Thoracoabdominal Normothermic Regional Perfusion: Technical Tips for Abdominal Transplant Surgeons

Abstract

Background

Donation after circulatory death (DCD) is characterized as organ procurement after irrevocable termination of cardiopulmonary function. Historically grafts from DCD donors were used with caution due to complication rates, but new techniques have led to significant strides in utilization. Normothermic regional perfusion (NRP) establishes in situ perfusion after circulatory death pronouncement, mitigating ischemic injury seen with classic cold perfusion. NRP has shown excellent clinical outcomes and the potential for significant donor pool expansion.

Methods

For every NRP case, our team consists of two perfusionists, one transplant surgeon, and one surgical assistant. Communication between team members as well as an organized setup of the mayo stand and perfusion system are crucial for success. Cases proceed in the following fashion: sternotomy incision and retractor placement, pericardial incision and innominate vein ligation, occlusion of the brachiocephalic arteries, venous cannula insertion, aortic cannula insertion, and initiation of NRP.

Results

Since October 2022, our center has utilized NRP for all DCD cases when possible, leading to 128 attempts, of which 108 progressed to cardiac death, resulting in 94 liver transplants.

Conclusions

Thoracic cannulation can be challenging, particularly in the hands of an abdominal transplant surgeon unfamiliar with the territory. The evolution of technique and strategy has permitted reliable results and desired outcomes to allow for proper and efficient cannulation. This article reviews the tips, tricks, and pitfalls of thoracic cannulation with NRP for the abdominal transplant surgeon.