It is very difficult to propagate expertise for rare procedures. Oftentimes the teaching center already has limited volume, so trainees may become "experts" wit

It is very difficult to propagate expertise for rare procedures. Oftentimes the teaching center already has limited volume, so trainees may become "experts" with a rather limited number of procedures under their belt. The problem becomes apparent when those trainees migrate back to smaller centers where volume is almost nil. I'm the perfect example of this myself, although being a cardiothoracic anesthesiologist it's easier to maintain my expertise compared to surgeons because surgical expertise almost only relies on continued practice, while anesthesiology mostly relies on know-how. The end result is mostly catastrophic outcomes on complex surgery that is rarely done. So this is very expensive and risky surgery, but the economics surrounding this type of program are a bit obscure. Some people are obviously making tons of money with such cases, but I doubt anyone really has a comprehensive overview of all the economic pro/cons. In Europe at least, insurance companies don't seem that reluctant towards transplants and there are other lower hanging fruits if the system wants to spend less. As for logistics, it's probably not that different from transplanting another organ. In anything involving the trachea, the technical details of the procedure and the coordination between surgery and anesthesia is where the difficulty lies.