Definition: transplantation of histologically different tissues including skin, connective tissue, blood vessels, muscle, ligaments, cartilage, tendon, bone, nerve tissue, and tissue-based products.9,10
CTA: early nomenclature for graft tissue regarding facial and hand transplants.11
Viewed as a complex science during the conceptual phase with multiple clinical, ethical, and psychosocial considerations12:
Determination of patient selection criteria
Societal considerations
Refining procurement techniques
Limitations of obtaining a fully informed consent
Immunological response and immunosuppressant requirements
Ethical issues
Donor family considerations
Definition: the simultaneous transplantation of multiple tissue types such as muscle, bone, nerve, and skin as a functional single unit (e.g., hand or face).9,13,14
Goal: restoration of sensory and motor functional status, anatomy, appearance, and psychosocial well-being including self-esteem and reintegration into family and social life.15,16,17,18
Surgical option when soft tissue and bone loss is accompanied by severe cosmetic, sensory, and functional deficiencies due to disease,3 trauma,4,5,6,19 or congenital malformations.8
VCA procedures are considered only after all conventional reconstructive methods, or prosthetics in the case of hand amputations, have failed.8,14
To date, more than 150 VCAs have been reported and include hand, abdominal wall, tongue, trachea, larynx, face,2,20,21,22,23 esophagus, and a vascularized knee and femurs.2,24
No cases of pediatric facial transplantation have been reported to date.24
Current clinical trials:
Facial allotransplantation: five trials actively recruiting13
Hand allotransplantation: five trials actively recruiting14
Criteria for body parts defined as a VCA per the Department of Health and Human Services (DHHS).4,25,26
Recovered from a human donor as an anatomical structural unit and contains multiple tissues.
Transplanted into a human recipient as an anatomical structural unit.
Vascularized tissue requiring blood flow by surgical connection of vessels to function following transplantation.
Processing does not alter the original characteristics of the “organ graft.”
The donated graft performs the same basic functions in the recipient as in the donor.
Not combined with another article or device.
Susceptible to ischemia requiring rapid re-establishment of blood flow; thus can be stored only temporarily (cold storage with preservation medium with the intention of implantation within hours of recovery).
Susceptible to allograft rejection requiring donor-recipient matching and generally requiring immunosuppression.
Long-term physical, emotional, and psychological effects on both VCA hand and face recipients as well as long-term (>10 years) consequences to the donor’s family are unknown.27
TABLE 16-1 Timeline—Development of Vascular Composite Allograft Transplantation | ||||||||||||||||||||||||||||||||
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First patient was noncompliant with immunosuppressive treatment.
Second patient developed recurrent squamous cell carcinoma of the hypopharynx.
Third patient developed multidrug-resistant Pseudomonas aeruginosa infection, graft failure, and cardiac arrest after a combined face and double-hand transplant.
The fourth and fifth deaths were related to tumor recurrence and self-inflicted injury.
TABLE 16-2 Facial Transplant Procedures: 2005-2014 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Purchase or sale of VCAs prohibited.
Issues concerning allocation and recipient safety currently fall under the auspices of the OPTN.26
VCAs under a research protocol/IRB must have approval by IRB with consideration of posting to the National Institutes of Health Clinical Trials Web site (https://clinicaltrials.gov/).26
Approval by the designated organ procurement organization, requiring hospitals to comply with the rules and requirements of the OPTN as a condition of participation in Medicare and Medicaid programs.26
In order to perform VCAs, an institution must
Be a designated organ-specific transplant center
Become a member of the OPTN
Comply with OPTN data submission requirements26
Institutions failing to comply with OPTN policies are subject to sanctions and possible termination from Medicare and Medicaid programs.26
Defects comprising 25% or more of the facial surface area and/or involving one or more central facial units such as the eyelids, lips, mouth, or nose.9,25
Transplantation of underlying bone (maxilla/mandible/nose) or tongue is indicated.
Defects are typically the result of trauma, burns, congenital conditions such as neurofibromatosis, or tumor resection resulting in severe irreversible aesthetic, sensory, and motor functions of the face.29
Important functions of the face such as air humidification, nonverbal expression, intelligible speech, breathing, oral competence (ability to chew, swallow, kiss, and control drooling), facial sensation, and eyelid closure are absent.9,43,44,45
Conventional reconstructive options have failed restoration and are deemed unsatisfactory.9,43,44,45
Severe anatomical and functional abnormalities have resulted in detrimental effects on the patient’s psyche, perception of body image, quality of life, and social interactions with loss of integration with family, friends, colleagues, and depression.25
American Society for Reconstructive Transplantation (ASRT) Advisory Council medically necessary Clinical Criteria9,25:
Comprehensive medical history and physical examinations conducted by a plastic and reconstructive surgeon, and/or a craniofacial surgeon, to evaluate the need for transplantation.
Surgical treatment plan (which outlines the surgical approach and the prognosis for improvement of clinical signs/symptoms pertinent to the diagnosis) has been developed.
Comprehensive medical history and physical examinations have been conducted by a transplant physician or surgeon to evaluate the physical ability of the patient to undergo transplantation.
Comprehensive psychosocial and mental health examinations have been performed to evaluate the patient’s motivation and ability to successfully manage a VCA allograft.
The patient has had inadequate or failed functional recovery with conventional reconstructive surgical treatment and/or nonsurgical rehabilitation.
The facial defect is accompanied by medical or functional complications and demonstrable loss of quality of life as determined by psychological evaluation.
Primary and secondary diagnoses with clinical symptoms and comorbid conditions
Complete history and physical, prior failed treatments and surgeries
Photographic and radiologic studies confirming the facial defects and the planned surgical treatment
Amputation or irreversible traumatic functional loss.
Failed use of prosthetic devices unless such devices were deemed medically contraindicated.
Patients with congenital deficits should seek opportunities in other clinical trials until research demonstrates plasticity of neural networks.
Eligibility determination is based on a combination of clinical data and indicators affecting the risks and benefits of the transplantation.
Comprehensive medical history and physical examination conducted by a transplant physician or surgeon to evaluate the need for transplantation.
Surgical treatment outlining the approach and prognosis for improvement of clinical findings pertinent to the diagnosis developed.
Comprehensive medical history and physical examination conducted by a transplant physician or surgeon evaluating the health status of the patient to undergo transplantation.
Comprehensive psychosocial and mental health examinations have been performed to evaluate the patient’s motivation and ability to successfully manage a VCA allograft.
Patient is generally over 18 years of age and has had inadequate functional recovery with previous conventional reconstructive surgical interventions and/or nonsurgical rehabilitation.
The amputation or loss of function is accompanied by
Medical or functional complications
Demonstrable loss of quality of life as determined by psychological evaluation
Tissue necrosis or ulcerations unresponsive to nonsurgical treatments
Comorbid etiologies have been considered and ruled out.
Currently, upper extremity and facial VCA procedures are considered “research protocols.”31,35,48,49
Inclusion and exclusion criteria vary between individual institutions including age limitations, infectious disease states, and US citizenship to name a few.15,45,46,50,51,52
Inclusion criteria
Face VCA
Facial defect or injury requiring facial transplantation as determined by the treating plastic and reconstructive surgeon.
Autologous tissue options must be available in the event of facial graft failure.
Recent (<6 months) or remote unilateral or bilateral upper limb loss below the shoulder desiring limb transplantation.
Unilateral arm transplant may be considered at some institutions even if the transplanted arm is the nondominant arm.23
Patient consent to bone marrow transfusion as part of treatment regimen is institution specific.46,52
Blind amputees may be considered poor candidates as sensory return in the hand may not provide sufficient protection; conversely, benefits to blind patients may outweigh this risk (K. Knott, personal communication, October 2nd, 2014. Johns Hopkins University, Transplant Nurse Practitioner).
Preexisting diseases or medical conditions that would negatively impact success.
Expose the patient to unacceptable risks under immunosuppressive treatments.
Unacceptable surgical risk to the recipient from transplantation.
Absolute and relative contraindications are determined by the specific institutional selection committees: diseases may include inherited coagulopathies, connective tissue or collagen diseases, amyloidosis, etc.
Human immunodeficiency virus (HIV) positive (active or seropositive) (relative contraindication).
Hepatitis B or C virus positive (relative contraindication).
Active infection including, but not limited to, tuberculosis, toxoplasmosis, or viral encephalitis.
Current malignancy.
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