Correspondence
Tracheal Replacement with Aortic Allografts
N Engl J Med 2006; 355:1938-1940November 2, 2006
- Article
To the Editor:
We report tracheal replacement with fresh aortic allografts in two patients with large chemotherapy-resistant and radiotherapy-resistant tumors (mucoepidermoid and adenoid cystic carcinomas). These interventions were made on the basis of the extent of the lesions (making them unresectable), the severity of each patient's clinical condition, the lack of alternative treatment options, and the success of this intervention in sheep and pig models.1-4 The transplantation was approved for each patient by the French National Bioethics Advisory Commission. Both procedures were performed through a median cervicosternotomy. In the first patient, tumor dissection was followed by sectioning of the trachea proximally just below the second ring and distally until the cross-section margins were negative for tumor on frozen section (subtotal resection of the main carina). Carinal restitution was achieved by suturing the right and left main bronchi together. An aortic allograft that was harvested from a brain-dead donor and splinted by means of a bifurcated silicone stent was interposed with end-to-end proximal and distal anastomoses (Figure 1Figure 1
CT Scans of the Chest Showing Tracheal Tumors in Patient 1 (Panel A) and Patient 2 (Panel B) and Diagrams Showing Tracheal Reconstruction with the Stent and Graft in Place in Patient 1 (Panel C) and Patient 2 (Panel D).). To protect the large vessels from the stent-splinted graft and to promote revascularization, the graft was wrapped with a pectoral muscle flap.The procedure was performed in a similar way in the second patient. However, since the tumor extension was wider, the trachea was sectioned just below the first cartilage. Distally, after a right upper lobectomy, the entire right main bronchus and the first two cartilages of the left main bronchus were resected. Restitution of the carina was achieved by suturing the bronchus intermedius and the left main bronchus together. With the use of end-to-end anastomosis, this new carina was then approximated to the distal segment of the aortic allograft.
The first patient had a fairly uneventful postoperative course. Because of the ineffectiveness of coughing, bronchoscopy was performed every other day during the first 2 weeks. Acute anterior spinal cord ischemia developed in the second patient on postoperative day 1. The definitive explanation for this severe complication is not known, but several factors may have played a role. These factors include microemboli as a result of a concussion injury to the ascending aorta, the anomalous origin of the left vertebral artery, and tumor-related thrombophilia. Fortunately, there was partial recovery (respiratory autonomy and strength and function in both arms).
Biopsy specimens of the aortic allografts in both patients 1 year after surgery showed the development of respiratory epithelium, as observed in animal models. It is unclear whether host mesenchymal stem cells engraft the aortic allograft and undergo cartilaginous differentiation, as in animal models. So far (with 18 months of follow-up), graft ischemia, problematic suture dehiscence, infection, and graft rejection have not been observed, despite the absence of immunosuppressive therapy. Since the stents are well tolerated, as a precautionary measure we have decided not to withdraw them before 2 years, or at least not before computed tomography or bronchoscopy shows that newly formed cartilaginous rings can stiffen the new trachea.
4 ReferencesAlain Wurtz, M.D.
Henri Porte, M.D., Ph.D.
Massimo Conti, M.D.
Jacques Desbordes, M.D.
Marie Christine Copin, M.D., Ph.D.
Centre Hospitalier Régional Universitaire, 59000 Lille, FranceJacques Azorin, M.D.
Hôpital Avicenne, 93000 Bobigny, FranceEmmanuel Martinod, M.D., Ph.D.
Laboratoire d'Etude des Greffes et Prothèses Cardiaques, 75014 Paris, FranceCharles-Hugo Marquette, M.D., Ph.D.
Université de Lille II, 59000 Lille, France
c-marquette@chru-lille.fr 1
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CrossRef | Web of Science | Medline3
Seguin A ,Martinod E ,Kambouchner M , et al. Carinal replacement with an aortic allograft. Ann Thorac Surg 2006;81:1068-1074
CrossRef | Web of Science | Medline4
Jaillard S ,Holder-Espinasse M ,Hubert T , et al. Tracheal replacement by allogenic aorta in the pig. Chest 2006;130:1397-1404
CrossRef | Web of Science | Medline
- Citing Articles (26)
Citing Articles
1
A. Wurtz, I. Hysi, C. Zawadzki, V. Soenen, T. Hubert, C. Banfi, R. Jashari, M.-C. Copin. (2011) Construction of a tube-shaped tracheal substitute using fascial flap-wrapped revascularized allogenic aorta. European Journal of Cardio-Thoracic Surgery
CrossRef2
E. Olender, I. Uhrynowska-Tyszkiewicz, A. Kaminski. (2011) Revitalization of Biostatic Tissue Allografts: New Perspectives in Tissue Transplantology. Transplantation Proceedings 43:8, 3137-3141
CrossRef3
Alain Wurtz, Ilir Hysi, Christophe Zawadzki, Marie-Christine Copin. (2011) Graft Contraction Phenomenon and Tracheal Stretching After Tracheal Replacement. The Annals of Thoracic Surgery 92:4, 1548
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E. Martinod. (2011) Remplacement trachéal par allogreffe aortique cryopreservée : un « hot topic » en chirurgie thoracique. Revue des Maladies Respiratoires
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A. Wurtz, I. Hysi. (2011) Remplacement trachéal par allogreffe aortique chez l’homme. Perspectives expérimentales. Revue des Maladies Respiratoires
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Silvia Baiguera, Barbara D’Innocenzo, Paolo Macchiarini. (2011) Current status of regenerative replacement of the airway. Expert Review of Respiratory Medicine 5:4, 487-494
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Thorsten Walles. (2011) Tracheobronchial bio-engineering: Biotechnology fulfilling unmet medical needs. Advanced Drug Delivery Reviews 63:4-5, 367-374
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Emmanuel Martinod, Dana M. Radu, Kader Chouahnia, Agathe Seguin, Anne Fialaire-Legendre, Pierre-Yves Brillet, Marie-Dominique Destable, Georges Sebbane, Sadek Beloucif, Dominique Valeyre, Christophe Baillard, Alain Carpentier. (2011) Human Transplantation of a Biologic Airway Substitute in Conservative Lung Cancer Surgery. The Annals of Thoracic Surgery 91:3, 837-842
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Tatsuo Nakamura, Koichi Ohmori, Shin-ichi Kanemaru. (2011) Tissue-engineered airway and “in situ tissue engineering”. General Thoracic and Cardiovascular Surgery 59:2, 91-97
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Charles-Hugo Marquette, Alain Wurtz. (2010) Tracheal Replacement With Aortic Allografts in the Pig. The Annals of Thoracic Surgery 90:6, 2091
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Chadrick E. Denlinger. (2010) A balanced perspective for management of tracheal salivary gland-type carcinomas. The Journal of Thoracic and Cardiovascular Surgery 140:2, 394
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Alain Wurtz, Henri Porte, Massimo Conti, Catherine Dusson, Jacques Desbordes, Marie-Christine Copin, Charles-Hugo Marquette. (2010) Surgical technique and results of tracheal and carinal replacement with aortic allografts for salivary gland–type carcinoma. The Journal of Thoracic and Cardiovascular Surgery 140:2, 387-393.e2
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Jimmie Honings, Henning A. Gaissert, Henricus F.M. van der Heijden, Ad F.T.M. Verhagen, Johannes H.A.M. Kaanders, Henri A.M. Marres. (2010) Clinical aspects and treatment of primary tracheal malignancies. Acta Oto-laryngologica 130:7, 763-772
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Dana M. Radu, Agathe Seguin, Patrick Bruneval, Anne Fialaire Legendre, Alain Carpentier, Emmanuel Martinod. (2010) Bronchial Replacement With Arterial Allografts. The Annals of Thoracic Surgery 90:1, 252-258
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Sebastien Gaujoux, Yann Le Balleur, Patrick Bruneval, Jerome Larghero, Séverine Lecourt, Thomas Domet, Benoit Lambert, Sarah Zohar, Frederic Prat, Pierre Cattan. (2010) Esophageal replacement by allogenic aorta in a porcine model. Surgery 148:1, 39-47
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Tamas F. Molnar, Judit E. Pongracz. (2010) Tissue engineering and biotechnology in general thoracic surgery. European Journal of Cardio-Thoracic Surgery 37:6, 1402-1410
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Alain Wurtz. (2010) Tracheal Replacement With Banked Cryopreserved Aortic Allograft. The Annals of Thoracic Surgery 89:6, 2072
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Pyng Lee, Elif Kupeli, Atul C. Mehta. (2010) Airway Stents. Clinics in Chest Medicine 31:1, 141-150
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Hisashi Tsukada, Armin Ernst, Sidhu Gangadharan, Simon Ashiku, Robert Garland, Diana Litmanovich, Malcolm DeCamp. (2010) Tracheal Replacement With a Silicone-Stented, Fresh Aortic Allograft in Sheep. The Annals of Thoracic Surgery 89:1, 253-258
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Dominique Fabre, Sunil Singhal, Vincent De Montpreville, Benoit Decante, Sacha Mussot, Olivier Chataigner, Olaf Mercier, Frederic Kolb, Philippe G. Dartevelle, Elie Fadel. (2009) Composite cervical skin and cartilage flap provides a novel large airway substitute after long-segment tracheal resection. The Journal of Thoracic and Cardiovascular Surgery 138:1, 32-39
CrossRef21
Agathe Seguin, Dana Radu, Muriel Holder-Espinasse, Patrick Bruneval, Anne Fialaire-Legendre, Martine Duterque-Coquillaud, Alain Carpentier, Emmanuel Martinod. (2009) Tracheal Replacement With Cryopreserved, Decellularized, or Glutaraldehyde-Treated Aortic Allografts. The Annals of Thoracic Surgery 87:3, 861-867
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Matthias Behrend, Eva Kluge. (2008) The Fate of Homograft Tracheal Transplants in Sheep. World Journal of Surgery 32:8, 1669-1675
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Toshihiko Sato, Hiroyuki Tao, Masato Araki, Hiroki Ueda, Koichi Omori, Tatsuo Nakamura. (2008) Replacement of the Left Main Bronchus With a Tissue-Engineered Prosthesis in a Canine Model. The Annals of Thoracic Surgery 86:2, 422-428
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Gordon N. Finlayson, Jay B. Brodsky. (2008) Anesthetic Considerations for Airway Stenting in Adult Patients. Anesthesiology Clinics 26:2, 281-291
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Demosthenes Makris, Charles-Hugo Marquette. (2007) Tracheobronchial stenting and central airway replacement. Current Opinion in Pulmonary Medicine 13:4, 278-283
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E. Brian, V. Gounant, J.-P. Fulgencio, B. Milleron, B. Bazelly. (2007) Remplacement de la trachée par l’aorte. Revue de Pneumologie Clinique 63:3, 224-229
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