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Betancur V, Zughul R, Ivanovic A, Madrazo BL, Castillo P, Casillas J, Alessandrino F. Ultrasound of pancreatic transplant complications: a primer for radiologists. Clin Radiol 2023; 78:861-871. [PMID: 37679209 DOI: 10.1016/j.crad.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/10/2023] [Accepted: 08/13/2023] [Indexed: 09/09/2023]
Abstract
Pancreatic transplantation is an established treatment for patients with type 1 diabetes patients and select type 2 diabetes patients, with excellent survival rates as graft health is evaluated through regular imaging and early detection of complications. Amongst the various imaging methods that may aid in diagnosis of pancreatic transplant complications, ultrasound is a widely available, quick, portable, and cost-effective technique, often used as the sole method to assess for pancreatic transplant complications. When assessing a patient with a pancreatic transplant, the radiologist should be methodical in assessing the vasculature, the pancreatic parenchyma, and the peripancreatic regions. Complications can be categorised based on time from transplant and type of complications, and include vascular, parenchymal, and enteric/anastomotic complications. Doppler has a major role in the diagnosis of vascular complications including arterial and venous thrombosis, arterial stenosis, pseudoaneurysms, and haematomas. Pancreatic complications include rejections and pancreatitis, and are often diagnosed through a combination of clinical, laboratory, and imaging findings, such as pancreatic heterogeneity or the presence of pancreatic pseudocysts. Enteric/anastomotic complications include leaks and bowel obstructions, and may require cross-sectional imaging in addition to ultrasound. This review covers the most common and high-impact vascular, parenchymal, and enteric/anastomotic complications that should be considered in every radiologist's search pattern when assessing a pancreatic graft, as well as their respective postoperative timeframes.
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Affiliation(s)
- V Betancur
- Leonard M. Miller School of Medicine, University of Miami, FL, USA
| | - R Zughul
- Department of Radiology, Jackson Memorial Hospital, Miami, FL, USA
| | - A Ivanovic
- Department of Diagnostic Imaging, Faculty of Medicine, Center for Radiology and MRI, Clinical Center of Serbia, Belgrade, Serbia
| | - B L Madrazo
- Division of Abdominal Imaging, Department of Radiology, Leonard M. Miller School of Medicine, Miami, FL, USA
| | - P Castillo
- Division of Abdominal Imaging, Department of Radiology, Leonard M. Miller School of Medicine, Miami, FL, USA
| | - J Casillas
- Division of Abdominal Imaging, Department of Radiology, Leonard M. Miller School of Medicine, Miami, FL, USA
| | - F Alessandrino
- Division of Abdominal Imaging, Department of Radiology, Leonard M. Miller School of Medicine, Miami, FL, USA.
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2
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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] [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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3
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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] [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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4
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Hemostasis caused by stent-graft insertion followed by graft removal for pancreas graft bleeding due to chronic rejection: A case report. TRANSPLANTATION REPORTS 2022. [DOI: 10.1016/j.tpr.2022.100095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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5
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de Oliveira Leite TF, Pazinato LV, Nunes TF, da Motta Leal Filho JM. Endovascular management of giant common iliac artery pseudoaneurysm after complications in simultaneous pancreas-kidney transplant: a case report. J Med Case Rep 2021; 15:329. [PMID: 34187552 PMCID: PMC8243608 DOI: 10.1186/s13256-021-02944-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/06/2021] [Indexed: 11/18/2022] Open
Abstract
Background Pancreatic transplantation is a definitive treatment for selected patients with insulin-dependent diabetes. It is a technically challenging surgery, and vascular complications are the most common cause of pancreatic graft failure. Although rare, pancreas transplants present higher rates of pseudoaneurysms at the vascular anastomosis than other visceral transplants. We present a case of a simultaneous pancreas–kidney transplant complicated with graft failure and common iliac artery pseudoaneurysm that was successfully treated through endovascular techniques. Case presentation A 34-year-old White woman presented with abdominal pain and a history of type 1 diabetes mellitus, end-stage renal disease, and two previous pancreas transplantation failures. The first was a simultaneous pancreas–kidney transplantation performed 7 months prior that was complicated by pancreas graft thrombosis within 1 month and required graft resection. Five months later, she underwent a second pancreas transplantation with another pancreatic graft thrombosis requiring graft resection. Abdominal angiotomography revealed a pseudoaneurysm in the right common iliac artery at the point of the previous graft anastomosis. The patient was successfully treated endovascularly with a covered stent in the common iliac artery. Conclusion Stent graft implantation for the treatment of common iliac artery pseudoaneurysm as a complication of simultaneous pancreas–kidney transplantation is a safe and feasible procedure.
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Affiliation(s)
- Túlio Fabiano de Oliveira Leite
- Interventional Radiologist, Radiology Department, Heart Institute (InCor), University of São Paulo, Rua Rafael Rinaldi, 365 apto 601, São Paulo, Uberlândia, 38400-384, Brazil.
| | - Lucas Vatanabe Pazinato
- Interventional Radiologist Unit, Department of Radiology, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Thiago Franchi Nunes
- Interventional Radiologist, Hospital Universitário Maria Aparecida Pedrossian (HUMAP), Universidade Federal de Mato Grosso do Sul (UFMS), Campo Grande, MS, Brazil
| | - Joaquim Mauricio da Motta Leal Filho
- Interventional Radiologist, Radiology Department, Heart Institute (InCor), University of São Paulo, Rua Rafael Rinaldi, 365 apto 601, São Paulo, Uberlândia, 38400-384, Brazil.,Interventional Radiologist Unit, Department of Radiology, University of São Paulo Medical School, São Paulo, SP, Brazil
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6
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Ibáñez JM, Robledo AB, López-Andujar R. Late complications of pancreas transplant. World J Transplant 2020; 10:404-414. [PMID: 33437673 PMCID: PMC7769730 DOI: 10.5500/wjt.v10.i12.404] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/18/2020] [Accepted: 10/09/2020] [Indexed: 02/06/2023] Open
Abstract
To summarize the long-term complications after pancreas transplantation that affect graft function, a literature search was carried out on the long-term complications of pancreatic transplantation, namely, complications from postoperative 3rd mo onwards, in terms of loss of graft function, late infection and vascular complications as pseudoaneurysms. The most relevant reviews and studies were selected to obtain the current evidence on these topics. The definition of graft failure varies among different studies, so it is difficult to evaluate, a standardized definition is of utmost importance to know the magnitude of the problem in all worldwide series. Chronic rejection is the main cause of long-term graft failure, occurring in 10% of patients. From the 3rd mo of transplantation onwards, the main risk factor for late infections is immunosuppression, and patients have opportunistic infections like: Cytomegalovirus, hepatitis B and C viruses, Epstein-Barr virus and varicella-zoster virus; opportunistic bacteria, reactivation of latent infections as tuberculosis or fungal infections. Complete preoperative studies and serological tests should be made in all recipients to avoid these infections, adding perioperative prophylactic treatments when indicated. Pseudoaneurysm are uncommon, but one of the main causes of late bleeding, which can be fatal. The treatment should be performed with radiological endovascular approaches or open surgery in case of failure. Despite all therapeutic options for the complications mentioned above, transplantectomy is a necessary option in approximately 50% of relaparotomies, especially in life-threatening complications. Late complications in pancreatic transplantation threatens long-term graft function. An exhaustive follow-up as well as a correct immunosuppression protocol are necessary for prevention.
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Affiliation(s)
- Javier Maupoey Ibáñez
- Hepato-Pancreatico-Biliary Surgery and Transplant Unit, La Fe University Hospital, Valencia 46026, Spain
| | - Andrea Boscà Robledo
- Hepato-Pancreatico-Biliary Surgery and Transplant Unit, La Fe University Hospital, Valencia 46026, Spain
| | - Rafael López-Andujar
- Hepato-Pancreatico-Biliary Surgery and Transplant Unit, La Fe University Hospital, Valencia 46026, Spain
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7
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Goussous N, St Michel DP, Mcdade H, Gaines S, Borth A, Dawany N, Al-Qaoud T, Bromberg JS, Barth RN, Scalea JR. Is Prophylactic Drainage After Pancreas Transplant Associated With Reduced Reoperation Rate? EXP CLIN TRANSPLANT 2020; 19:64-71. [PMID: 33272163 DOI: 10.6002/ect.2020.0010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Advances in surgery and perioperative care have contributed to improved outcomes after pancreas transplant. However, the development of peripancreatic infections carries a poor prognosis. It is not clear whether abdominal drainage is helpful in collection prevention. MATERIALS AND METHODS A retrospective review of adult consecutive pancreas transplants at a single institution between January 2017 and December 2018 was undertaken. Postoperative outcomes were compared between patients in whom prophylactic intraoperative drains were placed and patients with no drains. RESULTS We identified 83 patients who underwent pancreas transplant with a median age of 45 years; 54.2% were males, and median body mass index was 25.8. Thirty patients had 1 or 2 drains placed (36.1%). There was no difference in the readmission rate (70.0% vs 60.4%; P = .48), reoperation (20.0% vs 30.2%; P = .44), or percutaneous drainage of peripancreatic infections (20.0% vs 15.1%; P = .56) between patients with drains and no drains, respectively. However, prophylactic drainage was associated with a lower rate of reoperation for peripancreatic infections compared with those who were not drained (0.0% vs 13.2%; P < .05). No graft loss occurred in the drain group. CONCLUSIONS Prophylactic drainage after pancreas transplant may be helpful for reduction in the infection rate after reoperation. The risks of drain placement should be weighed against those of drain avoidance.
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Affiliation(s)
- Naeem Goussous
- From the Division of Transplantation, Department of Surgery, University of Maryland School of Medicine Baltimore, Maryland, USA
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8
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Witkowski G, Matejak-Górska M, Durlik M. Endovascular Treatment of Pseudoaneurysm After Simultaneous Pancreas-Kidney Transplant: A Case Report. Transplant Proc 2020; 52:2536-2538. [PMID: 32307150 DOI: 10.1016/j.transproceed.2020.02.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 02/05/2020] [Indexed: 01/18/2023]
Abstract
Pseudoaneurysm is a rare vascular complication in pancreas transplantation that can lead into life-threatening situations. A 44-year-old male patient after simultaneous pancreas-kidney transplant was admitted to the hospital for routine tests 3 months after surgery. A computed tomography scan and ultrasound examination were done, and a diagnosis of pseudoaneurysm was made. The patient was qualified for endovascular treatment. The pseudoaneurysm was closed using coils, and kidney and pancreas grafts stayed in proper condition. Endovascular interventions in patients after pancreas transplantation are safe and preferable in managing postoperative complications.
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Affiliation(s)
- Grzegorz Witkowski
- Department of General and Transplantation Surgery, Central Clinical Hospital, Ministry of the Interior, Warsaw, Poland; Centre of Postgraduate Medical Education, Warsaw, Poland.
| | - Marta Matejak-Górska
- Department of General and Transplantation Surgery, Central Clinical Hospital, Ministry of the Interior, Warsaw, Poland; Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Marek Durlik
- Department of General and Transplantation Surgery, Central Clinical Hospital, Ministry of the Interior, Warsaw, Poland; Centre of Postgraduate Medical Education, Warsaw, Poland
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9
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Huurman VAL, Lardenoye JHP. Pancreas graft salvage after successful endovascular treatment of Y graft pseudoaneurysm. J Surg Case Rep 2019; 2019:rjz124. [PMID: 31110652 PMCID: PMC6521681 DOI: 10.1093/jscr/rjz124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/29/2019] [Accepted: 05/05/2019] [Indexed: 12/17/2022] Open
Abstract
Pancreas transplantation is the most successful treatment option for patients with autoimmune type 1 diabetes. However, the surgical procedure is associated with high morbidity rates. The present case report describes a patient receiving simultaneous pancreas/kidney transplantation. After initial success, he develops a pseudoaneurysm of the iliac Y graft reconstruction, necessitating elective transplantectomy to avoid rupture. While on the waiting list for this operation, the patient is admitted to another hospital with acute bleeding from the pseudoaneurysm. An endovascular stent is successfully placed into the Y graft, stopping the bleeding with preserved pancreas function. Close follow-up using CT angiography shows successful treatment of the aneurysm. Pancreas graft function remains excellent. Although most experts until now have advised transplantectomy in the case of Y graft aneurysms, this case report advocates stent placement and close monitoring to preserve the pancreatic graft.
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Affiliation(s)
- V A L Huurman
- Transplant Center, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - J H P Lardenoye
- Department of Vascular Surgery, Rijnstate Hospital, Arnhem, The Netherlands
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10
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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] [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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11
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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] [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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12
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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] [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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13
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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: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [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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