The Bronchial Arterial Circulation in Lung Transplantation: Bedside to Bench to Bedside, and Beyond

ABSTRACTChronic allograft dysfunction (CLAD) remains a major complication, causing the poor survival after lung transplantation. Although strenuous efforts have been made at preventing CLAD, surgical approaches for lung transplantation have not been updated over the last 2 decades. The bronchial artery, which supplies oxygenated blood to the airways and constitutes a functional microvasculature, has occasionally been revascularized during transplants, but this technique did not gain popularity and is not standard in current lung transplantation protocols, despite the fact that a small number of studies have shown beneficial effects of bronchial artery revascularization (BAR) on limiting CLAD. Also, recent basic and clinical evidence has demonstrated the relationship between microvasculature damage and CLAD. Thus, the protection of the bronchial circulation and microvasculature in lung grafts may be a key factor to overcome CLAD.This review revisits the history of BAR, discusses the role of the bronchial circulation in lung transplantation, and advocates for novel bronchial-arterial-circulation-sparing (BACS) approaches as a future direction for overcoming CLAD. While there are some already published review articles summarizing the surgical techniques and their possible contribution to outcomes in lung transplantation, to the best of our knowledge, this review is the first to elaborate on bronchial circulation that will contribute to prevent CLAD from both scientific and clinical perspectivesfrom bedside to bench to bedside, and beyond.