BCTXP Exam: Vascularized Composite Allotransplantation

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Types of Vascularized Composite Allotransplantation (VAC)
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Types of Vascularized Composite Allotransplantation (VAC)
Hand
Face
Other: knee, abdominal wall, lower limb, uterus, penile

Tissue transplant, including multiple types (skin, bone, muscle, nerves, tendon, etc.)
When is face txp recommended?
Improves QoL, not survival, so only recommended if severe facial disfigurement after traditional reconstructive methods
VCA registry
International Registry on Hand and Composite Tissue Transplantation (IRHCTT)
-Voluntary reporting
Complications in VCA vs SOT
Similar
Common indications for VCA txp
Upper extremity: explosion, electrocution
Face: trauma
Considerations for listing for VCA txp
-No absolute inclusion/exclusion criteria established
-Defects impairing not only appearance but also critical functions which are difficult to restore with conventional reconstruction techniques
-May actually decrease survival - pt must understand risks
-Generally physically healthy, but many psychiatric disorders from their trauma
Considerations for VCA txp donor
Skin tone
Gender
Age
Indications for face txp
Severe facial injury leading to inability to perform critical functions (speech, eating, vision, breathing, etc.)
Other injuries that can't be reconstructed
VCA pre-txp non-pharmacologic considerations
-Psych disorders related to injuries (trauma, chronic pain, increased risk of estrangement and substance abuse)
-May have limited experience with chronic med use
-Support system and financial hardship after trauma
-Vision, swallowing, fine motor skill abilities
VCA txp common induction regimens
Upper extremity: ATG > IL2 > anti-CD52
Face: ATG >>>IL2

Intraop CS in 97%
Upper extremity txp: common maintenance IS-CNI: 94.8% FK trough 4-15 -AM: 91.2% MPA -CS: 87.5% -mTOR: 9.8% -Belatacept: 4.5%Face txp: common maintenance IS-CNI: 100% FK, trough 10-15 x6m then 8-10 -AM: 95.7% MPA -CS: 95.7% -mTOR: 6.6% -Belatacept: 3.3%VCA txp: how common is use of antimicrobial ppxUET -CMV: 76.4% -Fungal: 77.4% -PJP: 79.2% FT -CMV: 91% -Fungal: 67.7% -PJP: 87%VCA txp: typical antimicrobial ppx durationsCMV: 3-6m Fungal: no consensus PCP: 6-12mInfx complications in VCA compared to SOTAll CMV events have been in D+/R- Most OIs w/in 3mMetabolic complications in VCA compared to SOTSimilarComplications in face txp vs UE txpFace has increased infx and malignancy riskVCA txp rejection classification2007 Banff VCA working classification -ACR -AMR (single case thus far) -Chronic rejection (only 2 cases) Grade II+ generally treatedVCA rejection txMost ACR responsive to bolus systemic steroidsUnique therapies that can be used in VCA txpTopical: CNIs (FK, pimecrolimus), CS -Inconclusive evidence, usually adjunctUnique step to healing in VCANerve regenerationAverage revision surgeries post-VCA txpAverage 1-6 surgeries post-txpFace Transplant recipients have comparable rates of acute rejection (AR) during the first year post‐transplant to kidney transplant recipients: • A Yes, 15% of all face transplant recipient experience AR, compared to 13% of kidney transplant recipients • B Yes, 90% of all face transplant recipient experience AR, compared to 85% of kidney transplant recipients • C No, 15% of all face transplant recipient experience AR, compared to 85% of kidney transplant recipients • D No, 90% of all face transplant recipient experience AR, compared to 13% of kidney transplant recipientsDWhich of the following is the best treatment option for unilateral hand transplant recipient diagnosed with Banff grade 2‐3 acute rejection: • A No treatment is required, continue to visually monitor the allograft and consider therapy when visible lesions appear • B Initiate mTOR inhibitor (sirolimus) to augment immunosuppression and prevent chronic vasculopathy • C Methylprednisolone pulse of 500mg daily x3 doses, plus topical clobetasol daily for augmentation of therapy • D Initiate topical tacrolimus 2 times daily for 14 daysCBlindness is absolute contraindication to face transplant: • A Yes, all centers consider blindness an absolute contraindication transplant due to poor adherence post‐transplant • B Yes, blind face transplant recipients did not report improvement in quality of life as they are not able to visualize it • C No, a number of pre‐transplant blind candidates were transplanted with no difference in outcomes • D No, face transplant candidates gain back sight after the procedureC