**9. Bronchial artery revascularization**

Bronchial Artery Revascularization has been done to alleviate the Achilles heel of lung transplantation which bronchial healing. This has been an area of intense focus especially since the early issues that lung transplantation had with tracheal dehiscence and bronchial dehiscence. However, it is very labor intensive and has not taken off as a major standard of practice yet. There are a few proponents of this technique who have shown excellent results [22]. One of these groups is the Cleveland Clinic, championed by Prof. Gosta Pettersson who has worked on it for a long time since his days in Denmark. He has trained several surgeons in the Cleveland Clinic with this approach [23].

As one is aware, the lung has dual blood supply. One is from the bronchial arteries and one is from the pulmonary arteries. The major idea of the BAR procedure is to procure the lungs as we normally do, but to also retain the bronchial arteries from their origins in the aorta. In order to achieve this, the lungs are removed en bloc with the trachea intact like they are in a standard procedure, except this time

the thoracic esophagus and descending aorta accompany them as well. This way, the RICBA and left bronchial arteries are included.

After IV heparin administration, the donor aorta is cross clamped and cold lung perfusate is administered via the PA. Normally we flush the lungs with 4–6 L of perfadex. 4 Liters are used for antegrade perfusion and then 1 Liter perfadex for retrograde perfusion on the back table. One liter of perfedex must be infused into the descending aorta. A cross clamp should be put on the aortic arch to keep the solution from escaping. This ensures perfusion of the bronchial arteries which come off the descending thoracic aorta. The NG tube is pulled back (but not all the way, because it is still important to keep it in the esophagus) before stapling the esophagus off- this is to ensure the NG tube is not stapled inside the esophagus. Then one must go around to the aorta and transect it at the level of the diaphragm. To prevent spillage the esophagus must be also be stapled off as high as possible at the neck. Keep in mind that one must try to minimize the dissection around the trachea. The trachea is also stapled off as high as possible [22].

Finally, the double lung bloc and its accompanying tissue is excised from the donor while moving cranially. Be sure to include the paraspinal tissue as well to minimize any possibility of injury to the bronchial arteries. The PA is divided near its bifurcation, and sufficient left atrial cuff is harvested in standard fashion.

After arrival in the recipient operating room, the esophagus is separated on the back table. After the esophagus is removed, the descending aorta is opened vertically in the midline and the bronchial arteries identified. The surgeon must locate the RICBA and the left bronchial artery. The use of a coronary probe can help in this matter. The RICBA is identified in the right. On the right, once the RICBA is identified, clips are applied to its intercostal branch. The left bronchial artery (or arteries) is/are identified with probing if needed. On either side, a single bronchial artery of reasonable size is usually sufficient for complete revascularization. However, if a convincing bronchial artery is not identified or if an important bronchial artery is damaged, BAR should be aborted and standard bilateral sequential LTx should be performed [22].
