Successful Endovascular Salvage of a Pancreatic Graft After a Venous Thrombosis: Case Report and Literature Review

Abstract

Simultaneous kidney and pancreatic transplant is the criterion standard for treatment of end-stage renal failure because of diabetic nephropathy. Venous thrombosis occurs in approximately 5% of pancreatic transplants, and it is notoriously difficult to treat, forming the most common nonimmunologic cause of graft loss. We report a case of early detection of pancreatic graft venous thrombosis by measuring urinary amylase, resulting in the successful endovascular salvage of the pancreatic graft.

Early protocol computer tomography and endovascular interventions in pancreas transplantation

“…In a study of 47 patients with graft failure, the main indication for pancreatectomy was vascular thrombosis and all patients with graft loss within 14 days of initial surgery required pancreatectomy 47 . Graft salvage may be achievable with prompt diagnosis and treatment 30 ; however, endovascular thrombectomy remains uncommon within the literature, with most studies focusing on the role of anticoagulation 4,14,48 . A study of 188 pancreas transplants evaluated fixed low‐molecular‐weight heparin compared to adjusted unfractionated heparin and demonstrated that fixed‐dose heparin may not be inferior to dose‐adjusted heparin in preventing venous graft thrombosis 49 .…”

“…Directly, surgery damages the endothelial wall due to clamping and division of vessels, which activates the intrinsic coagulation pathway. Indirectly, surgery causes an inflammatory response, acute graft rejection, and dehydration all of which can precipitate thrombosis 14 …”

“…Once thrombosis has occurred salvage can be challenging, particularly venous thromboses, and rates of graft loss are high 21–23 . Partial venous thrombosis is more common and can often be managed with anticoagulation or interventional radiological techniques 14,24,25 . Extensive or proximal thrombosis normally results in graft loss, unless there is early identification with prompt thrombectomy or thrombolysis 5,26,27 …”

“…Indirectly, surgery causes an inflammatory response, acute graft rejection, and dehydration all of which can precipitate thrombosis. 14 Thrombosis can be difficult to diagnose clinically, and therefore, clinicians routinely rely on several different imaging modalities: ultrasonography (US), either doppler or contrast-enhanced, computer tomography angiography (CTA) or magnetic resonance angiography. 15,16 Diagnosis via these imaging modalities can be difficult due to complex post-transplant anatomy.…”

“…[21][22][23] Partial venous thrombosis is more common and can often be managed with anticoagulation or interventional radiological techniques. 14,24,25 Extensive or proximal thrombosis normally results in graft loss, unless there is early identification with prompt thrombectomy or thrombolysis. 5,26,27 Prior to a comprehensive review of our pancreas transplant protocol in 2013, we would only perform cross-sectional imaging in response to either clinical suspicion of graft thrombosis or to a documented decline in the pancreas allograft graft function as monitored by the above-mentioned parameters.…”