Early Pancreas Retransplantation for Vascular Thrombosis in Simultaneous Pancreas–Kidney Transplants C.V. Sansalone, P. Aseni, M.L. Follini, O. Rossetti, A.O. Slim, G. Colella, F. Di Benedetto, G. Rombola `, G.F. Rondinara, L. De Carlis, C. Brunati, A. Meroni, R. Confalonieri, G. Civati, and D. Forti V ASCULAR thrombosis is still the leading cause of nonimmunologic, technical pancreatic graft failure, usually occurring in the early postoperative period. 1 Few data exist regarding the issue of pancreas retransplantation (rePT). According to Registry data, about 150 rePT have been performed in the world in the last 10 years. One hundred twenty-five were rePT after pancreas transplant alone (PTA) and 25 after simultaneous pancreas– kidney transplant (PKT). In both groups, chronic rejection was the main cause of graft loss. 2 Furthermore, rePT one-year graft survival was 80% in PKT and 40% in PTA, which compared favourably to results achieved in primary PT. We present here the initial experience with rePT in two patients with early vascular thrombosis after pancreas transplantation (PT). MATERIALS AND METHODS From October 1993 to May 1997, 18 patients with type I diabetes mellitus underwent PT. Seventeen patients with end-stage renal disease received a PKT whereas one received a PTA. Thirteen patients were male and 5 female, with a mean age of 36.8 years (range, 25 to 56) and a mean duration of diabetes of 20 years (range, 16 to 25). All pancreas grafts were procured in combination with liver using the well-established technique described by Sollinger et al. 3 In all patients, arterial reconstruction was per- formed using a bifurcated donor common iliac artery graft while there was no need of lengthening the portal vein. Quadruple immunosuppression including antithymocyte globuline (ATG) (7 to 14 days) was used for induction therapy. Prednisone, azathio- prine, and cyclosporine were given for induction and maintenance therapy. Broad spectrum antibacterial agents were administered intravenously (IV) for seven days after the transplant and antifun- gal therapy was given systematically for 14 days. Acute rejection episodes were treated with steroid boluses. Thirteen had bladder drainage (BD) and 5 enteric drainage (ED). RESULTS One patient in the BD group (a 32-year-old woman) and one patient in the ED group (a 34-year-old man) developed vascular thrombosis of their pancreas graft seven and three days after SPK respectively. Both patients presented with hematuria, abdominal tenderness, pain, and edema of the ipsilateral lower limb. An enlarged boggy pancreas was detected by clinical and computed tomography examina- tions. Hyperglycemia and decrease of urine amylase output (in the BD patient) appeared two hours later. During operation, hemorrhagic necrosis involving the whole pan- creas with thrombosis of the portal vein extended to the external and common iliac veins were seen. Both patients received a second pancreas graft, at the same time of pancreasectomy in one and the day after in the other. They received systemic anticoagulation perioperatively and anti- platelet therapy postoperatively. The postoperative course was uneventful and the two patients were discharged 16 and 23 days after rePT with normal graft function. The patient in the ED group re- mained in an hyperglobulic state with a median hematocrite of 54% and again developed vascular thrombosis of the second graft nine months after rePT. In contrast to the first episode, the patient complained of sudden pain in the right lower quadrant without enlarged pancreas. Preoperative angiography showed thrombosis of splenic and superior mesenteric arteries confirmed during operation. This pa- tient is alive and well, under insulin regimen with normal renal function. DISCUSSION Pancreas thrombosis accounts for the majority of the clin- ical graft loss occuring the first few days after pancreas transplantation. 1–4 Retransplantation is not a routine sur- gical procedure. About 200 cases have been reported by the International Transplant Registry, almost all in PTA. Reperfusion injury, hyperperfusion injury at the moment of organ procurement, 5 and technical problems 6–7 are multi- ple risk factors considered to play a role in the loss of pancreatic venous microperfusion as in our two cases in which pancreas allografts were turgid, edematous, and From the Departments of General Surgery and Abdominal Organ Transplantation (C.V.S., P.A., M.L.F., O.R., A.O.S., G.C., F.D.B., G.F.R., L.D.C., A.M., D.F.), and Nephrology (G.R., C.B., R.C., G.C.), Niguarda Hospital, Milan, Italy. Address reprint request to Dott. Cosimo Vincenzo Sansalone, Pizzamiglio II, Ospedale Niguarda, 20162 Milano, Italy. © 1998 by Elsevier Science Inc. 0041-1345/98/$19.00 655 Avenue of the Americas, New York, NY 10010 PII S0041-1345(97)01248-7 Transplantation Proceedings, 30, 253–254 (1998) 253