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Facing Graft Failure: A Systematic Review of Explantation and Retransplantation in Vascularized Composite Allotransplantation
Alexis K. Gursky
*1, Y. Edward Wen
1, Anandhini Narayanan
1, Shaina M. Staffenberg
1, Hailey P. Wyatt
1, Sergio A. Segrera
1, Bruce E. Gelb
2, Daniel J. Ceradini
1, Eduardo Rodriguez
11Hansjörg Wyss Department of Plastic Surgery, New York University Langone, New York, NY; 2Transplant Institute, Department of Surgery, New York University Langone, New York, NY
Background: Vascularized composite allotransplantation (VCA) can restore function and aesthetics beyond conventional reconstruction, but acute (AR) and chronic rejection (CR) limit long-term allograft survival. When medical management fails, explantation or retransplantation may be required. This review examined the indications, immunologic features, rejection management, and operative considerations for VCA explantation and retransplantation.
Methods: A systematic review of PubMed, PubMed Central, MEDLINE, Scopus, and Web of Science to identify studies reporting patient-level data on VCA recipients who underwent allograft explantation or retransplantation. Extracted data included recipient demographics, immunologic characteristics, rejection history, and explantation or retransplantation outcomes.
Results: Nineteen studies reporting 25 VCA recipients were included, comprising 22 explants and three retransplants (two face, one abdominal wall). The most common VCA types were uterus (32%), face (24%), and hand (16%). The leading indications for graft removal were CR (44%), perfusion-related complications (32.0%), medication non-compliance (24.0%), and at the patient's request (12.0%). The median time to explant was 12.5 months, and to retransplant was 7.3 years. Management of CR included pulse steroids, increased immunosuppression, plasmapheresis, and biologic agents. Retransplantation was more technically challenging than the primary transplant due to scarring, distorted anatomy, and vessels affected by CR, requiring more proximal vascular anastomoses and nerve coaptations.
Conclusion: Explantation and retransplantation in VCA are feasible but last-line interventions. The leading cause of graft loss was CR, though perfusion-related and patient-related factors also contributed. Earlier recognition and management of AR, clearer definitions of CR, and overall improved strategies to prevent progression to irreversible graft failure are needed.
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