Muss Tessa E, Loftin Amanda H, Oh Byoung Chol, Brandacher Gerald
Department of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation (VCA) Laboratory.
Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Curr Opin Organ Transplant. 2023 Dec 1;28(6):419-424. doi: 10.1097/MOT.0000000000001107. Epub 2023 Oct 12.
A major hurdle hindering more widespread application of reconstructive transplantation is the very limited cold ischemia time (CIT) of vascularized composite allografts (VCAs). In this review, we discuss cutting edge machine perfusion protocols and preservation strategies to overcome this limitation.
Several preclinical machine perfusion studies have demonstrated the multifactorial utility of this technology to extend preservation windows, assess graft viability prior to transplantation and salvage damaged tissue, yet there are currently no clinically approved machine perfusion protocols for reconstructive transplantation. Thus, machine perfusion remains an open challenge in VCA due to the complexity of the various tissue types. In addition, multiple other promising avenues to prolong preservation of composite allografts have emerged. These include cryopreservation, high subzero preservation, vitrification and nanowarming. Despite several studies demonstrating extended preservation windows, there are several limitations that must be overcome prior to clinical translation. As both machine perfusion and subzero preservation protocols have rapidly advanced in the past few years, special consideration should be given to their potential complementary utilization.
Current and emerging machine perfusion and preservation technologies in VCA have great promise to transform the field of reconstructive transplantation, as every extra hour of CIT helps ease the complexities of the peri-transplant workflow. Amongst the many advantages, longer preservation windows may allow for elective procedures, improved matching, establishment of novel immunomodulatory protocols and global transport of grafts, ultimately enabling us the ability to offer this life changing procedure to more patients.
综述目的：阻碍重建移植更广泛应用的一个主要障碍是血管化复合异体移植物（VCA）的冷缺血时间（CIT）非常有限。在本综述中，我们讨论了前沿的机器灌注方案和保存策略，以克服这一限制。
最新发现：多项临床前机器灌注研究已证明该技术在延长保存窗口、移植前评估移植物活力以及挽救受损组织方面具有多方面的效用，但目前尚无用于重建移植的临床批准的机器灌注方案。因此，由于各种组织类型的复杂性，机器灌注在VCA中仍然是一个开放的挑战。此外，还出现了其他多种有望延长复合异体移植物保存时间的途径。这些包括冷冻保存、深低温保存、玻璃化和纳米复温。尽管有多项研究表明保存窗口有所延长，但在临床转化之前仍有几个限制必须克服。由于机器灌注和深低温保存方案在过去几年中都迅速发展，应特别考虑它们潜在的互补应用。
总结：VCA中当前和新兴的机器灌注及保存技术极有希望改变重建移植领域，因为CIT每延长一小时都有助于缓解移植周围工作流程的复杂性。在众多优势中，更长的保存窗口可能允许进行择期手术、改善匹配、建立新的免疫调节方案以及移植物的全球运输，最终使我们有能力为更多患者提供这种改变生活的手术。
