A. E. Cabrales1, T. Nikumbh1, R. S. Mangus1 1Indiana University School Of Medicine,Indianapolis, IN, USA
Introduction:
Vascular complications such as aortic pseudoaneurysm, AV fistula formation, vascular graft leak, vascular graft thrombosis, and venous outflow obstruction can result in significant morbidity and mortality in abdominal organ transplant patients. In this study, we review our experience with such complications in isolated intestine and multivisceral transplant patients.
Methods:
All records for isolated intestine, multivisceral, and modified multivisceral transplants over a 15-year period at a single center were reviewed. All cases of aortic pseudoaneurysm, AV fistula formation, vascular graft leak, vascular graft thrombosis, and venous outflow obstruction were included.
Results:
Of 263 transplants, 16 major post-transplant vascular complications were identified. There were five cases of venous outflow obstruction, three of which required revision of the venous anastomosis. One case resulted in colonic necrosis necessitating colectomy, and another required venotomy and thrombectomy. Four patients developed vascular graft thrombosis, one of which was found to have splenic artery thrombosis for which a distal pancreatectomy was eventually required. The second patient developed distal arterial thrombi of the intestinal graft resulting in small bowel necrosis that required resection of the distal ileum. The third patient developed hepatic artery thrombosis which was successfully treated with intra-arterial tPA infusion and anastomotic revision; this patient also had poor portal flow that was successfully re-established with anastomotic revision. The fourth patient was found to have minimal flow in the aortic jump graft with diffuse necrosis of the transplanted organs and died shortly thereafter from complications of severe acidosis. Four cases of vascular graft leak were identified, all of which involved the aortic graft and resulted in exsanguination and death. There were two instances of aortic pseudoaneurysm, both of which were successfully treated with stent graft placement. One case of AV fistula formation was identified involving the hepatic artery and portal vein, and was successfully treated with coil embolization of the hepatic artery.
Conclusion:
Vascular complications can result in significant morbidity and mortality in intestine and multivisceral transplant patients. Post-transplant clinical assessments including continuous hemodynamic monitoring, trending of hemoglobin, and use of imaging modalities including ultrasound with duplex doppler and CT angiography can be helpful in identifying vascular complications at an early stage and aid in surgical decision-making. In cases of pseudoanerysm and AV fistula formation, involvement of interventional radiology or vascular surgery can be beneficial.