Comparative evaluation of single-artery cannulation with passive venous drainage versus traditional dual-cannula ex vivo lung perfusion in a rat model

Abstract

Background: Ex vivo lung perfusion (EVLP) has emerged as a critical technique for lung preservation and evaluation prior to transplantation. While conventional rat EVLP systems utilize closed-loop dual cannulation of pulmonary artery (PA) and vein, the effect of the simplified model using single PA cannulation with passive venous drainage is unknown.

Methods: We developed two EVLP models in rats: a semi-closed circuit with PA-only cannulation and left atrial incision for passive venous drainage (SC-EVLP), and a closed circuit employing both arterial and venous cannulation (C-EVLP). Donor lungs were perfused for a defined duration and subsequently orthotopically transplanted. We evaluated pulmonary function parameters, histopathological injury scores, inflammatory cytokine levels, and apoptotic marker expression at the end of perfusion and posttransplantation.

Results: Compared to the conventional EVLP, the SC-EVLP group exhibited significantly lower PA pressure and improved dynamic lung compliance throughout perfusion. Although the levels of tumor necrosis factor-α in the perfusate were higher in the SC-EVLP group, other cytokine levels in the perfusate and bronchoalveolar lavage fluid exhibited no significant differences. Pulmonary edema was reduced in the SC-EVLP group, as indicated by a lower lung wet-to-dry ratio. After transplantation, lungs from the SC-EVLP group exhibited lower histological injury scores, reduced apoptosis, and decreased serum cytokine levels, suggesting attenuated inflammation and tissue damage.

Conclusions: In a rat model, single PA cannulation with passive venous drainage reduced pulmonary edema during EVLP and reduced lung injury and systemic inflammation after transplantation.

Keywords

ex vivo lung perfusion (EVLP) / lung preservation / lung transplantation / passive venous drainage

References

[1] Kotloff RM, Thabut G. Lung transplantation. Am J Respir Crit Care Med. 2011; 184(2): 159-171.

[2] Kukreja J, de la Cruz JL C-C, Van Raemdonck D, et al. The 2024 American Association for Thoracic Surgery expert consensus document: current standards in donor lung procurement and preservation. J Thorac Cardiovasc Surg. 2025; 169(2): 484-504.

[3] Watanabe T, Cypel M, Keshavjee S. Ex vivo lung perfusion. J Thorac Dis. 2021; 13(11): 6602-6617.

[4] Chang SH, Chan J, Patterson GA. History of lung transplantation. Clin Chest Med. 2023; 44(1): 1-13.

[5] Ponholzer F, Dumfarth J, Krapf C, et al. The impact and relevance of techniques and fluids on lung injury in machine perfusion of lungs. Front Immunol. 2024; 15:1358153.

[6] Bassani GA, Lonati C, Brambilla D, Rapido F, Valenza F, Gatti S. Ex vivo lung perfusion in the rat: detailed procedure and videos. PLoS One. 2016; 11(12):e0167898.

[7] Yu J, Zhang N, Zhang Z, et al. Diagnostic and therapeutic implications of ex vivo lung perfusion in lung transplantation: potential benefits and inherent limitations. Transplantation. 2023; 107(1): 105-116.

[8] Zhou AL, Larson EL, Ruck JM, Ha JS, Casillan AJ, Bush EL. Current status and future potential of ex vivo lung perfusion in clinical lung transplantation. Artif Organs. 2023; 47(11): 1700-1709.

[9] Capuzzimati M, Hough O, Liu M. Cell death and ischemia-reperfusion injury in lung transplantation. J Heart Lung Transplant. 2022; 41(8): 1003-1013.

[10] Jeon JE, Huang L, Zhu Z, Wong A, Keshavjee S, Liu M. Acellular ex vivo lung perfusate silences pro-inflammatory signaling in human lung endothelial and epithelial cells. J Transl Med. 2023; 21(1): 729.

[11] Wang X, Wang Y, Parapanov R, et al. Pharmacological reconditioning of marginal donor rat lungs using inhibitors of Peroxynitrite and poly (ADP-ribose) polymerase during ex vivo lung perfusion. Transplantation. 2016; 100(7): 1465-1473.

[12] Ehrsam JP, Chen J, Rodriguez Cetina Biefer H, Opitz I, Arni S, Inci I. Ex vivo lung perfusion with β-nicotinamide adenine dinucleotide (NAD(+)) improves ischemic lung function. Antioxidants. 2022; 11(5):843.

[13] Wei D, Gao F, Yang Z, et al. Ex vivo lung perfusion with perfusate purification for human donor lungs following prolonged cold storage. Ann Transl Med. 2020; 8(3): 38.

[14] Noda K, Shigemura N, Tanaka Y, et al. Successful prolonged ex vivo lung perfusion for graft preservation in rats. Eur J Cardiothorac Surg. 2014; 45(3): e54-e60.

[15] Takahashi M, Andrew Cheung HY, Watanabe T, et al. Strategies to prolong homeostasis of ex vivo perfused lungs. J Thorac Cardiovasc Surg. 2021; 161(6): 1963-1973.

[16] van Zanden JE, Leuvenink HGD, Verschuuren EAM, Erasmus ME, Hottenrott MC. A translational rat model for ex vivo lung perfusion of pre-injured lungs after brain death. PLoS One. 2021; 16(12):e0260705.

[17] Zhang J, Zhang X, He J. An optimized perfusate for enhanced rat ex vivo lung perfusion and lung transplant models. Anim Models Exp Med. 2025; 8: 1532-1536.

[18] Mizobuchi T, Sekine Y, Yasufuku K, Fujisawa T, Wilkes DS. Comparison of surgical procedures for vascular and airway anastomoses using a modified non-suture external cuff technique in rats. The Journal of Heart and Lung Transplantation. 2004; 23(7): 889-893.

[19] Rajab TK. Techniques for lung transplantation in the rat. Exp Lung Res. 2019; 45(9–10): 267-274.

[20] Oliveira P, Yamanashi K, Wang A, Cypel M. Establishment of an ex vivo lung perfusion rat model for translational insights in lung transplantation. J Vis Exp. 2023;(199):e65981.

[21] Liao H, Wang X, Lu Y, et al. Orthotopic left lung transplantation in rats. J Vis Exp. 2025;(221):e68106.

[22] Audi SH, Jacobs ER, Zhang X, et al. Protection by inhaled hydrogen therapy in a rat model of acute lung injury can be tracked in vivo using molecular imaging. Shock. 2017; 48(4): 467-476.

[23] Gloria JN, Yerxa J, Kesseli SJ, et al. Subnormothermic ex vivo lung perfusion attenuates graft inflammation in a rat transplant model. J Thorac Cardiovasc Surg. 2022; 164(2): e59-e70.

[24] Steen S, Ingemansson R, Eriksson L, et al. First human transplantation of a nonacceptable donor lung after reconditioning ex vivo. The Annals of Thoracic Surgery. 2007; 83(6): 2191-2195.

[25] Levvey BJ, Snell GI. How do we expand the lung donor pool? Curr Opin Pulm Med. 2024; 30(4): 398-404.

[26] Grando L, Boada M, Faner R, et al. The impact of the EVLP on the lung microbiome and its inflammatory reaction. Transplant International. 2024; 37:12979.

[27] Chen-Yoshikawa TF. Ischemia-reperfusion injury in lung transplantation. Cells. 2021; 10(6):1333.

[28] Chen Q, Malas J, Krishnan A, et al. Limited cumulative experience with ex vivo lung perfusion is associated with inferior outcomes after lung transplantation. J Thorac Cardiovasc Surg. 2024; 167(1): 371-379.e8.

[29] Li SS, Funamoto M, Singh R, et al. Outcomes of donation after circulatory death (DCD) and ex-vivo lung perfusion (EVLP) lung transplantation. J Heart Lung Transplant. 2025; 44(5): 721-733.

[30] Noda K, Chan EG, Furukawa M, et al. Single-center experience of ex vivo lung perfusion and subsequent lung transplantation. Clin Transpl. 2023; 37(2):e14901.

[31] Radomsky L, Koch A, Olbertz C, et al. Composition of ex vivo perfusion solutions and kinetics define differential cytokine/chemokine secretion in a porcine cardiac arrest model of lung preservation. Front Cardiovasc Med. 2023; 10:1245618.

[32] Bechet NB, Celik A, Mittendorfer M, et al. Xenotransplantation of mitochondria: a novel strategy to alleviate ischemia-reperfusion injury during ex vivo lung perfusion. J Heart Lung Transplant. 2025; 44(3): 448-459.

[33] Cloer CM, Givens CS, Buie LK, et al. Mitochondrial transplant after ischemia reperfusion promotes cellular salvage and improves lung function during ex-vivo lung perfusion. J Heart Lung Transplant. 2023; 42(5): 575-584.

[34] Linacre V, Cypel M, Machuca T, et al. Importance of left atrial pressure during ex vivo lung perfusion. J Heart Lung Transplant. 2016; 35(6): 808-814.

[35] Nilsson T, Gielis JF, Slama A, et al. Comparison of two strategies for ex vivo lung perfusion. J Heart Lung Transplant. 2018; 37(2): 292-298.

[36] De Wolf J, Glorion M, Jouneau L, et al. Challenging the ex vivo lung perfusion procedure with continuous dialysis in a pig model. Transplantation. 2022; 106(5): 979-987.

[37] De Wolf J, Gouin C, Jouneau L, et al. Prolonged dialysis during ex vivo lung perfusion promotes inflammatory responses. Front Immunol. 2024; 15:1365964.

[38] Dromparis P, Aboelnazar NS, Wagner S, et al. Ex vivo perfusion induces a time- and perfusate-dependent molecular repair response in explanted porcine lungs. Am J Transplant. 2019; 19(4): 1024-1036.

[39] Whiteley J, Shan H, Yeung JC. Noninflammatory causes of pulmonary edema during ex vivo lung perfusion. Ann Thorac Surg Short Rep. 2024; 2(4): 848-850.

RIGHTS & PERMISSIONS

2026 The Author(s). Animal Models and Experimental Medicine published by John Wiley & Sons Australia, Ltd on behalf of The Chinese Association for Laboratory Animal Sciences.