Assessment of Acute Rejection in a Lung Transplant Recipient Using a Sentinel Skin Flap

Dear Editors,Lung transplantation remains one of the only therapeutic options for patients suffering from end-stage lung disease (1).The long-term outcome of lung transplantation is limited because of acute rejection and chronic lung allograft dysfunction (CLAD) (1).The management of lung transplant recipients hinges on selecting the appropriate dose of immunosuppression which remains challenging and is currently guided by drug levels, clinical parameters, pulmonary function and surveillance transbronchial lung biopsies (TBBX).AR is graded according to the International Society for Heart and Lung Transplantation (ISHLT) grading system (2) which can be inaccurate, non-diagnostic, and carries risks including pulmonary hemorrhage, pneumothorax and death.Less invasive means for diagnosing AR are needed for management of lung transplant recipients.The monitoring of acute skin rejection within vascularized composite allotransplants (VCA) involves a biopsy of the skin and subcutaneous tissue and interpreted using the Banff 2007 working classification (3).AR in VCA requires multiple biopsies and can lead to aesthetic deformities.Hence, "sentinel flaps" have become a useful tool.Sentinel flaps are composed of skin, subcutaneous tissue and the vessels which supply them.They are procured from the same donor and transplanted into a recipient in an easily accessible site.They serve as secondary monitoring sites for rejection.These flaps can easily be biopsied with minimal risks and no pain.We describe the first clinical use of a sentinel flap in a lung transplant recipient.Research ethics board approval was obtained.A local donor was required to minimize flap ischemia time.Donor criteria was restricted to match recipient skin colour.The sentinel flap was procured by a team of plastic surgeons, composed of 4 cm × 8 cm of skin, subcutaneous tissue, radial artery and veins from the forearm of the donor from which the lungs were retrieved.The flap was flushed with heparinized saline solution and preserved under static cold storage at 4 ° C. The lungs were preserved in low potassium dextran solution for transportation.Sentinel flap transplantation was performed in the same setting as lung transplantation by a team of plastic surgeons.The radial artery and veins within the flap were anastomosed in an end-to-end fashion to the recipient vessels in the left forearm under microscope magnification.The time required to perform this procedure was 1.5 h after induction.The preservation time limitation of the sentinel flap kept the total lung preservation time well within the usual clinical time.The first patient to have undergone a sentinel flap procedure with bilateral lung transplantation is currently 3 years post-surgery.At the time of transplantation, the patient was 62 years old with chronic obstructive pulmonary disease with several severe exacerbations.The patient was right hand dominant with an intact palmar arch in the left hand and no history of trauma or surgeries to left upper extremity.The patient consented to undergo both procedures.

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