Pancreas venous graft thrombosis (PVGT) is the second most common cause of overall graft failure after rejection, being responsible for 2.7%–8% of graft loss.1 Surgical thrombectomy have been attempted, but they are often unsuccessful. Endovascular techniques have also been described in these situations, including venous thrombolysis and thrombectomy.1,2
We describe here a case of early PVGT successfully treated by catheter-directed thrombolysis and aspiration thrombectomy (CDT-AT).
The patient is a 34-year-old man with a 9-year history of type 1 diabetes mellitus with end-stage renal disease who underwent a deceased-donor simultaneous pancreas-kidney transplantation. The donor was a 45-year-old woman, nonsmoker, with no significant past medical history, who became brain dead because of a cerebral aneurysm rupture. Via a midline xypho-pubic incision, the pancreatico-duodenal graft was implanted intraperitoneally in the right iliac fossa. The donor portal vein was anastomosed to the recipient’s inferior vena cava without venous extension graft. The Y-graft reconstruction derived from the donor’s iliac bifurcation was anastomosed to the recipient’s right common iliac artery. Exocrine drainage was performed by a side-to-side duodeno-ileal anastomosis.
The total cold ischemic time was 7 hours. There were no intraoperative complications.
The postoperative course was marked by a primary pancreatic dysfunction with persistent elevated blood glucose levels despite high doses of insulin.
A contrast-enhanced computed tomography scan was performed the day after surgery, showing a subocclusive thrombus within the pancreatic transplant portal vein, involving splenic and superior mesenteric veins and extending to the inferior vena cava (Figure 1A). The Iliac Y graft and main arterial supply were intact. Although peripancreatic edema was noted, parenchymal enhancement suggested the viability of pancreas transplant. Based on these findings, we attempted an immediate endovascular therapy.
A direct venography was performed with a 5-F pigtail catheter, confirming the presence of a nearly occlusive thrombus (Figure 1B).
Catheter-directed thrombolysis was performed by the manual injection into the thrombus of urokinase (100,000 UI) using the 5-F pigtail catheter. A 7-F guiding sheath, advanced within the portal vein through a left femoral access, was used to perform an aspiration thrombectomy with a 50-mL syringe.
These procedures resulted in a significant decrease of the thrombus (Figure 1C).
Systemic anticoagulation was administered with an intravenous heparin infusion (25,000 UI per 24 h). The computed tomography scan performed 14 days after thrombectomy revealed a fully patent portal vein with a normal parenchymal enhancement (Figure 1D). The patient was discharged 16 days after transplant with no evidence of hyperglycemia.
Multiple risk factors of PVGT have been described, including donor risk factors such as donor age, atherosclerosis, cerebrovascular cause of brain death, obesity, and presence of shock at the time of death.
Management of PVGT is challenging. Systemic anticoagulation is used as conventional therapy in these patients but may be ineffective in cases of extensive luminal obstruction. Immediate reoperation, such as surgical thrombectomy, has been recommended for graft rescue. However, it exposes to high postoperative morbidity and mortality rates.3
Endovascular interventions have been described, including transarterial thrombolysis,4 mechanical thrombectomy,5 and CDT-AT.1,2
A successful case of transarterial thrombolysis was reported by Yoshimatsu et al,4 but this technique results in a delayed recanalization and requires high doses of urokinase. Mechanical thrombectomy using an inflated-ballon catheter has been described in one patient by Izaki et al5 allowing a graft salvage but presents the risk of venous anastomosis injury. This risk is supposedly lower with CDT-AT. Nevertheless, this issue was taken into consideration by our team and a prompt surgery would have been performed in case of vascular complication.
Barrufet et al2 recently evaluated a group of 17 patients treated by CDT-AT, describing patient and pancreas graft survival rates at 12 months of 94% and 76%, without any procedure-related complication. By way of comparison, a graft salvage rate of 45% for surgical thrombectomy was reported by Fridell et al.3
Some authors also reported the use of metal stents in cases of residual thrombus or anastomotic kinking or stenosis.1 We chose not to stent portal vein in our patient despite the fact that completion venography demonstrated residual thrombus, both because no anastomostic issue was suspected and because venous stenting may result in rethrombosis.1
There are limited literature data on the risk of hemorrhagic complications following pharmacomechanical techniques associated with systemic anticoagulation. Nevertheless, despite the fact that no direct procedure-related complications were observed in the single-center retrospective report from Barrufet et al,2 5 of the 17 patients presented bleeding complications associated with anticoagulation. Our patient did not present any postprocedural bleeding.
In conclusion, we report here a case of successful pancreatic graft salvage by prompt endovascular pharmacomechanical thrombolysis with aspiration thrombectomy.
1. Stockland AH, Willingham DL, Paz-Fumagalli R, et al. Pancreas transplant venous thrombosis: role of endovascular interventions for graft salvage.Cardiovasc Intervent Radiol2009322279–283doi: 10.1007/s00270-009-9507-9
2. Barrufet M, Burrel M, Angeles García-Criado M, et al. Pancreas transplants venous graft thrombosis: endovascular thrombolysis for graft rescue.Cardiovasc Intervent Radiol20143751226–1234doi: 10.1007/s00270-013-0799-4
3. Fridell JA, Mangus RS, Mull AB, et al. Early reexploration for suspected thrombosis after pancreas transplantation.Transplantation2011918902–907doi: 10.1097/TP.0b013e3182106069
4. Yoshimatsu R, Yamagami T, Terayama K, et al. Percutaneous transcatheter thrombolysis for graft thrombosis after pancreas transplantation.Pancreas2009385597–599doi: 10.1097/MPA.0b013e3181915972
5. Izaki K, Yamaguchi M, Matsumoto I, et al. Percutaneous selective embolectomy using a fogarty thru-lumen catheter for pancreas graft thrombosis: a case report.Cardiovasc Intervent Radiol2011343650–653doi: 10.1007/s00270-010-0093-7