Clinical evidence of the absence of brain perfusion during thoraco-abdominal normothermic regional perfusion in donation after circulatory determination of death.

The use of thoraco-abdominal normothermic regional perfusion (TA-NRP) has been associated with improved graft utilization and superior recipient outcomes compared with rapid recovery in donation after circulatory determination of death (DCDD). A major barrier to its broader adoption is the concern for inadvertent brain reperfusion, which would invalidate the determination of death. We aimed to confirm that, during TA-NRP in DCDD, clamping and sectioning of the supra-aortic vessels, with venting the cephalad ends to atmospheric pressure, effectively prevents brain perfusion. A prospective study was conducted in 10 DCDD donors. Mean intracranial arterial pressures were directly measured at the circle of Willis and the basilar artery, representing the anterior/middle and posterior cerebral circulations, in addition to systemic arterial pressure. Measurements were obtained from withdrawal of life-sustaining therapy through completion of the procedure. During circulatory arrest, pressures in the 3 territories remained low and comparable. Upon initiation of TA-NRP, the aortic pressure increased to levels required for adequate organ perfusion, while pressures at both the circle of Willis and basilar artery remained unchanged. These findings provide evidence that brain perfusion is effectively prevented during TA-NRP when the supra-aortic vessels are opened to atmospheric pressure, thereby upholding the dead donor rule.