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David A, Frampas E, Douane F, Perret C, Leaute F, Cantarovich D, Karam G, Branchereau J. Management of vascular and nonvascular complications following pancreas transplantation with interventional radiology. Diagn Interv Imaging 2020; 101:629-638. [PMID: 32089482 DOI: 10.1016/j.diii.2020.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/29/2020] [Accepted: 02/02/2020] [Indexed: 12/23/2022]
Abstract
Pancreas transplantation exposes to high rates of complications, either vascular (thrombosis, stenosis, pseudoaneurysm, arteriovenous fistula) or nonvascular (fluid collection, graft rejection). With advances in percutaneous and endovascular techniques, interventional radiologists are increasingly involved in the management of these complications. In this article, we review the anatomical considerations relevant to pancreas transplantation, the techniques used for image-guided interventions for vascular and nonvascular complications, and the expected outcomes of these interventions.
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Affiliation(s)
- A David
- Department of Radiology, Nantes University Hospital, University of Medicine of Nantes, 44093 Nantes, France.
| | - E Frampas
- Department of Radiology, Nantes University Hospital, University of Medicine of Nantes, 44093 Nantes, France
| | - F Douane
- Department of Radiology, Nantes University Hospital, University of Medicine of Nantes, 44093 Nantes, France
| | - C Perret
- Department of Radiology, Nantes University Hospital, University of Medicine of Nantes, 44093 Nantes, France
| | - F Leaute
- Department of Radiology, Nantes University Hospital, University of Medicine of Nantes, 44093 Nantes, France
| | - D Cantarovich
- Department of Nephrology, Nantes University Hospital, University of Medicine of Nantes, 44093 Nantes, France
| | - G Karam
- Department of Urology, Nantes University Hospital, University of Medicine of Nantes, 44093 Nantes, France
| | - J Branchereau
- Department of Urology, Nantes University Hospital, University of Medicine of Nantes, 44093 Nantes, France
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Zhou YX, Ji Y, Chen J, Yang X, Zhou Q, Lv J. Common iliac artery occlusion with small intestinal transection caused by blunt abdominal trauma: A case report and review of the literature. World J Clin Cases 2019; 7:2120-2127. [PMID: 31423446 PMCID: PMC6695536 DOI: 10.12998/wjcc.v7.i15.2120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/22/2019] [Accepted: 07/03/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Most major abdominal vascular injuries are caused by penetrating injuries. A common iliac artery occlusion caused by blunt force trauma is rare, and very few cases have been reported. Because of this low incidence, atypical symptoms, and frequent association with other severe injuries, the proper diagnosis tends to be missed or delayed. The gold standard for diagnosis is angiography, and treatment remains a challenge.
CASE SUMMARY We report here the unusual case of a common iliac artery occlusion caused by blunt abdominal compressive trauma, with transection of the small intestine. At presentation, the patient (a 56-year-old man) complained of pain and numbness in the left lower extremity and severe pain in the whole abdomen. Physical examination showed total abdominal tenderness with evidence of peritoneal irritation. The left lower limb was pulseless and cold. Abdominal computed tomography examination revealed digestive tract perforation, and abdominal computed tomography angiography showed left common iliac artery occlusion. The patient was treated successfully by anastomosis of the intestine, percutaneous transluminal angioplasty, and stenting. The patient was followed for more than 11 mo after the operation and showed a good recovery.
CONCLUSION Patients with abdominal trauma should be suspected of having major vascular injury. Individualized treatment strategies are needed for this condition.
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Affiliation(s)
- You-Xin Zhou
- Department of General Surgery, People’s Hospital of Jingjiang, Yangzhou University Medical Academy, Jingjiang 214500, Jiangsu Province, China
| | - Yong Ji
- Department of General Surgery, People’s Hospital of Jingjiang, Yangzhou University Medical Academy, Jingjiang 214500, Jiangsu Province, China
| | - Jing Chen
- Imaging Department, People’s Hospital of Jingjiang, Yangzhou University Medical Academy, Jingjiang 214500, Jiangsu Province, China
| | - Xin Yang
- Department of General Surgery, People’s Hospital of Jingjiang, Yangzhou University Medical Academy, Jingjiang 214500, Jiangsu Province, China
| | - Qing Zhou
- Department of General Surgery, Affiliated Hospital of Jiangsu University, Zhenjiang 212000, Jiangsu Province, China
| | - Jian Lv
- Department of General Surgery, People’s Hospital of Jingjiang, Yangzhou University Medical Academy, Jingjiang 214500, Jiangsu Province, China
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External Iliac Artery Dissection During Renal Transplantation: A Case Report and Literature Review. Transplant Proc 2019; 51:538-540. [PMID: 30879584 DOI: 10.1016/j.transproceed.2018.12.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 12/29/2018] [Indexed: 11/22/2022]
Abstract
Iliac artery dissection in the setting of renal transplant is a rare but potentially catastrophic event that may result in loss of kidney and lower extremity perfusion. We report a right external iliac artery dissection in a 45-year-old man with end-stage renal disease, diabetes, and hypertension who underwent a renal transplant at our institution. An external iliac artery dissection was diagnosed intraoperatively after completion of the arterial anastomosis given the mottled appearance of the kidney and loss of Doppler signal. The dissection was repaired via open endarterectomy, intimal tacking, bovine patching, and re-anastomosis of the kidney to a proximal site on the external iliac artery. To date, 23 cases of transplant-related iliac artery dissection have been described in the literature. Predisposing risk factors include atherosclerosis and hypertension combined with trauma from vascular clamps or suturing. There is a slight male predominance. Only one group utilized an open endarterectomy approach similar to ours, whereas others used synthetic vascular grafts (12 of 23), endovascular stents (4 of 23), donor iliac artery grafts (4 of 23), or saphenous vein grafts (2 of 23). In the absence of long-term outcomes data, the optimal repair mechanism is yet to be established.
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Outcomes of Endovascular Management of Late Vascular Hemorrhage After Pancreatic Transplant. AJR Am J Roentgenol 2018; 210:201-206. [DOI: 10.2214/ajr.17.18171] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Dar TI, Tyagi V, Khawaja AR, Chadha S, Jauhari H. External iliac artery polytetrafluoroethylene graft interposition: An effective rescuer for kidney transplant in progressive intimal dissection of external iliac artery. Urol Ann 2016; 8:223-5. [PMID: 27141197 PMCID: PMC4839244 DOI: 10.4103/0974-7796.177199] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Accepted: 06/26/2014] [Indexed: 11/25/2022] Open
Abstract
AIMS AND OBJECTIVE The aim of this study is to highlight the use of polytetrafluoroethylene (PTFE) interposition graft as an important salvage procedure in case of irreparable intimal injury of external iliac artery during renal transplant recipient surgery. MATERIALS AND METHODS Since 1987, we encountered irreparable intimal dissection of external iliac artery in five cases just after opening the clamp. It was successfully managed by PTFE interposition graft with subsequent end to side anastomosis of donor renal artery to the vascular graft. RESULTS No patient had bleeding or infective complications related to the graft and three patients had immediate diuresis. Normal immediate graft function was present in three patients while the other two had delayed graft function. CONCLUSION Polytetrafluoroethylene interposition graft is a successful procedure to salvage the kidney and lower limb in case of progressive intimal dissection of external iliac artery during renal transplant surgery.
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Affiliation(s)
- Tanveer Iqbal Dar
- Department of Urology and Kidney Transplant Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Vipin Tyagi
- Department of Urology and Kidney Transplant Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Abdul Rouf Khawaja
- Department of Urology and Kidney Transplant Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Sudhir Chadha
- Department of Urology and Kidney Transplant Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Harsha Jauhari
- Department of Urology and Kidney Transplant Surgery, Sir Ganga Ram Hospital, New Delhi, India
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Vascular complications of transplantation: part 2: pancreatic transplants. Cardiovasc Intervent Radiol 2014; 37:1415-9. [PMID: 24556832 DOI: 10.1007/s00270-014-0867-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 01/31/2014] [Indexed: 10/25/2022]
Abstract
Vascular complications after solid organ transplantation are not uncommon and may lead to graft dysfunction and ultimately graft loss. A thorough understanding of the surgical anatomy, etiologies, and types of vascular complications, their presentation and the options for management are important for managing these complex patients. This article reviews the basic surgical anatomy, the vascular complications, and endovascular management options of vascular complications in patients with pancreas transplants.
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Noninvasive Vascular Imaging in Abdominal Solid Organ Transplantation. AJR Am J Roentgenol 2013; 201:W544-53. [DOI: 10.2214/ajr.13.11306] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Saad WEA, Darwish WE, Turba UC, Angle JF, Wagner CE, Matsumoto AH, Brayman K, Hagspiel KD. Endovascular management of vascular complications in pancreatic transplants. Vasc Endovascular Surg 2012; 46:262-8. [PMID: 22492112 DOI: 10.1177/1538574412438949] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Vascular complications after pancreatic transplantation carry a high rate of graft loss. Endovascular management of these complications is confined to stent placement for iliac artery inflow disease and embolization for arteriovenous fistulae (AVFs), pseudoaneurysms, or active bleeding. The current study describes the endovascular management of pancreatic transplant venous thrombosis (N = 1), arterial stenosis (N = 5), thrombosis (N = 3), pseudoaneurysms (N = 1), and AVF (N = 2). In addition, embolization of nonfunctioning grafts is described as an endovascular alternative to pancreatectomy.
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Affiliation(s)
- Wael E A Saad
- Department of Radiology & Medical Imaging, Division of Vascular Interventional Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA.
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Abstract
Cadaveric, whole pancreas transplantation has proved an effective therapy in the treatment of long-standing type 1 diabetes mellitus and is capable of achieving an insulin-independent eugyclaemic state. As a result, this procedure is being increasingly performed. However, the surgical procedure is complex and unfamiliar to many radiologists. Imaging with computed tomography (CT) and magnetic resonance imaging (MRI) gives excellent results and can be used confidently to diagnose vascular, enteric, and immune-mediated complications. We present a review of the normal post-transplantation appearance and the features of early and late complications.
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Hagspiel KD, Nandalur K, Pruett TL, Leung DA, Angle JF, Spinosa DJ, Matsumoto AH, Ahmed H, Sanfey HA, Sawyer RG, Burkholder B, Brayman KL. Evaluation of vascular complications of pancreas transplantation with high-spatial-resolution contrast-enhanced MR angiography. Radiology 2007; 242:590-9. [PMID: 17255427 DOI: 10.1148/radiol.2422041261] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To retrospectively evaluate high-spatial-resolution contrast material-enhanced three-dimensional (3D) magnetic resonance (MR) angiography for assessment of vascular complications of pancreas allografts. MATERIALS AND METHODS The institutional review board approved the study and waived the requirement for informed patient consent owing to the retrospective nature of the study with use of an anonymous-subject database. The study was HIPAA compliant. The clinical and MR angiography findings in 11 patients (eight men, three women; mean age, 43 years; age range, 30-54 years) who had a history of pancreatic transplant dysfunction and underwent a total of 13 contrast-enhanced 3D MR angiography examinations were retrospectively reviewed. Comparison with conventional angiography findings was possible for four MR angiography examinations, comparison with surgical findings was possible for two examinations, and clinical follow-up was possible for all examinations. Two observers in consensus and blinded to the clinical results performed image analysis of the arterial and venous segments. Classification agreement was assessed with quadratic weighted kappa statistics. RESULTS Ten MR angiography examinations revealed vascular complications or signs suggestive of rejection. Only three examinations were considered to have completely normal results. All major complications were detected and included complete or partial arterial graft occlusion, stenosis of the arterial Y-graft caused by a kink, complete venous thrombosis, and arteriovenous fistula with pseudoaneurysm formation. For 46 arterial segments and 15 venous segments with angiographic and/or surgical comparison, overall agreement with MR angiography findings was nearly perfect (mean kappa, 0.983; standard error of the mean, 0.128). CONCLUSION High-spatial-resolution MR angiography of pancreas allografts enables assessment of the arterial and venous vascular anatomy and can be used to reliably identify clinically relevant vascular complications.
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Affiliation(s)
- Klaus D Hagspiel
- Department of Radiology and Division of Transplant Surgery, University of Virginia Health System, PO Box 800170, 1215 Lee St, Charlottesville, VA 22908, USA.
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Moon JI, Ciancio G, Burke GW. Arterial reconstruction with donor iliac vessels during pancreas transplantation: an intraoperative approach to arterial injury or inadequate flow. Clin Transplant 2005; 19:286-90. [PMID: 15740569 DOI: 10.1111/j.1399-0012.2005.00339.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Outcome of pancreas transplantation (PTX) has improved because of use of novel immunosuppression and advances in surgical technique. It is not uncommon for severe atherosclerosis in patients with type 1 insulin-dependent diabetes mellitus or the presence of a previously transplanted organ to limit the options for vascular anastomosis. Herein we report the novel application of donor iliac arterial interposition grafts for arterial reconstruction in patients with severe iliac artery arteriosclerosis, and/or previous transplant who develop an arterial injury or stenosis during surgery. METHODS In five patients undergoing PTX, the external iliac artery was severely atherosclerotic and/or occupied by a previous vascular anastomosis. In four of the five patients, an arterial intimal dissection became apparent. The external iliac artery was excised and reconstructed with donor iliac artery interposition graft (end-to-end anastomosis). Pancreas or kidney was engrafted onto this arterial interposition graft (end-to-side anastomosis). RESULTS There was no operative morbidity related to this surgical approach. All grafts functioned well after transplantation. Distal lower extremities have no evidence of vascular insufficiency with mean follow-up of 26 months (7-45 months). CONCLUSION This surgical technique is an acceptable option during PTX for the patient with severe iliac artery arteriosclerosis with intraoperative intimal dissection or stenosis, or perhaps those with challenging arterial access.
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Affiliation(s)
- Jang Il Moon
- Division of Transplantation, Department of Surgery, University of Miami School of Medicine, Miami, FL, USA.
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Hagspiel KD, Nandalur K, Burkholder B, Angle JF, Brayman KL, Spinosa DJ, Matsumoto AH, Veldhuis OL, Sanfey H, Sawyer RG, Pruett TL, Leung DA. Contrast-enhanced MR angiography after pancreas transplantation: normal appearance and vascular complications. AJR Am J Roentgenol 2005; 184:465-73. [PMID: 15671365 DOI: 10.2214/ajr.184.2.01840465] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Klaus D Hagspiel
- Department of Radiology, University of Virginia Health System, 1215 Lee St., PO Box 800170, Charlottesville, VA 22908, USA
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Mercer DF, Rigley T, Stevens RB. Extended donor iliac arterial patch for vascular reconstruction during pancreas transplantation. Am J Transplant 2004; 4:834-7. [PMID: 15084183 DOI: 10.1111/j.1600-6143.2004.00422.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Iliac arteries in allograft pancreas recipients may be compromised by the patient's underlying disease or previous surgical intervention. We describe a previously unreported arterial reconstruction using an extended segmental common/external iliac artery patch with anastomosis of the pancreatic Y-graft to the patch internal iliac artery, and review the options for arterial reconstruction reported by others. This technique may find application in both pancreas and kidney transplantation to salvage a damaged or diseased iliac artery.
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Affiliation(s)
- David F Mercer
- Section of Transplantation, Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
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