Partial venous thrombosis of the pancreatic allografts after simultaneous pancreas–kidney transplantation

Abstract

Despite new advances in transplantation, complete venous thrombosis (VT) of the pancreas after simultaneous pancreas kidney (SPK) transplantation usually results in graft loss. Data are limited regarding the outcome and treatment of partial VT of the pancreas allograft. From July 1994 to December 1999, 126 patients with IDDM/end-stage renal disease underwent SPK with systemic bladder drainage at the University of Miami. We retrospectively reviewed our experience regarding the outcome and treatment options of partial VT of the pancreas allografts. From July 1994 to April 1997, partial VT was not seen in the first 66 SPK patients induced with anti-CD3 rnAb and oral or intravenous (i.v.) tacrolimus (TAC) in the operating room. From May 1997 to June 1999, 14 (29%) out of 48 patients had VT. These cases were identified following the i.v. use of TAC with anti-IL-2R antibody-induction therapy (7/15) or without (7/33). Partial thrombosis of the splenic vein (PTSV) was documented in 10 patients, 2 had complete thrombosis of the splenic vein (CTSV), 1 had partial thrombosis of the superior mesenteric vein (PTSMV), and 1 patient had PTSV and PTSMV. These were identified incidentally during routine color Doppler ultrasonography (CDU). None of these SPK recipients demonstrates a change in clinical parameters. The first 8 patients were systemically heparinized, followed by oral anticoagulation, except 1 patient with CTSV. He progressed to complete thrombosis of the pancreas allograft and was treated with percutaneous thrombectomy and urokinase infusion, followed by heparinization and oral anticoagulation. One patient required exploration for bleeding. In an attempt to reduce the morbidity of heparinization, we treated the next 6 patients with PTSV with aspirin followed by serial CDU. All 14 patients had preservation of the endocrine and exocrine pancreatic functions. CDU showed resolution with recanalization of the thrombosed vein(s). From July 1999 to December 1999, 12 SPK recipients were administered TAC orally with or without induction therapy with anti-IL-2R antibody. So far, in this group, VT has not been identified. In summary, a total of 14 out of 126 patients (11%) had isolated VT with a mean follow-up of 36.4 months. Based on our experience, we suggest that extensive VT after pancreas transplantation, including splenic and superior mesenteric VT, be treated with heparin and subsequent oral anticoagulation for 3 months. For more limited, partial splenic VT, aspirin may be sufficient. Follow-up CDU is critical for a successful outcome. The i.v. use of TAC appears to be a risk factor for the increased incidence of VT. Currently, using IL-2rmAb as induction, TAC is started orally on postoperative days 3 or 4 and aspirin on postoperative day 2.

Pancreatic allograft thrombosis: Suggestion for a CT grading system and management algorithm

“…reported 6 patients with partial PAT of the splenic vein, who were started on aspirin 81 mg once daily and followed with serial Doppler USS. None progressed to complete thrombosis, and all had a functioning graft at the end of follow‐up 31. Delis et al.…”

Role of color Doppler sonography in post-transplant surveillance of vascular complications involving pancreatic allografts

“…The pancreas graft is uniquely susceptible to vascular thrombosis due to its intrinsically low blood flow, which can be further diminished by ischemiaereperfusion injury [10].…”

Pancreas Transplants Venous Graft Thrombosis: Endovascular Thrombolysis for Graft Rescue

“…Treatment choice depends on thrombosis location and extension, operator experience, and availability of skilled interventional radiologists [3]. Kuo et al [6] and Ciancio et al [7] reported that venous thrombosis after pancreas transplantation could be treated with heparin and subsequent oral anticoagulation or aspirin depending on the thrombus extension. However, in the study of Kuo et al [6], the results of anticoagulation treatment were significantly worse in the recipients of solitary pancreas transplantation (26.8 %) compared with the recipients of simultaneous kidney and pancreas transplantation (86.1 %) despite the fact that venous graft thrombosis was diagnosed earlier in patients with solitary pancreas transplantation.…”

“…The lack of randomization and a control group treated with anticoagulation prevents to assess in what number of these patients, particularly those with thrombus 30-60 % in length, anticoagulation alone would have been effective. The current literature dealing with the available salvage strategies is retrospective without comparing the different treatment options [4][5][6][7][8][9][10][11][12]. The low incidence of PVGT makes it difficult to compare the treatment options in a prospective randomized study in a single institution.…”

“…Color Doppler ultrasonography (CDUS), currently the firstline technique in postoperative pancreas graft monitoring, enables early diagnosis of PVGT, thus increasing the possibility of graft-rescue treatments. Graft-rescue treatments include anticoagulation, surgical thrombectomy, and endovascular treatment [4][5][6][7][8][9][10][11].…”