Faculty Bibliography

OBJECTIVE:Transplant renal artery stenosis (TRAS) after renal transplantation is a common cause of graft dysfunction and failure. Endovascular intervention in the form of percutaneous transluminal angioplasty (PTA) and stenting has rapidly become the dominant treatment modality for the TRAS. There is a paucity of clinical data on use of drug-eluting stent (DES) for TRAS. We investigated the outcomes of patients with clinically significant TRAS undergoing DES placement. METHODS:A retrospective review of patients with clinically significant TRAS undergoing PTA with DES placement from June 2014 to April 2021 was conducted. Patients treated for TRAS exhibited uncontrolled hypertension and/or unexplained allograft dysfunction. Patient demographics, procedural details, and follow-up outcomes were collected. Primary endpoints were the in-stent primary patency and graft survival. Secondary endpoints were freedom from reintervention, primary-assisted patency and access-related complications. RESULTS:Thirteen TRAS in twelve patients with graft function alteration were treated with DES. The median age was 57 years (interquartile range (IQR), 48-63 years), and nine (70%) patients were male (Table). The median follow-up was 9 months (IQR, 4-52 months). The most common comorbidity was hypertension (100%), coronary artery disease (83%) and diabetes. The median time from deceased donor transplant to intervention was 5.8 months (IQR, 3.5-6.7 months). TRAS was most commonly found at the juxta-ostial segment (77%). The procedure was performed with carbon dioxide angiography with minimal amount of iodinated contrast (median, 3 mL) under local anesthesia in nine (69%) and general anesthesia in four (31%) patients. The median stent diameter was 4.5 mm (IQR, 4-5 mm), and the median stent length was 15 mm (IQR, 15-18 mm). No intraoperative complications occurred. The rates of stenosis-free primary patency of the DES and graft survival were 76% and 100%, respectively. All three reinterventions for restenosis resulted from the kinking of the transplant renal artery proximal to the DES, which were treated by extending the stent more proximally 1-2 mm into the external iliac artery. There were no access-related complications. The median time to reintervention was 0.9 months (range, 0.23-2 months). Freedom from reintervention and primary-assisted patency were 76% and 100%, respectively. CONCLUSIONS:Our study demonstrates that DES is a safe and effective treatment modality in patients with TRAS at short to mid-term follow-up. As all reinterventions after DES were performed due to kinking of the transplant renal artery proximal to the stent, bridging of the DES 1-2 mm into the external iliac artery is recommended.

BACKGROUND:There is a paucity of data on the impact of cytomegalovirus (CMV) serostatus and CMV infection on outcomes in facial vascularized composite allotransplantation. METHODS:This international, multicenter, retrospective cohort study presents data on CMV and basic transplant-related demographics, including pretransplant viral D/R serostatus, and duration of antiviral prophylaxis. CMV-related complications (viremia, disease), allograft-related complications (rejection episodes, loss), and mortality were analyzed. RESULTS:We included 19 patients, 4 of whom received CMV high-risk transplants (D+/R-). CMV viremia was noted in 6 patients (all 4 D+/R- patients and 2 D-/R+), mostly within the first-year posttransplant, shortly after discontinuation of antiviral prophylaxis (median 2 mo). CMV disease occurred in 2 D+/R- patients. The high-risk group experienced relatively more rejection episodes per month follow-up. None of D+/R- patients suffered allograft loss due to rejection (longest follow-up: 121 mo). CONCLUSIONS:D+/R- patients were at increased risk of CMV-related complications. Although a higher number of rejections was noted in this group, none of the D+/R- patients lost their allograft or died because of CMV or rejection. Thus, CMV D+/R- face transplantation can likely be safely performed with prophylaxis, active surveillance, and prompt treatment.

BACKGROUND:Acute rejection (AR) is a common complication in facial transplant (FT) patients associated with allograft edema and erythema. Our study aims to demonstrate the feasibility of using software-based 3-dimensional (3D) facial analysis to quantify edema as it resolves during/after AR treatment in an FT patient. METHODS:Our patient is a 23-year-old man who underwent a face and bilateral hand allotransplant in August 2020. The Vectra H1 (Canfield, Fairfield, NJ) portable scanner was used to capture 3D facial images at 8 time points between postoperative day (POD) 392 and 539. The images were analyzed with the Vectra Software using a rejection-free image (POD 539) as a control. RESULTS:Edema increased in the periorbital, lower third, and submandibular regions before AR treatment (POD 392-415). At POD 448, total facial edema was reduced to near baseline values in response to plasmapheresis and thymoglobulin (+156.94 to +28.2 mL). The fastest and most notable response to treatment was seen in the periorbital region, while some edema remained in the submandibular (+19.79 mL) and right lower third (+8.65 mL) regions. On POD 465, after the initial improvement, the edema increased but was resolved with steroid use. Facial edema did not correlate with the histopathological evaluation in our patient. CONCLUSIONS:We demonstrated the feasibility of analyzing 3D facial images to quantify edema during/after AR treatment in an FT patient. Our analysis detected edema changes consistent with AR followed by an improvement after treatment. This technology shows promise for noninvasive monitoring of FT patients.

BACKGROUND:Mannitol is often administered during open juxtarenal or suprarenal aortic surgery to prevent ischemic injury to the kidneys. Prior evidence evaluating the benefits of intraoperative mannitol in reducing ischemia/reperfusion injury is conflicting and largely based on small, retrospective series. The aim of this study was to evaluate the effect of mannitol in preventing postoperative hemodialysis in patients undergoing open abdominal aortic aneurysm (AAA) repair where proximal control involved temporary renal ischemia. METHODS:The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing elective open AAA repair between 2003 and 2020. Patients were included in the current analysis if the proximal aortic clamp was placed above at least one renal artery. Chronic kidney disease (CKD) was defined as Cr > 1.8 mg/dL. Primary end points were 30-day major morbidity (myocardial infarction, respiratory complications, lower extremity or intestinal ischemia, and the need for temporary or permanent hemodialysis) and mortality. Comparisons were made between the mannitol and nonmannitol cohorts and stratified by the presence of preexisting CKD. RESULTS:During the study period, 4,156 patients underwent elective open AAA repair requiring clamp placement more than one (32.7%) or both (67.3%) renal arteries; 182 patients (4.4%) had preexisting CKD. Overall, 69.8% of patients received mannitol during their surgery. Mannitol was more frequently used in cases involving clamp placement above both renal arteries (70.3%) than one renal artery (61.5%). While prolonged ischemia time (more than 40 min) was associated with a higher risk of postoperative dialysis in patients without CKD, it was not significant in patients with baseline CKD. On a univariate analysis, mannitol use in patients with CKD was associated with a lower risk of postoperative dialysis (P = 0.005). This remained significant on a multivariate analysis (P = 0.008). Mannitol use did not appear to confer renal protective effects in patients without baseline CKD. CONCLUSIONS:Mannitol use was associated with a decreased risk of need for postoperative hemodialysis in patients with CKD undergoing suprarenal aortic clamping for open aneurysm repair. In appropriately selected patients, particularly those with underlying renal insufficiency, mannitol may confer a renal protective effect in open repair of pararenal AAA requiring suprarenal clamping.

Although the ethical and technical feasibility of face transplant (FT) has been established, current literature lacks consensus on functional outcomes monitoring for recipients. This systematic review aims to appraise and summarize the current literature on tools used to assess motor functional outcomes in FT. This study complied with the guidelines outlined in the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). On September 15, 2020, two reviewers conducted independent electronic searches using medical literature databases, without language or time frame limitations. Eligibility criteria included studies reporting on the evaluation of motor functional outcomes in face transplant recipients. Of 451 papers found in the literature, 12 fulfilled the study inclusion criteria. The reported tools included clinical scales/examinations, electromyography, optical movement tracking devices, muscle volumetric measurement using magnetic resonance imaging, and software-based video and photo analyses. The frequency of data collection varied from every three months to every year. Publications reporting on motor functional outcomes tracking tools vary broadly and demonstrate a lack of consensus. Although quantitative measurements are desirable, adapted clinical scales are still the current standard of care.

BACKGROUND:Vascularized composite allotransplantation (VCA) has redefined the frontiers of plastic and reconstructive surgery. At the cutting edge of this evolving paradigm, we present the first successful combined full face and bilateral hand transplant (FT-BHT). METHODS:A 21-year-old man with sequelae of an 80% total body surface area burn injury sustained following a motor vehicle accident presented for evaluation. The injury included full face and bilateral upper extremity composite tissue defects, resulting in reduced quality of life and loss of independence. Multidisciplinary evaluation confirmed eligibility for combined FT-BHT. The operative approach was validated through 11 cadaveric rehearsals utilizing computerized surgical planning. Institutional review board and organ procurement organization approvals were obtained. The recipient, his caregiver, and the donor family consented to the procedure. RESULTS:Combined full face (eyelids, ears, nose, lips, and skeletal subunits) and bilateral hand transplantation (forearm level) was performed over 23 hours on August 12-13th, 2020. Triple induction and maintenance immunosuppressive therapy and infection prophylaxis were administered. Plasmapheresis was necessary postoperatively. Minor revisions were performed over seven subsequent operations, including five left upper extremity, seven right upper extremity, and seven facial secondary procedures. At eight months, the patient is approaching functional independence and remains free of acute rejection. He has significantly improved range of motion, motor power, and sensation of the face and hand allografts. CONCLUSION/CONCLUSIONS:Combined FT-BHT is feasible. This is the most comprehensive VCA procedure successfully performed to date, marking a new milestone in plastic and reconstructive surgery for patients with otherwise irremediable injuries.

Introduction: Vascularized composite allotransplantation has redefined the frontiers of plastic and reconstructive surgery. The field has seen considerable advancement since its inception, with the first successful hand transplant in 1998 and the first partial face transplant in 2005. To date, over 40 bilateral hand transplants have been reported in the literature, along with 47 face transplants. Due to still limited available evidence and the heterogeneity of the sample population, little consensus exists on the anticipated timeline of functional recovery following vascularized composite allotransplantation. We hereby report on the early and accelerated functional recovery of a combined face and bilateral hand transplant recipient.
Method(s): A 21-year-old male was referred with sequelae of an 80% total body surface area burn sustained in a motor vehicle accident 1 year prior. The patient had extensive facial and bilateral upper extremity injuries. Serial debridement and split thickness skin grafting procedures left the patient with proximal digital syndactyly and distal digit amputations. Procurement and transplantation of the face and upper extremities was performed over a 23-h period in August of 2020. Postoperative functional assessment at predetermined time points included active range of motion, grip strength, sensory assessment, Carroll's Upper Extremity Function test, and the Disabilities of the Arm, Shoulder, and Hand questionnaire.
Result(s): Functional assessments were performed at 3 and 6 months post-transplant. Range of motion, grip strength, Carroll's test scores (left = 58 at 6 months post-transplant vs 13 pre-transplant, right = 61 at 6 months post-transplant vs 20 pre-transplant) and Disabilities of the Arm, Shoulder, and Hand evaluation (37 at 6 months post-transplant vs 90 pretransplant) showed substantial improvement. The patient remained rejection-free during the first 9 months post-transplant and has had steady and progressive functional improvement. He is highly motivated and consistently demonstrates functional independence in activities of daily living.
Conclusion(s): Combined face and bilateral hand transplant is a feasible, comprehensive reconstructive solution for composite face and bilateral hand injury in the appropriately selected recipient. Patient motivation, psychosocial support, intensive physical and occupational therapy, and vigilant clinical and immunologic surveillance are essential features of postoperative recovery

Introduction: Acute rejection is exceptionally common in the first year after vascularized composite allotransplantation. Recipients with burns are at increased risk of developing donor-specific antibodies due to sensitization. Lymphocyte depleting induction with rabbit antithymocyte globulin is commonly utilized. We hypothesized that combination B- and T-cell depletion induction therapy is more efficacious in preventing acute rejection in the early post-transplant period.
Method(s): Our induction protocol calls for intraoperative administration of methylprednisolone (1000 mg) and rabbit antithymocyte globulin beginning intraoperatively (1.5 mg/ kg, cumulative dose 6 mg/kg over the first postoperative week) and rituximab (1000 mg administered on postoperative day 1) for thorough T and mature B-cell depletion. Standard infection prophylaxis is utilized. Donor-specific antibodies are monitored postoperatively with Luminex single-antigen microbeads (mean fluorescence intensity >= 1000 considered clinically significant).
Result(s): Our latest recipient was a 22-year-old male with 80% total body surface area burns. The donor was an ABOidentical, 47-year-old brain dead male. Human leukocyte antigen (HLA) mismatch was 0, 1, 0 (A, B, DR), and 2 HLA-DPB1. Donor-recipient complement-dependent cytotoxicity and flow cytometric T- and B-cell crossmatch were all negative. Abrupt rise in donor-specific antibodies on postoperative days 7 and 8 was treated with two rounds of plasmapheresis and intravenous immunoglobulin. Persistent wound colonization (Acinetobacter baumannii) was treated with meropenem, polymyxin, and tigecycline. The recipient experienced a single episode of acute rejection 9 months post-transplant, successfully treated with pulse doses of methylprednisolone (500 mg intravenous, daily) over 3 days. We suspect this may have been triggered by inflammation induced by revision surgery of all three vascularized composite allotransplantation components in the preceding month
Conclusion(s): We present our third consecutive vascularized composite allotransplantation recipient utilizing this novel immune strategy. In the context of the most extensive vascularized composite allotransplantation performed to date, acute rejection was prevented until 9 months post-transplant in this highly sensitized patient. Two previous recipients remained rejection-free for greater than 1 year post-transplant and have experienced only one rejection episode each to date. Acute rejection in vascularized composite allotransplantation may be better prevented by including rituximab in the induction immunosuppression strategy, and the risk of metabolic or severe infectious complications appears to be manageable

Introduction: Vascularized composite allotransplantation provides a reconstructive option for patients with otherwise irreparable defects. Despite significant advances in the field, successful multi-vascularized composite allotransplantation has yet to be reported. We herein describe our experience with the first successful combined face and bilateral hand transplant, focusing on the sequence and timing of allograft procurement.
Method(s): The recipient was a 22-year-old male who presented for multi-vascularized composite allotransplantation evaluation after sustaining a motor vehicle accident resulting in 80% total body surface area burns, including his full face and bilateral upper extremities. Following multidisciplinary team evaluation and institutional review board approval, he was deemed an appropriate candidate for combined face and bilateral hand transplant. In defining his expectations for the transplant, the recipient wished to prioritize recovery of hand function above all else.
Result(s): Combined face and bilateral hand transplant was performed over 23 h and 3 min in two adjacent operating rooms. Given the recipient's right-hand dominance, we opted for procurement and transplantation of the right upper extremity first, followed by the left upper extremity, with the facial allograft procured last. The vascular pedicles in the donor left upper extremity allograft were only divided once vascular inflow and outflow was re-established in the right upper extremity. Similarly, the external carotid arteries were clamped and divided after the left upper extremity was reperfused. To minimize ischemia, no tourniquet was used in the donor room, while tourniquet use was limited to <2 h in the recipient room. Total ischemia times were 2 h and 30 min for the right upper extremity; 2 h and 46 min for the left upper extremity; and 2 h and 52 min for the face. Optimization of arterial inflow and venous outflow was ensured with preservation of the muscular perforators and reconstruction of both the deep and superficial venous systems. At 10 months post-transplant, the recipient is demonstrating continuous improvement in functional outcomes.
Conclusion(s): In this report, we describe our approach for procuring three allografts in the first successful face and bilateral hand transplant. In addition to meticulous preparation, this case highlights the importance of understanding and prioritizing the recipient's goals for the transplant