Balancing Preservation and Maximizing Utilization: A DCD Lung Procurement Strategy During Abdominal Normothermic Regional Perfusion

Chawannuch Ruaengsri ^1,* , Miguel Alvarez-Cortes ^1,2 , Marc Leon ¹, Manuel Quiroz-Flores ¹, Masafumi Shibata ¹, Yasuhiro Shudo ¹

1. Stanford University, CA, USA

2. University of Puerto Rico School of Medicine, San Juan, PR 00936, USA

* Correspondence: Chawannuch Ruaengsri 

Academic Editor: Chiara Lazzeri

Special Issue: Organ Preservation and Distribution

Received: June 30, 2025 | Accepted: January 21, 2026 | Published: January 22, 2026

OBM Transplantation 2026, Volume 10, Issue 1, doi:10.21926/obm.transplant.2601265

Recommended citation: Ruaengsri C, Alvarez-Cortes M, Leon M, Quiroz-Flores M, Shibata M, Shudo Y. Balancing Preservation and Maximizing Utilization: A DCD Lung Procurement Strategy During Abdominal Normothermic Regional Perfusion. OBM Transplantation 2026; 10(1): 265; doi:10.21926/obm.transplant.2601265.

© 2026 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

With the increasing demand for organ transplantation, optimizing the use of every available organ from each donor is both an ethical obligation and a logistical necessity. Donation after circulatory death (DCD) presents a vital opportunity to expand the donor pool, but these organs are often more susceptible to injury, necessitating meticulous management to ensure their viability for transplantation [1].

Abdominal normothermic regional perfusion (A-NRP) has emerged as an effective strategy for preserving abdominal organs in DCD donors [2]. However, utilizing DCD lungs during A-NRP can be challenging due to issues such as blood loss and fluid volume management. Some transplant centers favor direct recovery methods to evaluate lungs directly, while all teams must work swiftly and precisely, relying on measurable parameters to guide their decisions.

Various techniques have been developed to minimize blood loss and ensure that A-NRP does not compromise lung quality. This chapter will explore these strategies, focusing on how to maximize DCD lung procurement during A-NRP to improve outcomes and expand the donor pool.

2. A-NRP Cannulation

The implementation of NRP reintroduces a flow of oxygenated blood after cardiac arrest, effectively reversing the ischemic cascade and facilitating organ function assessment prior to procurement [3]. This approach contrasts sharply with traditional in situ cooling and rapid procurement techniques, which lack the ability to evaluate organ viability. Notably, A-NRP has been associated with a lower incidence of ischemic cholangiopathy, liver graft dysfunction, and delayed kidney graft function, underscoring its potential to improve outcomes in abdominal organ transplantation [2]. The adoption of NRP varies across Europe, with established DCD organ procurement programs in countries like France, Italy, Spain, the UK, Belgium, the Netherlands, Norway, and Switzerland. While Spain employs NRP routinely, it is mandated for liver procurement in France and Italy [1].

The technical aspects of NRP involve either pre- or post-mortem cannulation, depending on the legal framework of the country. For instance, Spain permits pre-mortem cannulation and heparinization to reduce warm ischemic time, with explicit consent obtained from the next of kin [4]. This involves peripheral femoral vessel cannulation, and the administration of heparin before cannulation is also allowed in Belgium, France, Norway, Spain, and Italy. Following vascular access, and depending on whether ante- or post-mortem, various methods are used to isolate flow distally to the cross-clamp. For A-NRP, upon confirming death, either aortic cross-clamp above suprailiac, a vascular clamp applied in the chest, or an intra-aortic occlusion balloon is positioned to block descending thoracic aorta to prevent ascending flow into the brain [5].

During the A-NRP process, various parameters such as flow, pH, temperature, and hematocrit are meticulously monitored and maintained within target ranges. After confirming death, the aortic occlusion balloon is inflated, ECMO is initiated, and surgical teams proceed with organ procurement, including lung perfusion, cold storage, and thorough inspection to determine suitability for transplantation (Figure 1) [5,6]. The duration of A-NRP typically ranges from 30 minutes to 4 hours, with 90-120 minutes considered routine practice, though the optimal duration remains a subject of ongoing debate [4].

Figure 1 Schematic flowchart of the donation after circulatory death (DCD) lung procurement workflow. The diagram depicts (1) confirmation of death, followed by (2) extracorporeal membrane oxygenation (ECMO) initiation, and culminating in (3) organ-procurement activities—inspection for graft suitability, lung perfusion, and cold storage.

When post-mortem cannulation is performed, the descending thoracic aorta is occluded to prevent flow into the upper body, but this is not usually performed in cases of premortem cannulation [7,8]. A rapid laparotomy is performed with direct cannulation of vessels.

The ability to cannulate ante- or post-mortem requires knowledge of the patient and legal policies, which vary among countries [9]. Regardless, these techniques enable greater allograft function and increase the possible donor pools.

3. Minimizing Blood Loss During A-NRP: Techniques to Support Thoracic and Abdominal Organ Viability

A key challenge during DCD lung procurement with concomitant A-NRP is managing blood loss within the thoracic cavity. Excessive bleeding can impair the viability of abdominal organs by reducing blood flow to the abdominal organs while maintaining perfusion during A-NRP. Therefore, implementing strategies to minimize blood loss is essential for optimizing the success of multi-organ DCD procurement involving A-NRP.

3.1 Scenario 1: Lung Procurement with A-NRP, No Heart Retrieval

When hearts are not intended for transplantation, DCD donors are prepared for lung procurement with concurrent A-NRP. Following the declaration of death and a 5-minute hands-off period, the abdominal team begins by opening the abdominal cavity and initiating cannulation for A-NRP. Simultaneously, the thoracic cavity is opened. Prior to starting A-NRP, the thoracic aorta is clamped within the chest by first opening the left pleural space and lysing the left inferior pulmonary ligament to expose the descending thoracic aorta. The clamp can alternatively be applied to the abdominal aorta inside the abdomen (Figure 2). A vent (DLP cannula) is then placed at the aortic arch, or in some cases, the aortic arch vessels are transectioned and opened to air, which may increase the risk of significant blood loss during the combined procedure. To mitigate this risk, selective cannulation and drainage of vessels are recommended as preferable alternatives. The aortic clamp is applied to isolate A-NRP from the thoracic circulation. This setup ensures that the brain is not perfused—confirmed by the absence of blood flow through the DLP cannula—and does not negatively impact cardiac function [10].

Figure 2 This diagram illustrates abdominal normothermic regional perfusion (A-NRP) during DCD lung recovery. Panel A: The abdominal aorta is clamped to prevent perfusion to the upper body and brain. The heart remains asystolic, allowing for the immediate retrieval of thoracic organs using the direct procurement technique. Panel B: An aortic occlusion balloon is deployed as an alternative to the traditional aortic cross-clamp.

3.1.1 Management of the Azygos Vein

Controlling the azygos vein during A-NRP is essential to prevent significant blood loss. This can be achieved through suture ligation or stapling. If the azygos vein is not identifiable until the initiation of A-NRP, attention should be directed to the proximal superior vena cava (SVC) specifically at the SVC-right atrial junction and the SVC-innominate vein junction on either side. Proper delineation and secure ligation of the azygos vein (Figure 3) are critical steps to ensure effective and safe perfusion [11].

Figure 3 This image illustrates the azygous vein ligation during A-NRP to prevent significant blood loss [12,13].

3.1.2 Clamping of the Inferior Vena Cava (IVC)

Conventionally, the IVC is clamped immediately after the descending thoracic aorta, regardless of whether A-NRP has been initiated. We recommend delaying IVC clamping until after starting A-NRP to allow drainage of the supra-diaphragmatic body and right heart into the NRP reservoir. This approach enables us to utilize donor blood for priming the reservoir, reducing the need to use blood from the blood bank. Typically, within 5 to 15 seconds of starting NRP, the heart appears deflated or drained, marking the optimal time to clamp the IVC, followed by clamping the SVC. Alternatively, a stapler can be used to close and transect the IVC. Using a stapler or oversewing the IVC can prevent clamp slippage during liver mobilization, thereby saving time and minimizing blood loss in case of inadvertent clamp release [11].

3.1.3 Drainage of the Pulmonary Artery

The previous step, involving delayed IVC clamping for right heart drainage, does not facilitate pulmonary artery (PA) drainage due to competent pulmonary valve. To address this, blood is rapidly drained by suctioning through a large-bore cannula inserted into the PA (Figure 4). This method can serve as an alternative to drainage from the right atrial appendage (RAA), particularly when avoiding incisions at the RAA is desired. We recommend a large-bore (cannula with medium-level suction) to prevent PA collapse and hemolysis. The process is straightforward, allowing for quick autologous blood drainage, which aims to reduce reliance on the blood bank for NRP circuit priming or ex-vivo heart perfusion circuit priming. The cannula is connected to sterile suction tubing with a blood collection reservoir. Typically, up to 800 ml of blood can be collected from the PA within 1 to 2 minutes. Once blood flow ceases, the PA cannula is clamped, and the suction tubing is disconnected and attached to a large-bore suction tip. At this point, the PA cannula can now be used for lung flush [11].

Figure 4 Pulmonary Artery Cannulation and Blood Collection Technique. A diagram representation of pulmonary artery (PA) cannulation for autologous blood collection during DCD lung procurement with A-NRP. The diagram illustrates large-bore cannula placement within the PA, connection to sterile suction tubing, and the blood reservoir. This technique facilitates rapid drainage of pulmonary blood, reduces hemolysis risk, and provides blood for NRP circuit priming.

Next, the left atrial appendage and right atrial appendage are cut and opened for venting while the lung flush is performed. Additional blood vented into the pericardium can then be collected into the reservoir or cell saver and then returned to the A-NRP circuit. Blood gas analysis of the reservoir can evaluate hematocrit, lactate, potassium, and hemolysis, which helps limit the use of blood from the blood bank and guide the optimal utilization of this autologous blood within the NRP system as needed.

3.1.4 Lung Procurement

Early donor intubation and ventilation in Donation after Circulatory Death (DCD) lung recovery is a critical strategy that involves quickly placing a breathing tube and initiating protective ventilation shortly after circulatory arrest [14]. This practice not only facilitates the prompt re-initiation of mechanical ventilation, minimizing the effects of warm ischemia on lung allografts, but also allows for better distribution of the flush solution. Following circulatory arrest, the lung parenchyma rapidly depletes its oxygen reserves, leading to cellular hypoxia and the onset of ischemic injury [15]. Typically performed by an anesthesiologist or a Certified Registered Nurse Anesthetist (CRNA), immediate re-intubation and subsequent mechanical ventilation promote early alveolar recruitment and re-oxygenation of lung tissue. This approach aims to prevent progressive cellular damage and reduce atelectasis, which can compromise lung viability. Ultimately, implementing early donor intubation and ventilation can lead to improved recipient outcomes, including decreased primary graft dysfunction (PGD) and shorter ventilation times [16,17].

Antegrade pulmonary perfusion with Perfadex solution is delivered through the PA cannula. Cardiectomy can be performed at this time, or the heart can be procured en-bloc with the lungs. Aortic arch vessels and SVC are securely ligated to avoid bleeding. Retrograde perfusion can be performed either in-situ or on the back table after lung removal [18]. The lung procurement proceeds as usual: paratracheal soft tissue is meticulously dissected using cautery, with visible blood vessels ligated or clipped to ensure hemostasis. The lungs are then recruited, and the trachea is stapled and transected before carefully delivering the lungs out of the thorax. After lung retrieval, meticulous hemostasis can be performed in the chest by the thoracic assistant surgeon or the abdominal surgeon, paying particular attention to the intercostal arteries to prevent significant bleeding that could compromise the A-NRP flow. Following this, the lung should be prepped and stored immediately before being transported to the recipient hospital without delay.

3.2 Scenario 2: Combined Lung and Heart Procurement with A-NRP and Ex Vivo Heart Perfusion

In this scenario, both the lungs and heart are procured for transplantation, with A-NRP used to preserve abdominal organs. For the heart and lung recovery, a direct procurement (DP) is employed, utilizing ex-vivo heart perfusion with the Transmedics Organ Care System (OCS) (Figure 5).

Figure 5 Ex-Vivo Heart Perfusion Using the Transmedics Organ Care System (OCS). This schematic illustrates the process of ex-vivo heart preservation during combined lung and heart procurement from DCD donors. Key features include the Transmedics OCS system and the blood flow pathways for myocardial reanimation and heart function assessment prior to transplantation. This image has been reproduced by permission of Transmedics (Andover, MA).

Autologous donor blood drainage is required for priming the ex-vivo heart perfusion device. Blood from the blood bank cannot be used for this purpose due to high potassium levels, which would impair myocardial reanimation within the machine. Accordingly, during simultaneously performed chest and abdominal cavity openings, donor blood is collected by cannulating the right atrial appendage, typically yielding 1200-1400 cc of blood for the Transmedics system [19].

Additional blood from the blood bank is then needed to prime the A-NRP circuit, compensating for blood loss during the collection process and ensuring adequate perfusion. Once blood collection is complete, the IVC, thoracic aorta, or abdominal aorta are clamped prior to initiating A-NRP. The azygos vein, aortic arch vessels, and SVC are ligated or stapled to secure hemostasis.

Following these preparations, heart and lung procurement are conducted using meticulous surgical technique to minimize bleeding and ensure optimal organ quality. To save time and avoid excessive bleeding, the heart and lungs can be procured en-bloc [12,13]. The lungs are then retrograde flushed and stored, while the heart is preserved using the ex-vivo perfusion system, facilitating assessment and preservation before transplantation [12,13].

3.3 Hypothermic Oxygenated Perfusion for DCD Heart Preservation

Recent advancements in heart preservation for Donation after Circulatory Death (DCD) have introduced novel techniques, notably direct procurement followed by hypothermic oxygenated perfusion (DP-HOPE) [20]. A report detailing the first three clinical cases of DCD heart transplantation using this method noted that the donors, categorized as Maastricht III and aged 40-52 years, experienced functional warm ischemic times of 15-21 minutes. All donor hearts were perfused using the XVIVO Heart Assist Transport (Figure 6), maintaining stable aortic flows during a total out-of-body time of 4-6 hours. Post-transplant, all three recipients were easily weaned off cardiopulmonary bypass and extubated in the operating room, with transesophageal echocardiography showing good biventricular function without significant inotropic support. Notably, none of the patients experienced Primary Graft Dysfunction (PGD), and all are in good health at follow-up periods of 110, 90, and 55 days [20]. Similarly, another study reported the first North American experience utilizing a novel portable hypothermic oxygenated perfusion device (HOPE) for direct procurement of DCD cardiac allografts [21]. In this study, five patients underwent orthotopic heart transplantation, with an average preservation time of 298 minutes and no cases of severe PGD observed. While one patient unfortunately died due to extracardiac complications, all surviving patients achieved acceptable functional outcomes [21]. Together, these findings underscore that DP-HOPE is a promising strategy for improving and simplifying DCD heart procurement and preservation, warranting further research and clinical trials to optimize outcomes in heart transplantation.

Figure 6 This picture demonstrates the XVIVO heart preservation system, the heart is immersed in a cold, oxygenated perfusion solution within a protective reservoir. A pressure-controlled pump regulates the perfusion pressure during the process. Additionally, the system is equipped with integrated sensors that monitor real-time flows, pressures, and temperatures. This picture has been adapted by permission of XVIVO perfusion, Inc.

Recently, the team at Vanderbilt University Medical Center have developed a pioneering method for recovering hearts from DCD donors, known as rapid recovery with extended ultra-oxygenated preservation (REUP) [22,23]. This innovative approach involves flushing the donor heart with a cold, oxygenated preservation solution immediately after circulatory death, avoiding the ethical concerns associated with normothermic regional perfusion (NRP) and the high costs linked to ex-situ perfusion systems. The new technique has demonstrated similar outcomes compared to existing methods, with successful applications in donor hearts for transplantation [22]. This method could vastly expand the availability of donor hearts and has the potential for broader applicability to other organs, such as livers, kidneys and lungs [23].

3.3.1 Results of DCD Lung Transplantation with Abdominal Normothermic Regional Perfusion (A-NRP)

Normothermic Regional Perfusion (NRP) has emerged as a prominent strategy for optimizing organ quality in donation after circulatory death (DCD) transplantation. While standard rapid recovery (SRR) has demonstrated positive results in DCD lung transplantation, abdominal organs like livers and kidneys often face higher complication rates. Consequently, NRP aims to mitigate warm ischemic injury during DCD organ procurement.

European studies, mainly from Spain, have investigated abdominal in-situ NRP (A-NRP) in combined lung and liver procurement from controlled DCD (cDCD) donors, focusing on outcomes in lung transplantation. These studies suggest that using A-NRP does not negatively affect the procurement rate of abdominal organs [8,24]. Comparing DCD lung recipients to those from brain-dead donors (DBD), results indicate comparable rates of grade 3 primary graft dysfunction (PGD) and similar lung transplant survival at 1 and 3 years, suggesting that the technique is effective [1,24]. In general, PaO₂/FiO₂ levels in the ICU are comparable between DCD and DBD lung recipients. Although previous data reported a higher incidence of grade 3 PGD with A-NRP [25], a recent Spanish multicenter study did not find a higher incidence of PGD in the A-NRP group [26]. This emphasizes the variability in early postoperative allograft outcomes. A study comparing A-NRP with SRR in single centers find equal PGD levels [1].

In most DCD lung transplant series, when A-NRP is used, 30-day mortality and midterm survival rates are similar to DBD lung transplant outcomes [1,25,26]. This overall picture emphasizes comparable or near-comparable outcomes between DCD lungs procured with NRP and DBD lungs procured with standard techniques, making a solid argument for NRP's role in growing the donor pool.

4. Future Directions and Challenges

Advancing organ preservation strategies such as A-NRP requires concerted efforts to standardize protocols across centers, ensuring consistency and safety in implementation. Establishing consensus guidelines through multicenter collaborations and expert panels will facilitate uniform practices, reduce variability, and enhance transplant outcomes. Large-scale, prospective registries and multicenter trials are essential to generate robust long-term data on graft durability, recipient survival, and late complications, thereby validating A-NRP and related techniques as mainstays of practice (Table 1).

Table 1 Future Directions and Challenges in DCD Lung Procurement.

Addressing ethical and logistical challenges is equally critical. Clear policies must be developed to navigate issues related to pre-mortem interventions, consent, and legal frameworks, which vary across regions. Transparent communication with donor families and the public will foster trust and uphold donor autonomy. Logistically, infrastructure development, including specialized operating rooms, perfusion equipment, and trained multidisciplinary teams is vital to support these complex procedures [1].

Technological innovations offer promising avenues to further improve outcomes. Advances in vessel sealing devices, minimally invasive cannulation techniques, and pharmacologic agents aimed at reducing bleeding and ischemic injury hold potential to streamline procedures and expand organ utilization. Combining A-NRP with emerging modalities such as ex-vivo lung perfusion (EVLP) can improve assessment and rehabilitation of marginal lungs, increasing their transplant eligibility.

Finally, ongoing research to refine optimal perfusion durations, evaluate long-term clinical outcomes, and develop ethical frameworks for resource allocation will be fundamental. Multidisciplinary collaboration, including clinicians, ethicists, policymakers, and transplant organizations is essential to ensure these innovations are implemented ethically and sustainably, ultimately maximizing donor organ utilization and saving more lives.

5. Implementation and Practical Considerations

Successful adoption of advanced DCD organ procurement techniques, such as combined thoracic and abdominal approaches with NRP, demands meticulous planning, seamless multidisciplinary coordination, and adherence to established protocols. Building dedicated teams, including thoracic and abdominal surgeons, anesthesiologists, perfusionists, nurses, and coordinators is fundamental. Regular joint training sessions, simulation exercises, and clear communication pathways are essential to ensure optimal teamwork, technical proficiency, and rapid intraoperative response.

Developing and implementing standardized protocols is critical to ensure consistency, safety, and efficiency across centers. These protocols should encompass all stages, from donor stabilization and timing of WLST to vessel cannulation, blood collection, perfusion parameters, and organ retrieval procedures (Figure 7). Proper blood management strategies, including autologous blood collection, can minimize transfusion needs and reduce associated risks.

Figure 7 Standardized Workflow for DCD Lung Procurement with A-NRP. A comprehensive flowchart summarizing the procedural workflow for lung procurement during A-NRP in DCD donors. The sequence includes donor stabilization, withdrawal of life-sustaining therapies (WLST), vessel cannulation, initiation of NRP, organ assessment, procurement, and cold storage. The schematic emphasizes multidisciplinary coordination and procedural efficiency.

Legal and ethical considerations vary by region, requiring careful navigation. Clear policies must be established to address consent, pre-mortem interventions such as heparinization and vessel cannulation, and the legality of such procedures. Engaging with ethics committees and legal entities ensures compliance and transparency, maintaining public trust [27].

Training personnel through simulation-based education is vital for mastering complex procedures like vessel cannulation, perfusion management, and complication handling. Regular skill-building exercises reduce intraoperative errors, improve efficiency, and optimize organ preservation outcomes.

Infrastructure investment, including specialized operating rooms, ECMO circuits, perfusion devices, and monitoring tools is necessary to support these complex procedures. Ensuring availability of equipment and trained staff reduces procedural delays, improves organ quality, and maximizes utilization rates (Table 2).

Table 2 Checklist for the Successful Implementation of Donation after Circulatory Death (DCD) Organ Procurement Procedures, Ensuring Standardization, Ethical Compliance, and Optimal Outcomes.

Finally, establishing comprehensive quality control systems, such as registries and audit programs, enables continuous monitoring of key performance indicators like ischemic times, blood loss, organ utilization, and recipient outcomes. These data-driven insights support ongoing protocol refinement and help drive improvements in practice.

6. Conclusion

The strategy of combining direct lung recovery with abdominal normothermic regional perfusion (A-NRP) offers a promising pathway to optimize organ preservation and expand the donor pool in DCD transplantation. Central to this approach is meticulous surgical planning, including techniques to control bleeding, such as secure vessel ligation and careful dissection that prevent hemorrhage and ensure the integrity of the A-NRP circuit. Maintaining a stable perfusion environment while avoiding circuit compromise requires close coordination and seamless collaboration among the multidisciplinary team. Effective communication, adherence to standardized protocols, and shared responsibility among surgical, perfusion, and anesthesia teams are essential for achieving optimal outcomes. As experience and evidence grow, ongoing refinement of these combined strategies will be critical to maximizing organ viability, ensuring ethical and legal compliance, and ultimately saving more lives through innovative and well-coordinated organ procurement practices.

Author Contributions

Dr. Chawannuch Ruaengsri: Responsible for overall project development and the writing of the main content. Dr. Marc Leon: Contributed to the writing of specific sections of the manuscript and provided relevant images. Miguel Alvarez-Cortes: Assisted with the editing of pictures to ensure that all visual elements accurately. Masafumi Shibata and Manuel Quiroz-Flores: Both contributed content to various sections of the manuscript. Yasuhiro Shudo: Supervised the project, providing guidance and oversight throughout the research process.

Competing Interests

The authors have declared that no competing interests exist.

AI-Assisted Technologies Statement

Artificial intelligence (AI) tools were used solely for basic grammar correction and language refinement in the preparation of this manuscript. Specifically, OpenAI’s ChatGPT was utilized to enhance the readability and linguistic clarity of the text. All scientific content, data interpretation, and conclusions related to the research on molecular signatures from heart preservation and perfusion media for predicting severe primary graft dysfunction were developed independently by the author. The author has thoroughly reviewed and edited the AI-assisted text to ensure its accuracy and accepts full responsibility for the content of the manuscript.