Novel Donor Transfer Algorithm for Multiorgan and Facial Allograft Procurement

To the Editor: The non-lifesaving nature of facial transplantation (FT) has raised concerns over the procurement of a facial allograft (FA) and allocated solid organs (SO) from a single donor. In response, FT teams have described their experiences performing simultaneous (1Bueno J Barret JP Serracanta J et al.Logistics and strategy of multiorgan procurement involving total face allograft.Am J Transplant. 2011; 11: 1091-1097Crossref PubMed Scopus (28) Google Scholar) and asynchronous procurement (2Pomahac B Papay F Bueno EM Bernard S Diaz-Siso JR Siemionow M Donor facial composite allograft recovery operation: Cleveland and Boston experiences.Plast Reconstr Surg. 2012; 129: 461e-467eCrossref PubMed Scopus (28) Google Scholar,3Brazio PS Barth RN Bojovic B et al.Algorithm for total face and multiorgan procurement from a brain-dead donor.Am J Transplant. 2013; 13: 2743-2749Crossref PubMed Scopus (20) Google Scholar). One unanimous conclusion is that the safe procurement of lifesaving organs must be given priority during the donor operation (1Bueno J Barret JP Serracanta J et al.Logistics and strategy of multiorgan procurement involving total face allograft.Am J Transplant. 2011; 11: 1091-1097Crossref PubMed Scopus (28) Google Scholar, 2Pomahac B Papay F Bueno EM Bernard S Diaz-Siso JR Siemionow M Donor facial composite allograft recovery operation: Cleveland and Boston experiences.Plast Reconstr Surg. 2012; 129: 461e-467eCrossref PubMed Scopus (28) Google Scholar, 3Brazio PS Barth RN Bojovic B et al.Algorithm for total face and multiorgan procurement from a brain-dead donor.Am J Transplant. 2013; 13: 2743-2749Crossref PubMed Scopus (20) Google Scholar). Another consistent viewpoint is that the ideal location for FA procurement is the FT team’s home institution (2Pomahac B Papay F Bueno EM Bernard S Diaz-Siso JR Siemionow M Donor facial composite allograft recovery operation: Cleveland and Boston experiences.Plast Reconstr Surg. 2012; 129: 461e-467eCrossref PubMed Scopus (28) Google Scholar,3Brazio PS Barth RN Bojovic B et al.Algorithm for total face and multiorgan procurement from a brain-dead donor.Am J Transplant. 2013; 13: 2743-2749Crossref PubMed Scopus (20) Google Scholar). This is due to several factors, including reduced ischemia time and guaranteed availability of specialized microsurgical equipment. Additionally, operating room staff familiarity with the surgical and ethical aspects of FT is crucial; the duration of FA procurement is longer than that of SO, and its graphic nature may distress previously unexposed team members. Operative time may increase further with more complex FA designs (3Brazio PS Barth RN Bojovic B et al.Algorithm for total face and multiorgan procurement from a brain-dead donor.Am J Transplant. 2013; 13: 2743-2749Crossref PubMed Scopus (20) Google Scholar), which may result in professional fatigue (1Bueno J Barret JP Serracanta J et al.Logistics and strategy of multiorgan procurement involving total face allograft.Am J Transplant. 2011; 11: 1091-1097Crossref PubMed Scopus (28) Google Scholar) and complicate coordination with the team performing the recipient dissection. Considering these challenges, the NYU FT team collaborated with LiveOn NY when determining a logistical algorithm prioritizing surgical team safety, SO allograft integrity, and reduced FA ischemia time (Figure 1). Upon FA donor identification and consent, the resulting protocol involves the transfer of the brain-dead donor to (and at the expense of) NYU. To ensure donor safety, a critical care unit–like environment is recreated in an ambulance. On arrival, preoperative evaluations that may not be possible in smaller hospital settings can be performed, including computed tomography, angiography, and cardiac catheterization. The donor is monitored in a critical care unit until all operative teams are confirmed. FA recovery begins and proceeds until source vessels are isolated. SO procurement ensues, and the FT team returns to the operating table after cross-clamp is performed; subsequently, allografts are simultaneously recovered and preserved for transplantation and/or transportation. At all times, NYU SO transplant surgeons are available to coordinate teams, and are prepared to rapidly procure SO allografts should the donor become unstable while non-NYU procurement teams are in transit. On August 12, 2015 a FA donor was identified as an ideal match to a candidate listed at NYU. Following the protocol described above, donor transportation proceeded without complications the following day. On August 14, 2015 FA procurement was performed, lasting 12 h; the donor remained stable throughout, and SO recovery was never at risk. Multiple non-NYU transplant teams successfully procured their allocated SO allografts after cross-clamp. Despite brief mention in the plastic surgery literature of another interhospital donor transport protocol for FT (2Pomahac B Papay F Bueno EM Bernard S Diaz-Siso JR Siemionow M Donor facial composite allograft recovery operation: Cleveland and Boston experiences.Plast Reconstr Surg. 2012; 129: 461e-467eCrossref PubMed Scopus (28) Google Scholar), to our knowledge, this is the first description of such an algorithm in the transplant literature. A study of SO procurements requiring donor transport demonstrated improved efficiency and considerable cost-savings without donor compromise (4Jendrisak MD Hruska K Wagner J Chandler D Kappel D Hospital-independent organ recovery from deceased donors: A two-year experience.Am J Transplant. 2005; 5: 1105-1110Crossref Scopus (5) Google Scholar), an important precedent for NYU’s protocol. Furthermore, while NYU only offers SO allograft recovery as a contingency, reports of liver procurement by local teams show equivalent posttransplant outcomes (5Salvalaggio PR Ferraz-Neto BH Liver grafts procured by other transplant teams do not affect posttransplantation outcomes.Transpl Proc. 2012; 44: 2293-2296Crossref PubMed Scopus (5) Google Scholar). Emphasizing SO allograft integrity and donor safety, FT and SO transplant teams can work efficiently to recover allocated allografts for their respective patients. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.