1999 Abstract: 2162 STRATEGIES FOR THE TREATMENT OF PANCREATIC GRAFT THROMBOSIS AFTER KIDNEY-PANCREAS TRANSPLANTATION
Abstracts
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To report the use of Duplex-Doppler Ultrasonography (DDUS) to detect total or partial early Pancreas Vascular Graft Thrombosis (PVGT) in symptomatic and asymptomatic patients after Pancreas-Kidney Transplantation (P + KTx), and the outcome of alternatives for rescue treatment, using surgery with Venous Thrombectomy (VTh) or interventional angiography procedures such as Percutaneous Mechanical Thrombectomy (PMT) and / or Thrombolisis with Urokinase Infusion (UKI). Methods: From 1983 to June 1998, 150 simultaneous whole organ P + KTx were performed, 106 with bladder drainage and 44 with enteric drainage. Postoperative monitoring included daily clinical examination and laboratory data. A baseline DDUS was done at 48-72 hours after grafting and thereafter in a weekly basis or when clinically indicated. Total PVGT was established when no venous flow was obtained and an increase in arterial resistance (IR=1 with reverse diastolic blood flow) at hilar and parenchymal levels. Partial PVGT was defined when a thrombi filling the vein lumen without complete occlussion was observed and arterial blood flow (IR < 0.75) was preserved at hilar and parenchymal levels. Results: Twenty patients (13%) developed total PVGT, 56% of patients presented hyperglycemia, 36% abdominal pain, 25% hyperamilasemia and 20% had a combination of hyperglycemia and pain over the graft, at mean 4.42 days (range 1 to 9 days) after transplantation. Graft pancreatectomy was done in 14 patients with an uneventful recovery but in one patient transplantectomy was followed by an immediate successful retransplantation (insulin free 32 months). In six patients with well preserved arterial supply surgical VTh was attempted and graft rescue was successful in 4 patients (insulin free 50, 23,17,12 months respectively). One complication, urinary fistula, was observed requiring reoperation. Partial PVGT was diagnosed in 4 (2.6%) asymptomatic patients at mean 6.75 days (range 5 to 10 days) after transplantation; arteriography confirmed the diagnosis in all cases. PMT and / or UKI (30.000 UL /20 min achieved success in three patients; after the procedure one patient had pulmonary embolism (<24hours) and GI hemorrhage (10 days) and another patient retroperitoneal hemorrhage (6 days). These three patients remained insulin free for 19, 10 and 9 months respectively. The fourth patient had associated thrombosis of the distal splenic artery requiring transplantectomy. Conclusion: Routine DDUS allows prompt diagnosis and to select the appropriate treatment. Patients with partial PVGT are optimal candidates for interventional procedures, whereas surgical thrombectomy or retransplantation should be reserved for total PVGT. These therapies achieved in one third of patients graft salvage without mortality. Copyright 1996 - 1999, SSAT, Inc. |