From the RESTOR Program, 59th Medical Wing, and the San Antonio Military Medical Center, Joint Base San Antonio; University of Texas Health at San Antonio; Baylor Scott & White Health; and the Wake Forest Institute for Regenerative Medicine.
Plast Reconstr Surg. 2019 Mar;143(3):637e-643e. doi: 10.1097/PRS.0000000000005352.
From 1996 to 2000, Diefenbeck et al. carried out six knee vascularized composite allotransplants. The allotransplants were composed of bone, soft tissue, and femoral vascular pedicle (25 to 40 cm). All rejected between 14 and 56 months. Failures were attributed to chronic rejection. In 2008, the Louisville team lost their fourth patient's hand transplant at 8 months. During the rejection workup, intraoperative findings noted a thickened arterial pedicle attributed to intimal hyperplasia with significant fibrotic perivascular tissue and a near "no-flow phenomenon." No cutaneous rejection was appreciated and failure was attributed to chronic rejection.
Data were collected from two teams, one in Germany and the other in Louisville, Kentucky. The population under study consisted of the six knee and one hand transplants. The factor of interest was the long donor arterial pedicle. The outcome measurements were transplant survival time and histopathologic results.
There are only seven published vascularized composite allotransplant cases where a donor artery longer than 25 cm was used. This cohort represents a 100 percent accelerated failure rate. The cause of these losses remains unexplained. The donor arteries suffered from T-cell-mediated rejection and ischemia-induced media/adventitial necrosis.
We hypothesize that the donor artery rejected at an accelerated rate because of ischemia caused by disruption of the external vasa vasorum in conjunction with intimal hyperplasia induced by T-cell-mediated rejection that led to disruption of the Windkessel effect. Loss of this effect presented as intimal hyperplasia accelerated by ischemia causing an expedited transplant failure.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.
1996 年至 2000 年，Diefenbeck 等人进行了六例膝关节血管化复合组织同种异体移植。同种异体移植由骨、软组织和股血管蒂（25 至 40 厘米）组成。所有患者均在 14 至 56 个月内排斥。失败归因于慢性排斥。2008 年，路易斯维尔团队失去了第四位患者的手部移植，移植后 8 个月发生排斥。在排斥反应检查过程中，术中发现动脉蒂增厚，归因于内膜增生，伴有明显的纤维血管周围组织和近乎“无血流现象”。未发现皮肤排斥反应，归因于慢性排斥。
数据来自德国和肯塔基州路易斯维尔的两个团队。研究人群包括六例膝关节和一例手部移植。研究的感兴趣因素是较长的供体动脉蒂。主要结局测量指标为移植体存活时间和组织病理学结果。
仅有七例发表的血管化复合组织同种异体移植病例使用了超过 25 厘米的供体动脉，这组患者的移植体加速失效率为 100%。这些损失的原因仍未得到解释。供体动脉发生 T 细胞介导的排斥反应和缺血引起的中膜/外膜坏死。
我们假设供体动脉以加速的速度排斥，是由于破坏外血管丛引起的缺血以及 T 细胞介导的排斥引起的内膜增生，导致稳压效应的破坏。这种效应的丧失表现为内膜增生加速，缺血导致移植体迅速衰竭。
临床问题/证据水平：治疗性，V。
