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Normothermic Regional Perfusion for Controlled Donation After Circulatory Death

A Technical Complication During Normothermic Regional Perfusion

Brogi, Etrusca*; Circelli, Alessandro; Gamberini, Emiliano; Russo, Emanuele; Benni, Marco; Pizzilli, Giancinto; Agnoletti, Vanni

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doi: 10.1097/MAT.0000000000000963
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Organ donation after circulatory death (DCD) refers to the category of donation taking place after death declared on the basis of cardiopulmonary criteria in contrast to the neurologic criteria used to declare brain death.1 Through the years, several classifications attempted to identified the different types of donors in distinctive end-of-life situation.1–3 However, DCD can be condensed in two principal types, controlled and uncontrolled. The organ procurement from donors after unexpected cardiac arrest or unsuccessful resuscitation is defined as “Uncontrolled DCD.” By contrast, controlled DCD indicates the organ procurement after planned withdraw of life-sustaining therapy.1 The whole organ procurement team has to deal with numerous challenges during the overall process of organ procurement: from the education of public and healthcare team, the family emotional and spiritual support, the identification of potential donors meeting the eligibility criteria, the matching/allocation of the organs, to the hemodynamic optimization and maintenance of effective end-organ perfusion.

After death, the cells are no longer supplied with oxygen and nutrients, leading to a shift from aerobic to anaerobic metabolism. The alteration of sodium-potassium pumps, the influx of free calcium into the cells, and the activation of phospholipases are direct consequences of the fall of ATP production. Even more, the accumulation of xanthine and free radicals, from ATP degradation, is responsible of lipid peroxidation and further cellular damage. Normothermic regional perfusion (NRP) during DCD, using a pump-driven extracorporeal circuit with membrane oxygenator, allows the perfusion of the abdominal viscera with a continuous flow. However, NRP not only restore the flow of oxygenated blood to the abdominal organs but also may reverse the effects of warm ischemia and consequently improve graft survival.4 In fact, besides avoiding the depletion of cellular energy, NRP also prevents the accumulation of waste products (i.e., nucleotide degradation products) and improves the concentration of antioxidants.5,6 Nevertheless, potential technical complications may occur on NRP, especially during first-center experience with this technique.7

In our case report, we present the description of a technical complication arisen during an NRP for DCD. We believe that it is remarkable to describe this case because, as a consequence of this complication, our clinical practice was modified and implemented. Even more, we believe that it is vital to report widely the technical challenges and complications of relatively new technique to spread knowledge of the risks and improve the safety and the effectiveness of this practice.


A 66 year old man was admitted to our intensive care unit for nontraumatic acute subdural hematoma (ASDH). He previously arrived to the emergency department with a story of headache, nausea, and a progressive deterioration of consciousness (Glasgow Coma Scale (GCS) = 5, M3). There was no history or obvious findings of head trauma. He was intubated and transferred to the radiology department. The three-dimension computed tomography angiography revealed the presence of a right-sided ASDH, subarachnoid hemorrhage, and a midline shift of 15 mm without abnormality of vessels (including aneurysm or arterial-venous malformation). Consequently, the patient was transferred to the operating room (OR) where he underwent emergency craniotomy for hematoma removal. After removing the hematoma, a complete hemostasis was achieved, intraparenchymal intracranial pressure monitoring inserted and the bone flap refixed. The following day, an episode of intracranial hypertension was observed. computed tomography (CT) scan was quickly performed and revealed that ASDH hematoma was caused by rebleeding. The patient underwent decompressing craniotomy and hematoma was removed. Postoperative CT, after the second surgery, showed that the ASDH was removed. CT also showed an extensive ischemic region of the right hemispheric and cerebral swelling. Critical care physician and neurosurgeon come to the conclusion that this was a nonsurvivable injury and brain death no longer appeared to be the likely outcome. After discussion of this prognosis with the family, a consensus to withdraw life support (i.e., cardiorespiratory support) was achieved and palliative sedation was started. After death assessment (absence of electrical cardiac activity for 20 min on Electrocardiography (ECG) in respect of Italian law), the maneuvers aimed at maintaining the functionality of organs was started (i.e., external cardiac massage). Contemporarily, two operators cannulated the femoral vessels (i.e., artery and vein), at the bedside in intensive care unit (ICU). Cannulation was performed using a percutaneous approach and a radiological control of catheter position was performed (Figure 1). A supradiaphragmatic intra-aortic balloon was positioned in zone 1 (Figure 2). Noteworthy, no immediate flush of blood was observed during venous cannulation; consequently, repositioning of the venous cannula had to be performed. We used a Xenios AG iLA-active platform with Novalung Xlung kit for the extracorporeal treatment plus an HLS MAQUET venous (23 Fr, 38 cm) and Novaport One arterial cannula (19 Fr, 15 cm). Then, NRP was started. At the beginning of NRP, a high negative inflow pressures was observed (−72 mm Hg); higher suction proportionately to cannula diameter. First, it was speculated that venous drainage was impeded for the hypovolemic status of the patient and, consequently, fluids was administered to improve the volume status. A decrease in the negative inlet pressure (−47 mm Hg) with a good blood flow (3 L/min; 5,700 rpm) was observed. Then, the patient was transferred to the OR to perform organ donation. In the OR, during the transfer of the patient from his bed to the operating table, the blood flow dramatically decreased (267 L/min; 500 rpm) with excessive negative inlet pressure (−345 mm Hg). The surgeon was suddenly advised of this technical complication and of the patient hemodynamic instability; then, the surgical team performed quickly a laparotomy and the cold perfusion initiated. During the surgery, the rate for a minute of the pump was increased (9,000 rpm) and fluids administered. It was possible to maintain an adequate blood flow (2,591 L/min) to accomplish organ donation. Both kidneys and the liver were retrieved and transplanted later that day successfully. Observing the operative field, it was possible to comprehend that the excessive negative pressure and the decrease in blood flow of the pump were because of venous cannula malposition. In fact, a part of the cannula was outside of the vessel lumen, near the right renal vein, surrounded by a hematoma (Figure 3).

Figure 1
Figure 1:
Radiological control of catheters’ position.
Figure 2
Figure 2:
Radiological control of aortic balloon catheter.
Figure 3
Figure 3:
Venous cannula malposition.


This case report described a technical complication occurred during an NRP for controlled DCD. Regardless of this issue, the donation was accomplished successfully. We reckon that we were able to maintain an adequate blood flow at the beginning of NRP because of the intrinsic configuration of the venous cannula. In fact, this cannula presents a series of multiple lateral holes along the course. Consequently, a couple of lateral holes were outside the venous vessel (surrounded by hematoma) and the rest of lateral holes were inside the vessel. It is most likely that during the percutaneous procedure, the vessel wall was perforated by the guidewire. Consequently, the catheter passed out through the wall of the vein and migrated out of the vessel. This finding is remarkable, because, despite inferior vena cava (IVC) perforation, the consequent injury resulted in tamponade (retroperitoneal hematoma) and, consequently, it was possible to obtain an adequate blood flow during NRP to complete successfully the DCD.

Furthermore, it is also important to highlight that radiological control was performed only for catheter position (Figure 1) but not for wire position. It is reasonable to speculate that if radiological control of the wire had performed, it would have been possible to observe in advance an abnormal position of the wire (outside the venous lumen) and subsequently to reposition it. As a consequence, our clinical practice was modified. Currently, a radiological control of the wire is performed before the insertion of the catheter. Additionally, to reduce this kind of technical complication, the implementation of transesophageal echocardiography should be evaluated during percutaneous access. In fact, the bicaval view allows the visualization of the passage of the wire from the IVC to the superior vena cava; ensuring that the venous wire is in the right place.8

In conclusion, technical complications represent a critical concern during extracorporeal treatments. This aspect highlights the importance of the early identification and management to a safe and effective practice. Furthermore, we want to emphasize the importance of reporting also the technical complications that may arise during a relatively new method to spread the awareness of the potential risk and to discuss and develop strategies to avoid and manage complications.


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normothermic regional perfusion; controlled donation after circulatory death; technical complications; extracorporeal treatments; critical care

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