect to morbidity in patients undergoing lung transplantation is significant. Over a 1-year period, case histories of all patients undergoing lung transplantation at Barnes Hospital, Washington University, were reviewed to examine the importance of organisms isolated in the donor lung in the development of subsequent invasive infection in transplant recipients. Twenty-eight of 29 bronchial washings (97%) taken from donors before retrieval grew at least one organism. The most common organisms identified were Staphylococcus and Enterobacter. In 12 of these cases (43%), similar organisms were isolated from the tracheobronchial tree of the recipients, and 6 of these recipients (21%) subsequently had invasive pulmonary infections as a result of the organism originally isolated in the donor. We recommend that antibiotic coverage in transplant recipients should be initiated on the basis of Gram stain results and modified on the basis of cultures obtained from the donor lungs. Pathologic analysis of donor lung tissue taken before transplantation was available in 12 cases. Four donors had histologic evidence of established pneumonia in the donor lung, and infections then developed in the recipients. One other patient who received a lung that had widespread bone marrow emboli and subsequent infarction later had a complete anastomotic dehiscence. An additional patient had profound early donor lung dysfunction without any evidence of rejection or infection. Pathologic findings from the donor in this case demonstrated preexistent acute vasculitis with emboli. We suggest that as preservation techniques improve, the opportunities for closer scrutiny of donor lung tissue before implantation will become increasing desirable and feasible.

Regional distribution of lung perfusion and ventilation at rest and during steady-state exercise after unilateral lung transplantation.

Cardiopulmonary exercise testing has previously demonstrated a reduced maximum oxygen uptake and anaerobic threshold, as well as abnormal wasted ventilation fraction and gas exchange after unilateral lung transplantation. To further explain the mechanisms of these abnormalities, we assessed the regional distribution of pulmonary blood flow and ventilation at rest and during steady-state exercise in nine recipients of unilateral lung transplants. Krypton-81 (81mKr) aerosol and technetium-99m (99mTc) were utilized to assess lung ventilation (V) and perfusion (Q), respectively. The digitalized images were trisected to analyze apical, mid-, and basilar lung perfusion and ventilation in both the transplanted and native lung, both at rest and steady-state upright exercise. Results were compared with previously reported data obtained in normal subjects in our laboratory using the identical technique. At rest, 75 +/- 13 percent of perfusion was directed to the transplanted lung; however, the corresponding fractional ventilation was only 67 +/- 14 percent. During exercise, there was no significant change in fractional perfusion or ventilation. Resting apical perfusion in the transplanted lung was higher than normal in four patients and comparable to normal in five patients. In contrast to the augmentation of apical perfusion observed in normal subjects during upright exercise, none of our patients increased the regional perfusion to the apices during exercise in either transplanted or native lungs. These unexpected responses suggest either more maximal allograft apical recruitment at rest due to the increased allograft perfusion or an abnormality in the apical pulmonary vasculature after transplantation. Furthermore, the relative mismatch in ventilation and perfusion in transplanted and native lungs suggests regions of high V/Q in the native, and low V/Q in the transplanted lung. This mismatch is most pronounced in recipients of single lung transplants for pulmonary vascular disease.

Detection of canine allograft lung rejection by pulmonary lymphoscintigraphy.

We previously demonstrated that lymphoscintigraphy could be used to study pulmonary lymphatic flow. Radiocolloids, high-molecular-weight proteins tagged with radioactive markers, are injected percutaneously in the periphery of the lung. These molecules enter the lymph, are transported via lymphatic channels, and concentrate in the tributary hilar and mediastinal lymph nodes, where they can be visualized by nuclear scan. The goal of this study was to determine whether pulmonary lymphoscintigraphy could be used to detect allograft rejection after lung transplantation. Thirteen mongrel dogs underwent left lung allotransplantation. Cyclosporine 15 mg/kg per day and azathioprine 1 mg/kg per day were given orally for postoperative immunosuppression. Lymphoscintigraphic studies were obtained 1 week after the operation and then at weekly intervals. In five dogs (group A), immunosuppression was continued until the animal died or was put to death 6 weeks later. Lymphoscintigraphy demonstrated reestablishment of lymphatic drainage between the lung graft and the mediastinum in all the animals 2 to 4 weeks after transplantation. In eight dogs (group B), immunosuppression was discontinued after reestablishment of graft lymphatic drainage was documented by two consecutive lymphoscintigraphic studies. The dogs continued to be studied with weekly scans. In group B, lymphatic drainage from the lung graft to the mediastinum disappeared 1 to 4 weeks after immunosuppression was stopped. Rejection was diagnosed clinically and confirmed histologically with open lung biopsies and/or autopsies in all animals. This study shows that canine allograft lung rejection is associated with disappearance of lymphatic drainage from lung graft to mediastinum, which can be documented by pulmonary lymphoscintigraphy, a minimally invasive technique that can be easily repeated. Pulmonary lymphoscintigraphy may be useful for early detection of lung allograft rejection.

Prolonged lung allograft survival with a short course of FK 506.

We examined the hypothesis that FK 506 would induce graft acceptance after lung transplantation. Left lung allotransplantation was performed in size-matched mongrel dogs allocated to control (no immunosuppression, n = 3) and FK 506 (n = 5) groups. FK 506 (1.2 mg/kg intramuscularly every day) was given on posttransplantation days 0, 1, and 2. No other immunosuppressive agents were administered to either group. Chest x-ray and transplant lung physiologic assessments were performed on the fifth day and weekly thereafter. On day 29 an open lung biopsy and a third-party skin graft were performed. Lymphocytes were harvested and frozen from the recipient peripheral blood before transplantation and on days 8 and 29 afterwards for assessment in mixed lymphocyte reaction. Dogs were killed when their chest x-ray films showed allograft opacification or when the skin graft was rejected. Control lungs were all rejected after a median of 5 days. In the FK 506 group, one of five dogs aspirated during the fifteenth-day assessment and was killed, on the twenty-ninth day, because of severe rejection. At day 29, in the other four dogs, the transplanted lung yielded an arterial oxygen tension of 613 +/- 25 mm Hg (mean +/- standard deviation) and lung biopsy specimens showed no abnormalities histologically. These four dogs rejected third-party skin grafts after a median of 10 days. In two FK 506 dogs, mixed lymphocyte reaction at day 8 showed suppression of proliferation responses against donor and third-party lymphocytes. By day 29 responses against third-party lymphocytes had returned to almost preoperative levels, whereas antidonor responses were still suppressed. After skin graft rejection and killing, one of four dogs showed no sign of rejection, and the other three showed minimal to mild lung rejection at the time they were killed. We conclude that a 3-day course of 1.2 mg/kg of FK 506 induced prolonged graft acceptance after lung transplantation in dogs.

Pulmonary vein obstruction following single lung transplantation.

Angiographic documentation after single lung transplant showed pulmonary venous obstruction due to compression by the omental pedicle. Retransplantation is described, and this complication is examined.

Medium-term patency and anatomic changes after direct bronchial artery revascularization in lung and heart-lung transplantation with the internal thoracic artery conduit.

OBJECTIVE: Our purpose was to study the 2-year patency of direct bronchial artery revascularization in lung transplantation. We wanted to clarify whether the revascularized bronchial artery system is functional after 2 years, whether bronchial artery vascularity changes with time, and whether posttransplantation bronchial artery disease is arteriographically evident after 2 years. METHODS: Bronchial artery revascularization is performed by anastomosing the internal thoracic artery to as many bronchial artery orifices in the donor descending aorta as possible. Twenty-three patients surviving 2 years or more have had internal thoracic artery-bronchial arteriography performed 1 month and 2 years after transplantation. One-month and 2-year arteriograms have been compared. RESULTS: Two-year patency of the internal thoracic artery conduit was 100%. The appearance of the bronchial arteries was unchanged after 2 years in 11 patients. A unilateral or bilateral increase in vascularity was found in two and seven patients, respectively. In three patients new vessels, not visible on the first arteriogram, had appeared. In four patients one or more small vessels visible on the first arteriogram had disappeared on the second arteriogram. We have found no arteriographic signs of bronchial artery disease, such as stenosis of the bronchial arteries, and no arteriographic evidence of arteriosclerotic disease in the internal thoracic artery. CONCLUSION: The internal thoracic artery is an excellent conduit for bronchial artery revascularization, with a 2-year patency of 100% in 23 patients. Only minor changes in the bronchial arteriograms have been found.

Intraoperative transesophageal echocardiographic assessment of vascular anastomoses in lung transplantation. A report on 18 cases.

BACKGROUND: In patients after lung transplantation, dysfunction of pulmonary venous and artery anastomoses leading to reoperation is described. METHODS AND RESULTS: Pulmonary artery and vein anastomoses were evaluated intraoperatively by monoplane transesophageal echocardiography (TEE) in 18 patients undergoing lung transplantation (nine right, five left single lung transplantations, and four bilateral transplantations). All 13 right pulmonary artery anastomoses and all 22 pulmonary vein anastomoses could be visualized by TEE. None of the nine left pulmonary anastomoses could be visualized. Of the 13 right pulmonary anastomoses, 12 were considered normal, their diameter ranging from 1 to 1.7 cm (mean, 1.26 +/- 0.24 cm). A moderate stenosis of one pulmonary artery anastomosis was identified but did not require reoperation. Of the 22 pulmonary vein anastomoses, 16 were considered normal, their diameter being > 0.5 cm and the peak systolic flow velocity < or = 1 m/s at the location of the anastomoses. In five cases, the anastomoses were not considered normal, but reoperation was not indicated. In one case, a severe stenosis of pulmonary vein associated with graft dysfunction led to an early reoperation. CONCLUSION: Intraoperative TEE during lung transplantation contributes to the immediate evaluation of pulmonary vein and right pulmonary artery anastomoses and allows immediate surgical correction. Further investigations are necessary to establish threshold values requiring reoperation.