Bronchial artery revascularization and en bloc lung transplant in children.
BACKGROUND
Long-term success in pediatric lung transplantation is limited by infection and bronchiolitis obliterans syndrome (BOS). The bilateral sequential lung transplantation (BSLT) technique may result in airway ischemia leading to bronchial stenosis, dehiscence, or loss of small airways. En bloc lung transplant (EBLT) with bronchial artery revascularization (BAR) minimizes airway ischemia, thus promoting superior airway healing. BAR also allows for safe tracheal anastomosis, circumventing the need for bilateral bronchial anastomoses in small children.


METHODS
This was a retrospective review of bilateral transplantations from 2005 to 2014. Both techniques were used in parallel. Redo and multiorgan transplants were excluded.


RESULTS
There were 119 recipients comprising 88 BSLTs and 31 EBLTs. Follow-up time was 3 years (interquartile range, 1-5 years). Donor ischemic and cardiopulmonary bypass times were not different between techniques (p = 0.48 and p = 0.18, respectively). Degree of graft dysfunction and cellular rejection scores were not different (p = 0.83 and p = 0.93, respectively). There were 3 hospital deaths after BSLT and 2 after EBLT (p = 0.60). Overall survival was 61% for the BSLT group and 77% for the EBLT group (p = 0.54). Freedom from BOS was 71% in the BSLT group and 94% in the EBLT group (p = 0.08). On routine bronchoscopy, 57% BSLT and 16% EBLT patients had 1 or more airway ischemic findings (p < 0.0001). Multivariate analysis showed BSLT was associated with higher ischemic injury (relative risk, 2.86; 95 confidence interval, 1.3-6.5; p = 0.01) and non-airway complications (relative risk, 4.62; 95% confidence interval, 1.1-20.2; p = 0.04) but not airway reinterventions (p = 0.07). Airway dehiscence occurred in 3 BSLT patients.


CONCLUSIONS
Pediatric EBLT with BAR can be safely performed without increasing operative or graft ischemic times. Airway ischemia and non-airway complications were significantly reduced when BAR was combined with tracheal anastomosis, potentially diminishing morbidity caused by anastomotic healing complications.
Lung Transplant Program, Baylor College of Medicine, Houston, Texas; Lung Transplant Program, Texas Children's Hospital, Houston, Texas.
Francisco A
FA
Guzman-Pruneda
Lung Transplant Program, Baylor College of Medicine, Houston, Texas; Lung Transplant Program, Texas Children's Hospital, Houston, Texas.
Yishay
Y
Orr
Lung Transplant Program, Baylor College of Medicine, Houston, Texas; Lung Transplant Program, Texas Children's Hospital, Houston, Texas.
Jeffrey G
JG
Trost
Lung Transplant Program, Texas Children's Hospital, Houston, Texas.
Wei
W
Zhang
Lung Transplant Program, Baylor College of Medicine, Houston, Texas; Lung Transplant Program, Texas Children's Hospital, Houston, Texas.
Shailendra
S
Das
Lung Transplant Program, Baylor College of Medicine, Houston, Texas; Lung Transplant Program, Texas Children's Hospital, Houston, Texas.
Ernestina
E
Melicoff
Lung Transplant Program, Texas Children's Hospital, Houston, Texas.
Jennifer
J
Maddox
Lung Transplant Program, Texas Children's Hospital, Houston, Texas.
Melissa
M
Nugent
Lung Transplant Program, Baylor College of Medicine, Houston, Texas; Lung Transplant Program, Texas Children's Hospital, Houston, Texas.
Carlos M
CM
Mery
Lung Transplant Program, Baylor College of Medicine, Houston, Texas; Lung Transplant Program, Texas Children's Hospital, Houston, Texas.
Iki
I
Adachi
Lung Transplant Program, Cincinnati Children's Hospital Cincinnati, Ohio.
Marc G
MG
Schecter
Lung Transplant Program, Baylor College of Medicine, Houston, Texas; Lung Transplant Program, Texas Children's Hospital, Houston, Texas.
George B
GB
Mallory
Lung Transplant Program, Cincinnati Children's Hospital Cincinnati, Ohio.
David L
DL
Morales
Lung Transplant Program, Baylor College of Medicine, Houston, Texas; Lung Transplant Program, Texas Children's Hospital, Houston, Texas.
Jeffrey S
JS
Heinle
Lung Transplant Program, Baylor College of Medicine, Houston, Texas; Lung Transplant Program, Texas Children's Hospital, Houston, Texas. Electronic address: edmckenz@texaschildrens.org.
Emmett D
ED
McKenzie
D000293:Adolescent; D001981:Bronchial Arteries / Q000601:surgery*; D001999:Bronchoscopy; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000453:epidemiology / Q000209:etiology / Q000601:surgery*; D006801:Humans; D015994:Incidence; D007223:Infant; D016040:Lung Transplantation / Q000009:adverse effects*; D008297:Male; D011183:Postoperative Complications; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013781:Texas / Q000453:epidemiology; D013997:Time Factors; D014656:Vascular Surgical Procedures / Q000379:methods*; D055815:Young Adult
bilateral sequential lung transplantation; bronchial artery revascularization; bronchiolitis obliterans; en bloc lung transplant; tracheal anastomosis