ANRP and Total Inflow Occlusion of the Chest with 4 Clamps Techniques

In combined DCD heart and lung procurement via Abdominal Normothermic Regional Perfusion (A-NRP), achieving absolute vascular isolation of the thoracic cavity is paramount to prevent inadvertent warm cerebral or coronary reperfusion while ensuring optimal perfusion of the sub-diaphragmatic organs. Following immediate sternotomy and laparotomy upon declaration of death, surgeons must rapidly execute a precise clamping sequence to completely seclude the thorax from the abdominal circuit. This isolation is achieved by clamping the descending thoracic aorta just superior to the diaphragm, preventing the retrogradely directed arterial flow from the abdominal ECMO circuit from ascending into the chest. Simultaneously, venous return from the upper body is blocked by placing an azygocaval clamp or separate inferior vena cava (IVC) and azygos vein clamps, which effectively interrupts all systemic venous inflow back toward the right atrium from these collateral pathways.