ANASTOMOTIC PITFALLS IN LUNG TRANSPLANTATION

Although airway, arterial, and venous connections required for lung tr ansplantation appear simple, in practice we have encountered morbid ea rly stenosis and obstructions, which are now avoided by technical modi fications gradually made since 1985 in 134 cases (60 single lung and 7 4 double lung). Our initial eight double lung transplant procedures we re done with tracheal anastomoses and omental wraps, but ischemic disr uption, with a 75% (6 of 8) rate of complications, resulted in the sub sequent use of bibronchial connections. A total of 192 bronchial anast omoses were reviewed (60 single lung, 66 double lung). Although all an astomoses were constructed between the donor trimmed to one to two rin gs above the upper lobe origin and the host divided at its emergence f rom the mediastinum, the suture technique has evolved. Nine (32%) of 2 8 cases with early bronchial anastomoses with end-to-end suture and in tercostal muscle wrap had ischemic or stenotic complications, but the telescoping technique without wrap in 164 bronchial anastomoses reduce d the problem to 12% (19 of 164). Twelve anastomoses required temporar y intraluminal stenting. Vascular anastomotic obstructions occurred in five arterial (excessive length 2, short allograft artery 1, restrict ive suture or clot 2) and two venous (excessive length 1, restrictive suture or clot 1) connections. Suspicion of arterial obstruction was p rompted by persisting pulmonary hypertension and reduced flow to the a llograft measured by postoperative nuclear scan and hypoxia. Venous ob structions were suggested by persisting radiographic and clinical pulm onary edema. Modifications of earlier techniques have improved our ear ly success in lung transplantation and might be considered by others e ntering this demanding field.