Feasibility of Bioengineered Tracheal and Bronchial Reconstruction Using Stented Aortic Matrices

作者：Martinod Emmanuel^*; Chouahnia Kader; Radu Dana M; Joudiou Pascal; Uzunhan Yurdagul; Bensidhoum Morad; Portela Ana M Santos; Guiraudet Patrice; Peretti Marine; Destable Marie Dominique; Solis Audrey; Benachi Sabiha; Fialaire Legendre Anne; Rouard Helene; Collon Thierry; Piquet Jacques; Leroy Sylvie; Venissac Nicolas; Santini Joseph; Tresallet Christophe; Dutau Herve; Sebbane Georges; Cohen Yves; Beloucif Sadel; d'Audiffret Alexandre C; Petite Herve; Valeyre Dominique

来源：Journal of the American Medical Association, 2018, 319(21): 2212-2222.

DOI：10.1001/jama.2018.1653

IMPORTANCE Airway transplantation could be an option for patients with proximal lung tumor or with end-stage tracheobronchial disease. New methods for airway transplantation remain highly controversial. OBJECrIVE To establish the feasibility of airway bioengineering using a technique based on the implantation of stented aortic matrices.
DESIGN, SETTING, AND PARTICIPANTS Uncontrolled single-center cohort study including 20 patients with end-stage tracheal lesions or with proximal lung tumors requiring a pneumonectomy. The study was conducted in Paris, France, from October 2009 through February 2017; final follow-up for all patients occurred on November 2, 2017.
EXPOSURES Radical resection of the lesions was performed using standard surgical techniques. After resection, airway reconstruction was performed using a human cryopreserved (-80 degrees C) aortic allograft, which was not matched by the ABO and leukocyte antigen systems. To prevent airway collapse, a custom-made stent was inserted into the allograft. In patients with proximal lung tumors, the lung-sparing intervention of bronchial transplantation was used.
MAIN OUTCOMES AND MEASURES The primary outcome was 90-day mortality. The secondary outcome was 90-day morbidity.
RESULTS Twenty patients were included in the study (mean age, 54.9 years; age range, 24-79 years; 13 men [65%]). Thirteen patients underwent tracheal (n = 5), bronchial (n = 7), or carinal (n = 1) transplantation. Airway transplantation was not performed in 7 patients for the following reasons: medical contraindication (n = 1), unavoidable pneumonectomy (n = 1), exploratory thoracotomy only (n = 2), and a lobectomy or bilobectomy was possible (n = 3). Among the 20 patients initially included, the overall 90-day mortality rate was 5% (1 patient underwent a carinal transplantation and died). No mortality at 90 days was observed among patients who underwent tracheal or bronchial reconstruction. Among the 13 patients who underwent airway transplantation, major 90-day morbidity events occurred in 4 (30.8%) and included laryngeal edema, acute lung edema, acute respiratory distress syndrome, and atrial fibrillation. There was no adverse event directly related to the surgical technique. Stent removal was performed at a postoperative mean of 18.2 months. At a median follow-up of 3 years 11 months, 10 of the 13 patients (76.9%) were alive. Of these 10 patients, 8 (80%) breathed normally through newly formed airways after stent removal. Regeneration of epithelium and de novo generation of cartilage were observed within aortic matrices from recipient cells.
CONCLUSIONS AND RELEVANCE In this uncontrolled study, airway bioengineering using stented aortic matrices demonstrated feasibility for complex tracheal and bronchial reconstruction. Further research is needed to assess efficacy and safety.

• 出版日期2018-6-5