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.

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.

Surgical and arteriographic results of bronchial artery revascularization in lung and heart lung transplantation.

BACKGROUND: On the basis of our experience with bronchial artery revascularization (BAR) in lung transplantation since its introduction in Copenhagen in 1992, a description of the surgical anatomy of the bronchial arteries and the results of attempted BAR in these patients will be presented. METHODS: Since June 1992, BAR was performed in 50 en bloc double lung, six single lung, and nine heart-lung transplantations. The location, number, type, and size of each bronchial artery identified and revascularized were recorded. Our choice of conduit for BAR was the internal mammary artery. Routine internal mammary-bronchial arteriography was performed early after the transplantation to evaluate the result of BAR. All arteriograms were carefully studied together with the surgical records. The arteriographic results after attempted BAR were classified as complete, incomplete (bilateral, hemilateral, or poor), or failed. The surgical and arteriographic anatomy of the bronchial arteries has been described, and nomenclature for the as yet unnamed bronchial arteries has been developed. RESULTS: During surgery 128 bronchial arteries were identified in the descending aorta of the 64 donor lung blocs. Internal mammary-bronchial arteriography was performed in 53 patients. BAR was complete in 32, incomplete in 18, and failed in 3. The number of bronchial arteries identified and revascularized in each case increased with experience. The central and intrapulmonary bronchial artery anatomy was described, and different patterns have been identified. CONCLUSIONS: Bronchial artery identification is reliable, but a learning process is involved. BAR is possible with a high success rate. Complete BAR is an obtainable goal in most cases.

Direct bronchial artery revascularization and en bloc double lung transplantation--surgical techniques and early outcome.

BACKGROUND: Lung transplantation including direct bronchial artery revascularization (BAR) has produced promising early results in small clinical series. METHODS: In Copenhagen primary en bloc double lung transplantation with BAR, with the left mammary artery used as conduit, has been performed in 47 patients from 1992 to the end of 1995. After introduction of the bloc into the recipient, the mammary-to-bronchial artery anastomosis is performed as the first anastomosis, allowing perfect exposure and early reperfusion. Internal mammary-bronchial artery arteriography has been performed routinely after operation. RESULTS: Bronchoscopic examination performed in all patients documented normal airway healing in 42, disturbed in two, and complicated in three. Arteriography performed in 42 patients demonstrated complete BAR in 25, incomplete in 15, and failed BAR in 2. Failed BAR was associated with complicated airway healing. The 1- and 2-year survival rate (Kaplan-Meyer) is 83%. Eleven patients have died, only one within 30 days. The total incidence of bronchiolitis obliterans syndrome at 3 years (with Kaplan-Meier technique) is 33%. Successful BAR has also been performed with an adjusted technique in a limited number of heart-lung and single lung transplantations. Our total experience of BAR in any type of lung transplantation includes 65 patients with an arteriographic BAR success rate of 94% (50 of 53 examined patients). CONCLUSIONS: Experience has improved the surgical technique and has made BAR reliable and safe, be it double lung, single lung, or heart-lung transplantation. Early results are good, but only follow-up will show if long-term results after lung transplantation will be improved by BAR. Already today, en bloc double lung transplantation with BAR is a viable alternative to sequential bilateral lung transplantation.

Human bronchial artery blood flow after lung Tx with direct bronchial artery revascularization.

The inaccuracy of measuring human bronchial artery blood flow has previously been considerable. En bloc double-lung transplantation with bronchial artery revascularization (BAR) using a single conduit offers the unique opportunity of direct measurement of the total bronchial artery blood flow. In eight en bloc double-lung-transplanted patients with complete BAR, the basal blood flow was measured by using a 0.014-in. Doppler guide wire and arteriography. The average peak velocity in the conduit was 12-73 cm/s [+/-2.1 (SD) cm/s], and the conduit diameter was 1.7-3.1 mm [+/-0.10 (SD) mm], giving individual basal flow values between 19 and 67 ml/min [+/-5 (SD) ml/min], or 0.2-1.9% of estimated cardiac output. In three patients basal measurements were followed by injection of nitroglycerin and verapamil into the conduit. This increased the bronchial artery flow to 121-262% of basal values (31-89 ml/min). The measured values appear more physiologically plausible than previous bronchial artery blood flow measurements in humans.

Revascularization of the bronchial arteries in lung transplantation: an overview.

Development of the surgical technique has minimized the incidence of airway problems associated with single as well as sequential bilateral lung transplantation. Although early results are good, long-term results remain unsatisfactory. The main problems after lung transplantation are pulmonary infections and the bronchiolitis obliterans syndrome. The bronchiolitis obliterans syndrome is usually considered to be chronic rejection, but a multifactorial genesis including airway ischemia has been suggested. We reviewed the literature relevant to direct bronchial artery revascularization during lung transplantation. Although information is limited, there are good reasons to believe that reestablishment of the dual blood supply to the transplanted lung is beneficial not only for healing of the airway anastomoses, but also for the airway and the lung responses to pathologic conditions. In small series, methods of bronchial artery revascularization have proved successful and have been associated with good early results. We believe it is justified to test the impact of direct bronchial artery revascularization on outcome after lung transplantation in large clinical series.

Does bronchial artery revascularization influence results concerning bronchiolitis obliterans syndrome and/or obliterative bronchiolitis after lung transplantation?

OBJECTIVE: To study the frequency of histological obliterative bronchiolitis and clinical bronchiolitis obliterans syndrome after en bloc double lung transplantation with bronchial artery revascularization and bilateral lung transplantation without bronchial artery revascularization. METHODS: Primary en bloc double lung transplantation with bronchial artery revascularization using the internal mammary artery as conduit was performed in 62 patients. The frequencies of obliterative bronchiolitis and bronchiolitis obliterans syndrome have been established from transbronchial biopsies and lung function measurements. Results have been analyzed in relation to the arteriographic success of bronchial artery revascularization and have been compared to results from Stanford University, obtained through personal communications. RESULTS: Survival after 1, 2, 3, 4 and 5 years was 85, 81, 69, 69, and 69%, respectively. Fifteen patients developed bronchiolitis obliterans syndrome while seven developed obliterative bronchiolitis. Survival was superior for patients with bronchial artery revascularization classified as complete or incomplete bilateral versus incomplete hemilateral, incomplete poor or failed (P = 0.016, log-rank test). For patients surviving > or = 3 months post-transplant, the post-operative baseline FEV1 was lower for patients who later developed bronchiolitis obliterans syndrome compared to patients who did not (P = 0.007). The development of bronchiolitis obliterans syndrome and obliterative bronchiolitis were both correlated to observation time post-transplant but not to the number of rejections or infections when corrected for observation time. CONCLUSIONS: In a subgroup of lung transplant patients, a process in the transplanted lungs, eventually leading to bronchiolitis obliterans syndrome diagnosis, seems to start in the donor during the transplantation and/or in the early post-operative cause. A comparison with results after bilateral lung transplantation without bronchial artery revascularization suggests that good direct bronchial artery revascularization may postpone the onset of bronchiolitis obliterans syndrome and obliterative bronchiolitis. The positive trend motivates further use of direct bronchial artery revascularization in lung transplantation.

Airway epithelium of transplanted lungs with and without direct bronchial artery revascularization.

OBJECTIVE: Normal systemic blood flow to the airways and lung parenchyma of transplanted lungs can only be re-established by direct bronchial artery revascularization. The purpose of the present study was to investigate whether such direct bronchial artery revascularization would preserve ciliary function, previously shown to be reduced in lungs transplanted without revascularization. METHODS: Twenty-five single lung transplanted patients were included in this study. Complete direct bronchial artery revascularization was achieved in eight patients. In 16 patients the procedure had either failed (n = 10) or was not attempted (n = 6). In one patient the result of the revascularization was unknown. Airway epithelium samples were obtained from the native and the transplanted lungs during bronchoscopic examinations. Airway erythema and excessive secretion were registered. The epithelium samples underwent histological examination and ciliary beat frequency was measured in vitro by video recording. Transbronchial biopsies from the transplanted lungs were examined for signs of rejection and bronchitis. RESULTS: No differences in ciliary beat frequency nor in the distribution of ciliated/de-ciliated columnar epithelium cells between native lungs and transplanted lungs with or without successful direct bronchial artery revascularization could be demonstrated. In 38% of the transplanted lungs without successful revascularization metaplastic or squamous epithelium was present, while lungs with successful revascularization had only normal columnar epithelium. Ongoing rejection or airway erythema did not influence ciliary beat frequency. Excessive secretion in the airways was the only finding associated with significantly increased ciliary beat frequency. CONCLUSIONS: Ciliary beat frequency of epithelium cells of transplanted lungs did not differ from that of native lungs and consequently direct bronchial artery revascularization did not have any demonstrable important influence. Excessive secretion in the airways was associated with increased ciliary beat frequency. The histological findings also showed that the abundance of ciliated cells was preserved in transplanted bronchi irrespective of bronchial artery revascularization. However, epithelium metaplasia was only seen in transplanted bronchi without revascularization.

Twenty-to-thirty-seven-year follow-up after repair for Tetralogy of Fallot.

OBJECTIVE: To describe the long-term prognosis after repair of Tetralogy of Fallot with pulmonary stenosis beyond 20 years. METHODS: One hundred and eighty five patients underwent corrective repair of Tetralogy of Fallot at Rigshospitalet in Copenhagen between January 1960 and July 1977. Ninety seven patients had undergone a palliative operation prior to Tetralogy of Fallot repair. All the 125 patients who were discharged from the hospital were traced through the population register and the patients alive July 1997 were contacted by mail and/or telephone and questioned about use of medicine, professional status, family status and ability to perform sport activities. RESULTS: Sixty patients died in hospital and 125 patients, 78 males and 47 females, were discharged alive. Among operative survivors, median age at operation was 12.8 years (range 0.4-41 years). Thirteen patients required a reoperation, the main indication was failed VSD closure. There were 16 late cardiac deaths, out of which seven were sudden and unexpected and three were in immediate relation to reoperations. One hundred and nine patients were alive at follow-up. The mean follow-up time was 25.5 years (range 20-38 years). Sixteen percent used cardiac drugs, 89% were, or had been, working normally (all professions from academics to hard manual labors were represented), 53% (64% of women) had given birth after the repair and 51% performed sport activities regularly. No patients were lost to follow-up. CONCLUSIONS: The vast majority of the patients seemed to live normal lives 20-37 years after Tetralogy of Fallot repair. Late deaths were cardiac in origin, including sudden death from arrhythmias. The number of late reoperation has been low. Considering the natural history of the disease, Fallot repair has proven to be a beneficial procedure even including the very early experience short after introduction of open heart surgery.

[Life-threatening postoperative rectal hemorrhage after appendectomy]. / Livstruende haemorrhagia per rectum postoperativt efter appendektomi.

A case of life-threatening haemorrhage nine days after appendicectomy is described in a 51 year old previously healthy man. Coecotomy revealed a bleeding artery near the invaginated appendiceal stump. The bleeding artery was presumably an intramural branch to the appendix from the posterior coecal artery that had not been included in the primary appendiceal ligature. This artery was presumably electrocoagulated during the appendicectomy but bleeding ensued when the coagulated tissue sloughed.

[Clinical results after en block double lung transplantation with direct bronchial revascularization. The first three and a half years' experience in Denmark]. / Kliniske resultater efter en bloc dobbeltlungetransplantation med direkte bronkial revaskularisering. De første tre et halvt års erfaring i Danmark.

En-bloc double lung transplantation with tracheal anastomosis and direct revascularization of the bronchial arteries to the left internal mammary artery has been carried out in Denmark since June 1992. Forty-seven patients (32 with alfa-1 antitrypsin deficiency, 11 with chronic obstructive pulmonary disease, two with cystic fibrosis and two with primary pulmonary hypertension), 25 men and 22 women, average age 39 years (17-64 years), have received their first double-lung transplant with bronchial artery revascularization. Arteriography of the internal mammary artery and bronchial arteries was performed in 42 (89%) of the patients from 1-150 days after the operation. Successful bronchial artery revascularization was demonstrated arteriographically in 40 patients, in two patients the arteriography failed to show bronchial artery revascularization. Arteriography was not performed in five patients due to early complications and death. Bronchoscopy showed rapid, uncomplicated airway healing in 42 patients. Mucosal necrosis under the tracheal anastomosis was found in three patients, and severe obstructive endobronchial growth of the fungus Aspergillus fumigatus was diagnosed in the last two patients. The one- and two-year survival is 83% (Kaplan-Meier). Eleven patients are dead, five due to pulmonary causes and six due to extra-pulmonary causes. Pulmonary function became normal in nearly all surviving patients between three to six months after the transplantation. In conclusion, en-bloc double-lung transplantation with bronchial artery vascularization has shown good short-term results, and the one- and two-year survival gives hope that a successful bronchial artery revascularization will improve the long-term survival following lung transplantation.

The porcine bronchial artery: surgical and angiographic anatomy.

The pig is often used in experimental studies on the significance of bronchial artery circulation, but the anatomy of this artery is only poorly described. The purpose of this study was to improve the anatomical basis for experimental studies on the porcine bronchial artery circulation. The origin of the artery from the aorta is described in 32 pigs. Heart-lung blocks were perfused with saline and removed in 16 pigs, and the broncho-oesophageal orifice was identified and cannulated. In these 16 specimens the intrapulmonary ramification was studied by angiography, and the extrapulmonary distribution and supply area by injection of Evans Blue. The broncho-oesophageal artery originated from the aorta as a single trunk in 91%. Angiography showed that each principal bronchus was accompanied by 2 bronchial artery branches far into the lung parenchyma. The central branching pattern of the artery between the aorta and the principal bronchi was divided into 3 subtypes. Evans Blue showed communication with the whole mediastinum. The anatomical relations are described. It is concluded that the broncho-oesophageal artery divides to follow each bronchus with 2 bronchial branches. A nomenclature for these branches is suggested. The pig anatomy is suited for experimental investigations on the bronchial circulation.

The porcine bronchial artery. Anastomoses with oesophageal, coronary and intercostal arteries.

Information about the existence and anatomy of arterial anastomoses with the porcine bronchial artery is lacking in the literature. Prior to basic physiological investigations in a porcine model related to lung transplantation with bronchial artery revascularisation, this study was designed to examine the anatomy of systemic arterial anastomoses with the bronchial artery system. Twenty pigs were studied in 3 groups. In 2 groups the heart-lung block was removed with all mediastinal structures. One group served for investigation of coronary-bronchial artery anastomoses and one for investigation of oesophageal-bronchial artery anastomoses. The systemic arteries to be examined were cannulated. The inflated heart-lung block was examined macroscopically with Evans blue, and radiographically after contrast injection. In the 3rd group intercostobronchial artery anastomoses were studied radiographically with the heart-lung block in situ. Coronary-bronchial artery anastomoses were demonstrated in 3 of the 5 pigs with an aortic 'pouch' technique, but contrast was very limited in 2 of these 3. Oesophageal arterial anastomoses with bronchial arterial branches and/or the pulmonary veins were demonstrated in 6 of the 7 pigs and more markedly than the coronary-bronchial anastomoses. Intercostobronchial artery anastomoses could not be demonstrated angiographically. It was concluded that the existence of coronary-bronchial and oesophageal-bronchial artery anastomoses in the pig appear to establish an arterial net between the base of the heart and the distal oesophagus. The resemblance to human oesophageal-bronchial artery anastomoses supports use of a porcine model for experimental studies.