1. UCLA: VCA Program Update
Erin Core, RN, BSN, CCTC
Coordinator, Reconstructive Transplantation

2. UNOS/OPTN Oversight
VCAs should be included within the definition of organs covered by the OPTN Final Rule (42 CFR part 121) and section 301 of NOTA
Planning and implementation began in earnest in 2014 for UNOS/OPTN oversight

3. UNOS/OPTN Oversight VCA participation as of February 2014
28 VCA transplant recipients had been transplanted at 11 different transplant centers
9 patients at 6 different transplant centers were waiting for a VCA transplant
 28 VCA transplant recipients were transplanted at 11 different transplant centers.
6 face transplants
7 bilateral upper extremities
14 unilateral upper extremities
1 multiple VCA transplant – a face and a bilateral upper extremity. 
9 patients at 6 different transplant centers were waiting for a VCA transplant
4 awaiting a face transplant
4 awaiting a bilateral upper extremity transplant
1 awaiting a unilateral upper extremity transplant.

4. UNOS/OPTN Oversight
As of August 29, 2014, there were 15 OPTN approved VCA transplant hospitals and seven VCA candidates registered on the OPTN waiting list.
OPTN changed the membership criteria to delineate specific VCA transplant programs to upper limb, face, lower limb, and abdominal wall.

5. UNOS/OPTN VCA Criteria
That is vascularized and requires blood flow by surgical connection of blood vessels to function after transplantation
Containing multiple tissue types
Recovered from a human donor as an anatomical/structural unit
Transplanted into a human recipient as an anatomical/structural unit

6. UNOS/OPTN VCA Criteria (continued)
Minimally manipulated (i.e., processing that does not alter the original relevant characteristics of the organ relating to the organ's utility for reconstruction, repair, or replacement)
For homologous use (the replacement or supplementation of a recipient's organ with an organ that performs the same basic function or functions in the recipient as in the donor)

7. UNOS/OPTN VCA Criteria (continued)
Not combined with another article such as a device
Susceptible to ischemia and, therefore, only stored temporarily and not cryopreserved
Susceptible to allograft rejection, generally requiring immunosuppression that may increase infectious disease risk to the recipient

8. UNOS/OPTN VCA Program Criteria
A reconstructive surgical director and medical director identified as responsible VCA program staff
VCA program must be at a transplant hospital
Required to have a functioning solid organ transplant program
Requires a letter from the program’s local OPO

9. UNOS/OPTN VCA Program Criteria (continued)
A letter of intent from the institution signed by (chief administrative officer, a reconstructive surgeon, and a transplant specialist) designated as responsible for the VCA transplant program would serve as the application for a VCA program

10. UNOS/OPTN VCA Waitlist Management
Transplant programs will register their VCA candidates in a document that they will securely transmit to UNOS
UNOS will compile all of the candidate registrations into a master list which would be distributed to OPOs
OPOs will match VCA donors to candidates using the master list

11. UNOS/OPTN VCA Waitlist Management (continued)
If an OPO identifies a VCA donor that is suitable for more than one candidate from the master list, allocation will first be offered to regional candidates
If the organ is not accepted regionally, allocation will be offered to national candidates
Within each classification, waiting time will be used as the tie breaker between candidates

12. UCLA VCA Programs UCLA Reconstructive Transplant Programs
Hand(s)/Upper Extremity(extremities)
Face
Abdominal Wall (always with liver or intestine transplantation)

13. UCLA Donor Selection Criteria
Developed in conjunction with OneLegacy
Consent for organ donation
Second consent for VCA
ABO compatible
Similar size, age, and skin tone/hair match
No identifying marks on the tissue being transplanted
Introduction of PHS High risk donor
No DCD donors
No malignancies
No trauma or musculoskeletal disorders of the affected structure(s)
Assessment of social/criminal history

14. UCLA Policies and Procedures
Policies and procedures written to meet existing solid organ standards set by CMS and UNOS
Provide prosthetic at time of donation for limb and facial donation

15. UCLA VCA Matching Criteria
Skin Tone – match and acceptable range
Relative Age
Size
Hair quality and quantity
General features: height, weight, hair color, eye color, ethnicity

16. UCLA Upper Limb Transplantation
Standard of care prior to VCA is prosthetics
Candidates feel prosthetics do not provide adequate replacement
Currently two candidates in screening
Female bilateral upper extremity one below and one above the elbow
Male unilateral above the elbow

17. UCLA Face Transplantation
Restore function – oral competency, respiratory system, and communication
Regain identity and societal acceptance
Reestablish non-verbal communication
Recover protection of intact craniofacial structures

18. Standard of Care Prior to VCA

19. Univ. of Maryland Full Face Transplant

20. UCLA Face Candidate

22. Looking at the defect and planning the cuts in the superiorly on the nose, mandibular Ramus, lateral orbit and posterior zygomatic arch

23. UCLA Abdominal Wall Transplantation
Currently finalizing protocols and planning
Identified multivisceral candidate
Candidates are unable to undergo life-saving transplant of multivisceral organs without the abdominal wall
Current candidate unable to receive intestine, liver, and pancreas due to inadequate soft tissue coverage

24. UCLA Abdominal Wall Transplantation

25. UCLA Abdominal Wall Transplantation

26. Conclusions
Exponential growth of VCA programs across US necessitated standardization of practices, oversight, and a formal allocation mechanism
Keys to success are collaboration and communication between the transplant programs, OPO, and extended care provider network
Research with each and every transplant performed

27. Questions?

28. References
1. Glazier, A. Regulatory Face-Off: What agency should oversee face transplants? American Journal of Transplantation 2008; 8:
2. Levi D, Tzakis A, Kato T, Madaraga J, Mittal N, Nery J, Nishida S, Ruiz P. Transplantation of Abdominal Wall. The Lancet Vol
3. Petruzzo P, Lanzetta M, Dubernard JM, Landin L, Cavadas P, Margreiter R, Schneeberger S, Breidenbach W, Kaufman C, Jablecki J, Schuind F, Dumontier C. The International Registry on Hand and Composite Tissue Transplantation. Transplantation 2010; 90: 1590
Implement the OPTN's Oversight of Vascularized Composite Allografts (VCAs) of-vascularized-composite-allografts-vcas/ Retrieved March 9, 2015