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Pfister M, Kobe A, Pfammatter T, Bonani M, Rössler F. Peritransplant Varicosis After Simultaneous Pancreas and Kidney Transplantation Is an Uncommon Cause of Late-Onset and Recurrent Gastrointestinal Bleeding. Cureus 2023; 15:e40522. [PMID: 37461789 PMCID: PMC10350313 DOI: 10.7759/cureus.40522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2023] [Indexed: 07/20/2023] Open
Abstract
Ectopic peritransplant varicosis represents an uncommon cause of late-onset gastrointestinal (GI) bleeding after simultaneous pancreas and kidney transplantation (SPK). We report on a 53-year-old female patient who suffered from recurrent upper GI bleeding seven years after SPK with persistent graft function. Upper endoscopy revealed perianastomotic angiodysplasias, treated by clipping and Argon-Plasma-Coagulation. Repeated endoscopy showed no signs of anastomotic ulcer. With persistent symptoms, computed tomography and angiography revealed extensive ectopic varicosis around the pancreas and duodenal graft. With no signs of portal hypertension, pancreas graft venous outflow impairment or arterio-venous fistula, the origin of variceal formation remained unknown. The extended finding did not allow for endovascular treatment by embolization. Surgery with extensive variceal ligation led to persistent cessation of hemorrhage and maintained stable graft function. In patients with unclear recurrent upper GI bleeding after SPK, one should consider ectopic peritransplant varicosis as an exceptional bleeding cause. If endoscopic treatments fail, angiography should be performed to rule out unusual causes of vascular complications. In case of extensive peritransplant varicosis, surgery may remain the only successful therapy, whenever possible including graft preservation in well-functioning grafts.
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Affiliation(s)
- Matthias Pfister
- Surgery and Transplantation, Universitatsspital Zürich, Zürich, CHE
| | - Adrian Kobe
- Diagnostic and Interventional Radiology, Universitätsspital Zürich, Zürich, CHE
| | - Thomas Pfammatter
- Diagnostic and Interventional Radiology, Universitätsspital Zürich, Zürich, CHE
| | - Marco Bonani
- Nephrology, Universitätsspital Zürich, Zürich, CHE
| | - Fabian Rössler
- Surgery and Transplantation, Universitätsspital Zürich, Zürich, CHE
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2
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Anand K, Cizman Z, Smith T, Strain D, Patel S, Campsen J, Baker T, Saad W. Persistent Bleeding after Coil Embolization of a Pancreatic Transplant Pseudoaneurysm: Should Covered Stents Be the Primary Management? Semin Intervent Radiol 2023; 40:283-285. [PMID: 37484441 PMCID: PMC10359117 DOI: 10.1055/s-0043-1769763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
Life-threatening arterial complications after pancreatic transplantation can be dire. Pseudoaneurysms can be challenging to treat. There are multiple strategies to treat such complications. We present a case of pancreatic pseudoaneurysm which was initially treated by coiling followed by subsequent covered stent placement for a more durable outcome. We advocate for a "stent first" approach to these lesions if feasible.
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Affiliation(s)
- Keshav Anand
- Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ziga Cizman
- Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Tyler Smith
- Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - David Strain
- Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Suraj Patel
- Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jeffrey Campsen
- Division of Transplant and Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Talia Baker
- Division of Transplant and Hepatobiliary Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Wael Saad
- Department of Radiology, University of Utah School of Medicine, Salt Lake City, Utah
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3
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Stern J, Negash B, Hickey R, Lugo J, Cayne NS, Lonze BE, Ali NM, Stewart ZA. Staged Endovascular and Surgical Management of a Mycotic Pseudoaneurysm After Pancreas Transplant. EXP CLIN TRANSPLANT 2023; 21:175-179. [PMID: 36919726 DOI: 10.6002/ect.2022.0326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Mycotic pseudoaneurysms are a rare, life-threatening complication after pancreas transplant. There have been limited reports of endovascular treatment of mycotic pseudoaneurysms in pancreas transplant recipients. Herein, we report on a case of a mycotic pseudoaneurysm from Pseudomonas aeruginosa after pancreas transplant. A 53-year-old male recipient underwent an uneventful simultaneous pancreas and kidney transplant. He was readmitted 48 days posttransplant with fevers and rigors. Pan-cultures were performed and broad-spectrum antibiotics were initiated. Imaging studies demonstrated a large mycotic pseudoaneurysm arising from the right common iliac artery adjacent to the arterial Y-graft anastomosis of the transplant pancreas. Endovascular stent placement was used to exclude the pseudoaneurysm prior to transplant pancreatectomy. During pancreatectomy, the lateral wall of the common iliac artery was found to be necrotic with significant exposure of the endovascular stent. After ligation and excision of the common iliac artery, a femorofemoral bypass was performed to revascularize the lower extremity. This case report highlights the advantage of a staged endovascular and surgical management strategy for complex mycotic pseudoaneurysms after pancreas transplant.
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Affiliation(s)
- Jeffrey Stern
- From the Transplant Institute, NYU Langone Health, New York, New York, USA
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4
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Tan SL, Tan RYP, Cehic G, Wu M, Kanellis J, Barbara J. Simultaneous Pancreas-Kidney Transplant Complicated by Kidney Allograft Torsion and Pseudoaneurysms of the Y-Allograft: A Case Report and Review of the Literature. Case Rep Nephrol 2022; 2022:1-7. [DOI: 10.1155/2022/1748141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 11/01/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022] Open
Abstract
Background. We report and review the literature of two rare complications of simultaneous pancreas-kidney transplantation (SPKT) occurring in one patient. Case Report. A 39-year-old man with dialysis-dependent kidney failure secondary to type 1 diabetes mellitus underwent successful SPKT in October 2018. Three months later, he presented with an acute kidney injury (AKI) and returned to dialysis. Kidney scintigraphy showed a central photopenic region, and angiograms showed absent flow in the kidney transplant artery without treatable thrombus and the incidental finding of two pseudoaneurysms of the pancreatic Y-graft. He remained dialysis-dependent for three weeks before spontaneous partial recovery of allograft function; repeat kidney scintigraphy showed significant improvement in perfusion. However, in April 2019 he was readmitted with a sudden deterioration in kidney allograft function again necessitating haemodialysis. Repeat imaging confirmed that the kidney allograft had shifted from the left iliac fossa to the midline. He underwent surgical exploration, during which torsion of the kidney allograft was confirmed and a nephropexy was performed. The kidney allograft was originally implanted in the left retroperitoneum via a midline transperitoneal approach, which likely predisposed it to torsion. The pseudoaneurysms of the pancreatic Y-graft were managed conservatively, and surveillance imaging demonstrated that they remained stable in size. The patient regained reasonable kidney allograft function (estimated glomerular filtration rate, eGFR, of 45 mL/min) and maintained normal pancreatic allograft function. Conclusion. Kidney allograft torsion should be considered post-SPKT in patients with AKI and absent arterial flow. Although most case reports describe surgical management of pseudoaneurysms post-SPKT, our case demonstrates successful conservative management.
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5
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Matejak-Górska M, Witkowski G, Durlik M. Vascular Complications After Simultaneous Pancreas and Kidney Transplantation: A Case Report. Transplant Proc 2022; 54:1183-1188. [PMID: 35450723 DOI: 10.1016/j.transproceed.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/21/2022] [Accepted: 03/01/2022] [Indexed: 10/18/2022]
Abstract
A 51-year-old patient with type I diabetes and end-stage renal disease was qualified for a simultaneous kidney and pancreas transplant. The procedure was performed in a typical manner: arterial anastomosis to the right common iliac artery, the graft's portal vein with inferior vena cava, and side-to-side duodenal intestinal anastomosis. The kidney was implanted retroperitoneally. Six months after the transplant, the patient reported pain in the right lower abdomen, and imaging examinations revealed arterial anastomosis. Reconstruction of the right common iliac artery was performed with a Gore-Tex prosthesis and the pancreatic artery reanastomosed to the right external iliac artery. After the surgery, the function of the transplanted pancreas deteriorated, the level of C-peptide was decreased, and the patient required low doses of insulin. After another 8 months, the imaging studies revealed an aneurysm located in the bifurcation of the aorta up to the anastomosis of the pancreatic graft artery with the iliac artery. The patient was qualified for the implantation of an endovascular of 2 prosthesis, which improved the graft's function. After another 2 months, the presence of an aneurysm at the endovascular prosthesis was found again. The patient was requalified for endovascular prosthesis implantation. Currently, there is no aneurysm but the function of the pancreas graft is impaired, though the kidney graft function is good. Patients after simultaneous kidney and pancreas transplant are a group of patients with an increased risk of vascular complications. Treatment should take place in a multidisciplinary center.
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Affiliation(s)
- Marta Matejak-Górska
- Department of General Surgery and Transplantology, Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw, Warsaw, Poland; Centre of Postgraduate Medical Education, Warsaw, Poland.
| | - Grzegorz Witkowski
- Department of General Surgery and Transplantology, Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw, Warsaw, Poland; Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Marek Durlik
- Department of General Surgery and Transplantology, Central Clinical Hospital of the Ministry of the Interior and Administration in Warsaw, Warsaw, Poland; Centre of Postgraduate Medical Education, Warsaw, Poland
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6
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Leiberman D, Sharma V, Siddagangaiah V, Lake E, van Dellen D, Dhanda R, Augustine T, Seriki D, Singh R. Radiological initial treatment of vascular catastrophes in pancreas transplantation: Review of current literature. Transplant Rev (Orlando) 2021; 35:100624. [PMID: 33906064 DOI: 10.1016/j.trre.2021.100624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/06/2021] [Accepted: 04/10/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Arterio-enteric fistula (AEF) is a rare but potentially devastating complication of solid organ pancreatic transplantation. Traditional management has been to remove the pancreas-duodenum allograft and control the vascular defect. Interventional radiological (IR) techniques present a new method of managing AEF related haemorrhage without re-operation and the potential to preserve graft function. This paper examines the available literature to assess efficacy and safety of this novel approach. METHODS Aggregate results tables were constructed from 28 cases identified in the English language literature where IR was used in the management of AEF following pancreas transplantation. Outcomes recorded were death, re-bleeding, surgical intervention required and post intervention graft function. These were analysed with respect to technical factors and graft function at time of presentation. RESULTS 28 cases of AEF managed by IR methods were identified. Mortality was high at 17.9%. 78.6% of all AEFs were present in failed pancreas allografts. Median time from transplant to bleeding event was 29 months. There was a trend of bleeding event occurring within 12 months of allograft failure or rejection. Of the AEFs present in functioning grafts, graft salvage rate was 33% from available data. Coil embolization or use of haemostatic compressed sponge as primary intervention was associated with a higher rate of re-bleeding and death versus arterial stenting. Arterial stenting resulted in a higher rate of distal ischaemia requiring surgical re-vascularisation. All deaths occurred in patients who did not have a transplant pancreatectomy as part of their definitive treatment. CONCLUSION IR can be an effective way to manage bleeding in the context of AEF associated with pancreas transplantation. If patient condition allows, it should be the first-choice intervention to manage AEF associated bleeding. Use of arterial stenting is more effective in controlling and preventing further bleeding. In a non-functioning graft, transplant pancreatectomy should be strongly considered, possibly in conjunction with or following arterial stenting.
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Affiliation(s)
- David Leiberman
- Manchester University Hospitals NHS Foundation Trust, Department of Renal and Pancreatic Transplantation, Manchester Academic Health Science Centre, Manchester, Greater Manchester, M13 9WL, UK.
| | - Videha Sharma
- Manchester University Hospitals NHS Foundation Trust, Department of Renal and Pancreatic Transplantation, Manchester Academic Health Science Centre, Manchester, Greater Manchester, M13 9WL, UK; University of Manchester, Faculty of Biology, Medicine and Health, Division of Informatics, Imaging and Data Science, Manchester, Greater Manchester M13 9PT, UK
| | - Vishwanath Siddagangaiah
- Manchester University Hospitals NHS Foundation Trust, Department of Renal and Pancreatic Transplantation, Manchester Academic Health Science Centre, Manchester, Greater Manchester, M13 9WL, UK
| | - Edward Lake
- Manchester University Hospitals NHS Foundation Trust, Department of Radiology, Manchester Royal Infirmary, Manchester, Greater Manchester M13 9WL, UK
| | - David van Dellen
- Manchester University Hospitals NHS Foundation Trust, Department of Renal and Pancreatic Transplantation, Manchester Academic Health Science Centre, Manchester, Greater Manchester, M13 9WL, UK; University of Manchester, Faculty of Biology, Medicine and Health, Division of Diabetes, Endocrinology and Gastroenterology, Manchester, Greater Manchester M13 9PT, UK
| | - Raman Dhanda
- Manchester University Hospitals NHS Foundation Trust, Department of Renal and Pancreatic Transplantation, Manchester Academic Health Science Centre, Manchester, Greater Manchester, M13 9WL, UK
| | - Titus Augustine
- Manchester University Hospitals NHS Foundation Trust, Department of Renal and Pancreatic Transplantation, Manchester Academic Health Science Centre, Manchester, Greater Manchester, M13 9WL, UK; University of Manchester, Faculty of Biology, Medicine and Health, Division of Diabetes, Endocrinology and Gastroenterology, Manchester, Greater Manchester M13 9PT, UK
| | - Dare Seriki
- Manchester University Hospitals NHS Foundation Trust, Department of Renal and Pancreatic Transplantation, Manchester Academic Health Science Centre, Manchester, Greater Manchester, M13 9WL, UK
| | - Rajinder Singh
- Manchester University Hospitals NHS Foundation Trust, Department of Renal and Pancreatic Transplantation, Manchester Academic Health Science Centre, Manchester, Greater Manchester, M13 9WL, UK
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7
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Surowiecka-Pastewka A, Matejak-Górska M, Frączek M, Sklinda K, Walecki J, Durlik M. Endovascular Interventions in Vascular Complications After Simultaneous Pancreas and Kidney Transplantations: A Single-Center Experience. Ann Transplant 2019; 24:199-207. [PMID: 30975974 PMCID: PMC6482861 DOI: 10.12659/aot.912005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Vascular failures are serious complications in pancreas transplantation. Open surgery is a reliable and quick intervention method, but it carries a risk of infection and bleeding. Endovascular procedures are rare among patients after a SPK, but are becoming more frequently used. One of the main risks of the endovascular approach is that the renal function impairment caused by contrast agent. Material/Methods We performed a retrospective analysis of 200 transplanted pancreases at our center over the last 14 years. The analyses included those patients after pancreas transplantation who required the most challenging vascular interventions and ones that were non-standard for the procedure. Results Severe vascular conditions requiring endovascular intervention were observed in 3% of SPKs. In one retransplanted patient, there was an acute ischemia of the lower extremity due to the narrowing of the common iliac artery following a previous transplantectomy, above the new pancreas graft anastomoses. In another patient, local inflammation led to the disruption of the external iliac artery on the level of transplantectomy, caused severe bleeding, and we had to implement a stent-graft to reconstruct the iliac artery wall. A third patient had a pseudoaneurysm demanding further treatment with a stent-graft implemented into the femoral artery due to a pseudoaneurysm of the right external iliac artery. Conclusions Intravenous interventions in patients with a transplanted or retransplanted pancreas are safe and feasible. It is a technically demanding procedure, but the risk of kidney graft function deterioration, as well as of bleeding due to the high dose of heparin used, is lower than with open vascular surgery.
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Affiliation(s)
- Agnieszka Surowiecka-Pastewka
- Department of Gastroenterological Surgery and Transplantation, Medical Centre of Postraguade Medicine, Warsaw, Poland.,Department of Surgical Research and Transplantology, Mossakowski Medical Research Center of the Polish Academy of Sciences, Warsaw, Poland
| | - Marta Matejak-Górska
- Department of Gastroenterological Surgery and Transplantation, Medical Centre of Postraguade Medicine, Warsaw, Poland
| | - Michał Frączek
- Diagnostic Radiology Department, Central Clinical Hospital of the Ministry of the Interior in Warsaw, Warsaw, Poland.,Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Katarzyna Sklinda
- Diagnostic Radiology Department, Central Clinical Hospital of the Ministry of the Interior in Warsaw, Warsaw, Poland.,Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Jerzy Walecki
- Diagnostic Radiology Department, Central Clinical Hospital of the Ministry of the Interior in Warsaw, Warsaw, Poland.,Centre of Postgraduate Medical Education, Warsaw, Poland.,The Committee on Medical Physics, Radiobiology, and X-Ray Diagnosis of the Polish Academy of Sciences, Warsaw, Poland
| | - Marek Durlik
- Department of Gastroenterological Surgery and Transplantation, Medical Centre of Postraguade Medicine, Warsaw, Poland.,Department of Surgical Research and Transplantology, Mossakowski Medical Research Center of the Polish Academy of Sciences, Warsaw, Poland
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8
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Mafeld S, Logue JA, Masson S, Thakkar R, Amer A, Wilson C, Sen G, Manas D, White S, Williams R. Treatment of Visceral Transplant Pseudoaneurysms Using Physician-Modified Fenestrated Stent Grafts: Initial Experience. Cardiovasc Intervent Radiol 2019; 42:920-6. [PMID: 30725157 DOI: 10.1007/s00270-019-02168-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/16/2019] [Indexed: 01/28/2023]
Abstract
Pseudoaneurysms after visceral transplantation represent a significant risk to patients. We report the successful treatment of three transplant (pancreas, liver and kidney) artery anastomotic pseudoaneurysms using physician-modified fenestrated endovascular stent grafts. In all cases, surgical repair was considered high risk and would have compromised the arterial supply to the graft. The endovascular approach in all cases obviated the need for surgical intervention and maintained graft arterial supply.
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9
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Kurose S, Inoue K, Yoshino S, Nakayama K, Yamashita S, Yoshiya K, Yoshiga R, Morisaki K, Kaku K, Okabe Y, Furuyama T, Maehara Y. Successful Bridge Therapy with Initial Endovascular Repair for Arterioenteric Fistula Resulting from Pseudoaneurysm Rupture with Massive Gastrointestinal Hemorrhage after Pancreas Transplantation. Ann Vasc Surg 2019; 58: 379.e15-379. e22. [PMID: 30711503 DOI: 10.1016/j.avsg.2018.10.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/09/2018] [Accepted: 10/11/2018] [Indexed: 02/07/2023]
Abstract
Pseudoaneurysm after pancreas transplantation has a reported incidence of 1.4 to 8.0% and may be caused by perioperative infection. Subsequent pseudoaneurysm rupture is a rare cause of arterioenteric fistula. Only 28 cases of arterioenteric fistula after pancreas transplantation have been reported in the past 20 years. We experienced a rare case of arterioenteric fistula resulting from pseudoaneurysm rupture after pancreas transplantation. We successfully treated the arterioenteric fistula with multistaged bridge therapy composed of initial endovascular aneurysm repair, secondary isolation of the fistula, and definitive open repair with extraanatomic bypass. No complications occurred in 1 year of follow-up; this staged therapy seems feasible for patients with arterioenteric fistula.
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10
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Messner F, Bösmüller C, Oberhuber R, Maglione M, Cardini B, Resch T, Scheidl S, Öfner D, Schneeberger S, Margreiter C. Late recurrent bleeding episodes from duodenojejunostomy after pancreas transplantation. Clin Transplant 2018; 32:e13350. [PMID: 30007083 DOI: 10.1111/ctr.13350] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/29/2018] [Accepted: 07/09/2018] [Indexed: 12/19/2022]
Abstract
In response to a number of late, repetitive bleeding episodes from the site of the enteric anastomosis, we herein analyze the clinical courses and etiologies of 379 consecutively performed pancreas transplants between January 2000 and December 2016. Duodenojejunostomies for enteric drainage were performed at the upper jejunum in a side to side, double layer fashion. Five patients (1.3%) developed recurrent late hemorrhagic episodes originating from the graft duodenal anastomosis. Bleeding from the anastomotic site was associated with hematochezia, hemodynamic instability and decrease in serum hemoglobin. Mean onset was 6.4(±2.8) years after transplantation. Bleeding was recurrent (mean 5.2 ± 2.6) and required 9(±2.5) interventions. Hypervascularization, mucosal vulnerability, and bleeding at the site of the enteric anastomosis could be identified in all cases. In four patients, the enteric pancreas anastomosis was resected and a new duodenojejunostomy was performed. No pancreas graft loss occurred due to bleeding. In two patients, hepatic cirrhosis and portal hypertension were identified, one patient had a liver fibrosis as putative cause for the repetitive bleeding episodes. Late anastomotic hemorrhage is a rare but severe complication following pancreas transplantation. The treatment is challenging and includes endoscopy, interventional radiology, and surgery. Hepatic conditions with an increased portal pressure may be the underlying cause.
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Affiliation(s)
- Franka Messner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudia Bösmüller
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Manuel Maglione
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Resch
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Scheidl
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Margreiter
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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11
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Abstract
PURPOSE OF REVIEW Despite improvements in pancreas allograft outcome, graft complications remain a significant cause of morbidity and mortality. This review analyses the issues involved in the management of conditions that may require graft pancreatectomy, including the indications and techniques for graft salvage. RECENT FINDINGS With early recognition of graft complications, liberal use of radiological interventions, improved infection control, access to critical care and innovative surgical techniques, graft salvage is now feasible in many circumstances where graft pancreatectomy would previously have been necessary. SUMMARY The outcome of pancreas transplantation continues to improve with advances in the management of graft-threatening complications.
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12
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Yadav K, Young S, Finger EB, Kandaswamy R, Sutherland DER, Golzarian J, Dunn TB. Significant arterial complications after pancreas transplantation-A single-center experience and review of literature. Clin Transplant 2017; 31. [PMID: 28787529 DOI: 10.1111/ctr.13070] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2017] [Indexed: 12/14/2022]
Abstract
Arterial fistulas and pseudoaneurysms are rarely described significant arterial complications associated with pancreas transplantation that sometimes present with herald or catastrophic bleeding. We herein describe our institutional case series with a focus on management and outcomes. Of 2256 pancreas transplants, 24 arterial complications were identified in 23 recipients. Chart review was performed to describe the clinical characteristics, treatments, and outcomes of the complications (pseudoaneurysm, arterial enteric/cystic/ureteric fistula, or arteriovenous fistula). Of these 23 patients, 57% had a failed allograft at the time of the complication. Nine patients underwent primary surgical repair of 10 complications, 13 were treated by endovascular methods, and one patient by medical management. In total, 3 embolized patients rebled, 2 of which had failed allografts prior to treatment. Of those with graft function that were treated by embolization alone, all retained graft function. Diagnosis of arterial complications requires a high degree of suspicion and should involve early systemic angiography to evaluate the pancreatic vasculature. Management can be endovascular or surgical and should be individualized. We report our center's evolution from a predominantly surgical to endovascular approach as a definitive vs stabilizing therapy, with selective coiling mostly reserved for well-defined peripheral lesions in patients with a functioning allograft.
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Affiliation(s)
- Kunal Yadav
- Division of Transplantation, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Shamar Young
- Department of Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Erik B Finger
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Raja Kandaswamy
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - David E R Sutherland
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Jafar Golzarian
- Department of Radiology, University of Minnesota, Minneapolis, MN, USA
| | - Ty B Dunn
- Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
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13
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Arantes RM, Pantanali CAR, Santos VR, Carneiro D'Albuquerque LA. Arterial Pseudoaneurysm Associated with Pancreas and Kidney Transplantation: A Case Report. Am J Case Rep 2017; 18:198-202. [PMID: 28232659 PMCID: PMC5335644 DOI: 10.12659/ajcr.900790] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Patient: Male, 49 Final Diagnosis: Arterial pseudoaneurysm Symptoms: Abdominal pain • fever and a pulsatile tumor located in the right iliac fossa Medication: — Clinical Procedure: Endovascular and surgical approach Specialty: Transplantology
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Affiliation(s)
- Rubens Macedo Arantes
- Liver and Digestive Organ Transplantation Division, Department of Gastroenterology, Clinicas Hospital, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Carlos Andrés Rodriguez Pantanali
- Liver and Digestive Organ Transplantation Division, Department of Gastroenterology, Clinicas Hospital, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Vinicius Rocha Santos
- Liver and Digestive Organ Transplantation Division, Department of Gastroenterology, Clinicas Hospital, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Luiz Augusto Carneiro D'Albuquerque
- Liver and Digestive Organ Transplantation Division, Department of Gastroenterology, Clinicas Hospital, University of São Paulo Medical School, São Paulo, SP, Brazil
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14
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Uchima HI, Araujo IK, Ferrer J, Burrell M, Sotomayor A, García-Criado Á, Feu F, Ricart MJ, Llach J, González-Suárez B. Superior mesenteric artery pseudoaneurysm fistulised to the small intestine in a pancreas-kidney transplant recipient: Can it be detected by capsule endoscopy? Gastroenterol Hepatol 2017; 41:109-111. [PMID: 28215709 DOI: 10.1016/j.gastrohep.2016.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 11/28/2016] [Accepted: 12/02/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Hugo I Uchima
- Unitat d'Endoscòpia Digestiva, Servei de Gastroenterologia, ICMDiM, Hospital Clínic de Barcelona, Catalunya, Spain
| | - Isis K Araujo
- Unitat d'Endoscòpia Digestiva, Servei de Gastroenterologia, ICMDiM, Hospital Clínic de Barcelona, Catalunya, Spain
| | - Joana Ferrer
- Servei de Cirugia General i Digestiva, ICMDiM, Hospital Clínic de Barcelona, Catalunya, Spain
| | - Marta Burrell
- Centre de Diagnòstic per Imatge, Hospital Clínic de Barcelona, Catalunya, Spain
| | - Alejandro Sotomayor
- Centre de Diagnòstic per Imatge, Hospital Clínic de Barcelona, Catalunya, Spain
| | | | - Faust Feu
- Unitat d'Endoscòpia Digestiva, Servei de Gastroenterologia, ICMDiM, Hospital Clínic de Barcelona, Catalunya, Spain
| | - M J Ricart
- Servei de Nefrologia i trasplantament renal, IDIBAPS, CIBERehd, Hospital Clinic de Barcelona, Catalunya, Spain
| | - Josep Llach
- Unitat d'Endoscòpia Digestiva, Servei de Gastroenterologia, ICMDiM, Hospital Clínic de Barcelona, Catalunya, Spain
| | - Begoña González-Suárez
- Unitat d'Endoscòpia Digestiva, Servei de Gastroenterologia, ICMDiM, Hospital Clínic de Barcelona, Catalunya, Spain.
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15
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Abstract
Whole pancreas transplantation is an effective treatment for obtaining euglycemic status in patients with insulin-dependent diabetes mellitus, and is usually performed concurrent with renal transplantation in the affected patient. This article discusses complex surgical anatomical details of pancreas transplantation including surgical options for endocrine and exocrine drainage pathways. It then describes several possible complications related to surgical factors in the immediate post operative period followed by other complications related to systemic issues, vasculature, and the pancreatic parenchyma.
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Affiliation(s)
- Ryan B O'Malley
- Department of Radiology, University of Washington Medical Center, Seattle, WA, USA
| | - Mariam Moshiri
- Department of Radiology, University of Washington Medical Center, Seattle, WA, USA.
| | - Sherif Osman
- Department of Radiology, University of Washington Medical Center, Seattle, WA, USA
| | | | - Douglas S Katz
- Department of Radiology, Winthrop-University Hospital, Mineola, NY, USA
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16
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17
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Yiannoullou P, van Dellen D, Khambalia H, Forgacs B, Tavakoli A, Murray D, Augustine T. Successful Management of a Ruptured Mycotic Pseudoaneurysm Following Pancreas Transplantation Using Bovine Pericardial Patch: A Case Report. Transplant Proc 2014; 46:2023-5. [DOI: 10.1016/j.transproceed.2014.06.051] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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18
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Villa M, Siskind E, Jaimes N, Eckstein D, Bhaskaran M, Sachdeva M, Jhaveri K, Calderon K, Greben C, Sharan L, Coppa G, Krishnasastry K, Molmenti E, Nicastro J. Arterio-enteric fistula in failed enteric-drained pancreas transplants: an impending danger. Int J Angiol 2014; 23:65-8. [PMID: 24627620 DOI: 10.1055/s-0033-1349169] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Enteric drainage is the preferred method of exocrine diversion in simultaneous kidney-pancreas transplantation. Because of improvements in immunosuppression, enteric drainage has become the preferred method of pancreas transplantation in general. Although associated with less potential complications than bladder-drained pancreas, potentially lethal arterio-enteric fistulas in the setting of nonfunctioning allografts represent a constant threat. We herein present a case report, a review of the literature, and a call for caution.
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Affiliation(s)
- Manuel Villa
- Department of Transplantation, North Shore Long Island Jewish Health System-Hofstra University School of Medicine, Manhasset, New York
| | - Eric Siskind
- Department of Transplantation, North Shore Long Island Jewish Health System-Hofstra University School of Medicine, Manhasset, New York
| | - Natalia Jaimes
- Department of Transplantation, North Shore Long Island Jewish Health System-Hofstra University School of Medicine, Manhasset, New York
| | - Donna Eckstein
- Department of Transplantation, North Shore Long Island Jewish Health System-Hofstra University School of Medicine, Manhasset, New York
| | - Madhu Bhaskaran
- Department of Transplantation, North Shore Long Island Jewish Health System-Hofstra University School of Medicine, Manhasset, New York
| | - Mala Sachdeva
- Department of Transplantation, North Shore Long Island Jewish Health System-Hofstra University School of Medicine, Manhasset, New York
| | - Kenar Jhaveri
- Department of Transplantation, North Shore Long Island Jewish Health System-Hofstra University School of Medicine, Manhasset, New York
| | - Kellie Calderon
- Department of Transplantation, North Shore Long Island Jewish Health System-Hofstra University School of Medicine, Manhasset, New York
| | - Craig Greben
- Department of Transplantation, North Shore Long Island Jewish Health System-Hofstra University School of Medicine, Manhasset, New York
| | - Lauren Sharan
- Department of Transplantation, North Shore Long Island Jewish Health System-Hofstra University School of Medicine, Manhasset, New York
| | - Gene Coppa
- Department of Transplantation, North Shore Long Island Jewish Health System-Hofstra University School of Medicine, Manhasset, New York
| | - Kambhampaty Krishnasastry
- Department of Transplantation, North Shore Long Island Jewish Health System-Hofstra University School of Medicine, Manhasset, New York
| | - Ernesto Molmenti
- Department of Transplantation, North Shore Long Island Jewish Health System-Hofstra University School of Medicine, Manhasset, New York
| | - Jeffrey Nicastro
- Department of Transplantation, North Shore Long Island Jewish Health System-Hofstra University School of Medicine, Manhasset, New York
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19
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Abstract
Whole organ pancreas transplantation is increasingly being performed for the treatment of diabetes mellitus. To date, over 32,000 pancreas transplants have been performed worldwide. The procedure is associated with significant mortality and morbidity in early transplant period. However, the successful pancreas transplantation has the potential to render patients insulin-independent and halt the progression of complications of diabetes, thereby improving both quality of life and patient survival.
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Affiliation(s)
- Afshin Tavakoli
- Department of Renal and Pancreas Transplantation, Manchester Royal Infirmary, Manchester, UK.
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20
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Bratton CF, Hamid A, Selby JB, Baliga PK. Case report: gastrointestinal hemorrhage caused by a pancreas transplant arteriovenous fistula with large psuedoanuerysm 9 years after transplantation. Transplant Proc 2012; 43:4039-43. [PMID: 22172898 DOI: 10.1016/j.transproceed.2011.09.071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Accepted: 09/16/2011] [Indexed: 02/07/2023]
Abstract
Reported cases of arteriovenous fistulae in transplant recipients are uncommon. We present a case of an arteriovenous fistula associated with a large pseudoaneurysm in the root of the small bowel mesentery of a pancreas transplant. Uniquely, in our case, the arteriovenous fistula presented with an episode of gastrointestinal (GI) hemorrhage 9 years postoperatively. Radiographic imaging including coronal computed tomography angiogram and conventional angiogram demonstrated an arteriovenous fistula in the patient's pancreas transplant between the distal superior mesenteric artery (SMA) and superior mesenteric vein (SMV) with 6 cm aneurysmal dilatation. The tremendous flow in the fistula in the root of the graft small intestine mesentery led to graft duodenal mucosal congestion and lower GI hemorrhage. After successful embolization of the SMA-SMV fistula and pseudoaneurysm using interventional radiographic techniques, the arteriovenous fistula remained thrombosed. The patient had no further episodes of GI bleeding and her endoscopic evaluation was otherwise negative. The presence of arteriovenous fistulae and pseudoaneurysms in pancreas transplant recipients is uncommon, but has been previously documented. This case is further distinguished from previous reports by the notable 9-year interval between transplantation and the onset of hemorrhage. Historically, symptomatic vascular malformations have been associated with significant patient morbidity and mortality. Successful patient management involves timely and accurate diagnosis and intervention.
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Affiliation(s)
- C F Bratton
- Department of Surgery, Division of Transplant, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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21
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Liong SY, Dixon RE, Chalmers N, Tavakoli A, Augustine T, O'Shea S. Complications following pancreatic transplantations: imaging features. ACTA ACUST UNITED AC 2011; 36:206-14. [PMID: 20563577 DOI: 10.1007/s00261-010-9632-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Whole organ vascularized pancreatic transplant is a recognized treatment for diabetes and is increasingly being performed worldwide. The procedure itself is complex and is associated with significant mortality and morbidity. Despite improvements in surgical techniques, postoperative complications of pancreatic transplantation are still common and include graft rejection, pancreatitis, peripancreatic fluid collections, exocrine leaks, vascular thrombosis, and hemorrhage. In this pictorial essay, we review clinical presentation and imaging features of these complications. We also briefly discuss technique and complications of islet cell transplants.
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Affiliation(s)
- S Y Liong
- Department of Clinical Radiology, Manchester Royal Infirmary, Oxford Road, Manchester, UK.
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22
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Nikeghbalian S, Bahador A, Salahi H, Kakaei F, Kazemi K, Dehghani M, Ghaffaripour S, Malek-Hosseini S. Non–Marginal Donor C-Loop Ulcers as a Cause of Gastrointestinal Bleeding After Pancreas Transplantation: Three Case Reports. Transplant Proc 2009; 41:2930-2. [DOI: 10.1016/j.transproceed.2009.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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23
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Bollo J, Corcelles R, López-Boado MA, Astudillo E, Fernández-Cruz L. [Massive gastrointestinal haemorrhage in a pancreas transplant patient]. Cir Esp 2009; 86:179-80. [PMID: 19539900 DOI: 10.1016/j.ciresp.2008.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Accepted: 04/28/2008] [Indexed: 11/15/2022]
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24
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Abstract
Arterioenteric fistula is a rare but serious complication of enteric drained pancreas transplant, which may lead to massive gastrointestinal bleeding. We present 3 patients with failed enteric drained pancreas transplants and massive gastrointestinal bleeding secondary to arterioenteric fistula. One patient was treated by embolization and the 2 others by stent graft placement. Bleeding was successfully controlled in all cases, at follow up of 5 days, 8 months, and 12 months, respectively. One patient died 24 days after embolization, of unknown causes.
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Affiliation(s)
- Aslihan Semiz-Oysu
- Vascular and Interventional Radiology, University of Michigan Hospital, Ann Arbor, Michigan 48109, USA
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25
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Fujita S, Fujikawa T, Mekeel KL, Foley DP, Kim RD, Howard RJ, Ree AI, Hemmin AW, Flynn TC, Lee A, Caridi JG. Successful Endovascular Treatment of a Leaking Pseudoaneurysm without Graft Loss after Simultaneous Pancreas and Kidney Transplantation. Transplantation 2006; 82:717-8. [PMID: 16969300 DOI: 10.1097/01.tp.0000234930.24555.12] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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