Uterus transplantation: a rescue technique to save the viability and functionality of the graft after intra-operative outflow thrombosis
Giuseppe D'Amico, M.D.,
Koji Hashimoto, M.D.,
Luca Del Prete, M.D.,
Elliott Richards, M.D.,
Stephanie Ricci, M.D.,
Rebecca Flyck, M.D.,
Bijan Eghtesad, M.D.,
Teresa Diago, M.D.,
Tommaso Falcone, M.D.,
Charles Miller, M.D.,
Andreas Tzakis, M.D.,
Cristiano Quintini, M.D.
Affiliations
Giuseppe D'Amico, M.D.
Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
Koji Hashimoto, M.D.
Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
Luca Del Prete, M.D.
IRCCS Fondazione Ca’ Granda Ospedale Maggiore Policlinico di Milano, General Surgery and Liver Transplant Unit, Milan, Italy
Elliott Richards, M.D.
Department of Obstetrics, Gynecology and Reproductive Biology, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
Stephanie Ricci, M.D.
Department of Obstetrics, Gynecology and Reproductive Biology, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
Rebecca Flyck, M.D.
Division of Reproductive Endocrinology and Infertility, University Hospitals, Beachwood, Ohio
Bijan Eghtesad, M.D.
Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
Teresa Diago, M.D.
Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
Tommaso Falcone, M.D.
Department of Obstetrics, Gynecology and Reproductive Biology, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
Charles Miller, M.D.
Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
Andreas Tzakis, M.D.
Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
Cristiano Quintini, M.D.
Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio; Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Correspondence: Cristiano Quintini, M.D., Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, 112412, United Arab Emirates.
Objective: To study a surgical approach to venous vascular thrombosis after uterus transplantation (UTx). Uterus transplantation is the only treatment for uterine factor infertility when conventional therapies are not possible. One of the major limitations of UTx is the high incidence of vascular thrombosis, which in most series reaches approximately 20%. Design: A case report. Setting: Hospital. Patients: We report here a technique used in a 30-year-old woman with congenital absence of the uterus who developed intraoperative thrombosis after a UTx from a brain-dead donor. Intervention: The UTx was performed by revascularizing the graft through bilateral donor internal iliac vessels (artery and vein) anastomosed end-to-side to the external iliac vessels of the recipient. The superior uterine veins were not anastomosed and were left unreconstructed. An end-to-end graft to the recipient’s vaginal anastomosis was performed. After uterus reperfusion, congestion of the organ was noted, and bilateral venous thrombosis of the internal iliac veins of the graft was found. A “Y-shaped” venous jump graft was used to restore venous outflow of the left superior uterine vein and the internal iliac vein of the graft after thrombectomy. Main Outcome Measures: Viability and functionality of the uterus graft after intraoperative bilateral venous thrombosis. Results: The postoperative course was uneventful, and this UTx resulted in the delivery of a healthy infant. Conclusion: To our knowledge, this is the first successful rescue technique used to restore venous outflow and save the viability and functionality of a transplanted uterus. We demonstrated that a transplanted uterus from a deceased donor with a monolateral outflow could succeed in pregnancy and the delivery of a healthy infant.
