• Mycotic aneurysm at the site of a Carrel patch arterial anastomosis occurred in four patients who had undergone whole pancreas transplantation 2.5 to 14.5 months previously. In all patients, the graft had been removed, leaving the Carrel patch on the iliac artery. The aneurysms ruptured into the intestine or the extraperitoneal space. The ruptures were sudden and life-threatening in three of four cases. This diagnosis must be suspected in patients with a history of pancreas transplantation in the immediate or distant past if they present with unexplained hypotension, cardiac arrest, or gastrointestinal tract bleeding. © 1989, American Medical Association. All rights reserved

Carroll, PB

Gordon, RD

Makowka, L

Starzl, TE

Tzakis, AG

Yokoyama, I

English

PubMed

D-Scholarship@Pitt

Arterial Mycotic Aneurysm and Rupture #ff A Potentially Fatal Complication of Pancreas Transplantation in Diabetes Mellitus 9 7 ~ Andreas G. Tzakis, MD; PatriciaB. Carroll, MD; Robert D. Gordon, MD; Itsuo Yokoyama, MD; Leonard Makowka, MD, PhD; Thomas E. Starzl, MD, PhD • Mycotic aneurysm at the site of a Carrel patch arterial anas-tomosis occurred in four patients who had undergone whole pancreas transplantation 2.5 to 14.5 months previously. In all patients, the graft had been removed, leaving the Carrel patch on the iliac artery. The aneurysms ruptured into the intestine or the extraperitoneal space. The ruptures were sudden and life-threat-ening in three of four cases. This diagnosis must be suspected in patients with a history of pancreas transplantation in the immedi-ate or distant past if they present with unexplained hypotension, cardiac arrest, or gastrointestinal tract bleeding. (Arch Surg.1989;124:660-661) Pancreas transplantation has been performed with increas-ing frequency in patients with diabetes mellitus, often at the same time as renal transplantation. '5 Mycotic arterial aneurysms developed in four patients at the site of the Carrel patch, which was used to rearterialize the whole pancreas homograft. This life-threatening complication could be con-fused with cardiac arrhythmias or myocardial infarction, the most common causes of sudden death in advanced diabetes. PATIENTS AND METHODS The four complications occurred in 16 patients who received 17 pancreas grafts between 1983 and 1985 in a pilot study of whole pancreas transplantation at the University of Pittsburgh (Pal. 6 The 4 patients were 24 to 36 years of age and had type I diabetes mellitus and a history of ketosis for 18 years or more. All patients had neuropathy and retinopathy. All but 1 had renal failure, which was treated earlier or at the same time with cadaveric kidney transplantation. A pancreaticoduodenal graft was used in each case. The donor celiac axis and origin of the superior mesenteric artery were included in a Carrel patch of the donor aorta, which was anastomosed to the side of the recipient common iliac artery. 6. 7 The end of the graft portal vein was anastomosed to the side of the common iliac vein of the recipient. The graft exocrine secretions were directed into the recipi-ent jejunum by anastomosing the duodenum directly into the recipi-ent jejunum (cases 1 and 2) or through a defunctionalized Roux-en-Y limb of jejunum (cases 3 and 4), with techniques that have been described elsewhere. 6,7 Immunosuppression was achieved with cyclo-sporine and prednisone, supplemented with azathioprine and mono-clonal antibody (OKT3, Orthoclone), as indicated. Perioperative antibiotics administered at the time of transplanta-tion consisted of cefazolin in patients 1 and 2, cefotaxime in patient 3, and cefota.xime and ampicillin in patient 4. RESULTS Clinical Presentation Failed pancreatic grafts had been removed 5 days to 14 months before the aneurysm ruptures occurred (Table). In patients 1, 2, and 3, the ruptures occurred, fortunately, while the patients were in the hospital. Patient 1 had a peripancrea-tic abscess drained 1 week before pancreatectomy. No ab-scess was encountered in patient 2. There was no disruption of the enteric anastomosis. Both patients became pulseless at the same time that they developed swelling in the area of the Accepted for publication February 20, 1989. From the Departments of Surgery (Drs Tzakis, Gordon, Yokoyama. Ma-kowka, and Starzl) and Medicine (Dr Carroll), University of Pittsburgh (Pa) Health Center; and Veterans Administrdtion, Pittsburgh (Drs Tzakis, Carroll, Gordon, Yokoyama, Makowka, and Starzl). Reprint requests to Falk Clinic Transplantation Section, 3601 Fifth Ave, Pittsburgh, PA 15213 (Dr Tzakis). 660 Arch Surg-VoI124, June 1989 graft and bleeding through the graft pancreatectomy incision . The incisions were opened at the bedside, and the bleeding was controlled as the patients were rushed to the operating room. The graft in patient 3 had been removed 2112 months previ-ously because of venous thrombosis, 10 days after the trans-plantation. The reason for his hospitalization was persistent serous wound drainage. A few hours after admission he had a cardiac arrest after suddenly developing abdominal pain and distention. The diagnosis was obvious, and the patient was resuscitated as he was brought to the operating room. Patient 4 presented with upper gastrointestinal tract bleeding 1 year after graft pancreatectomy for pancreatitis. Upper and lower gastrointestinal tract endoscopy, techne-tium bleeding scanning, ultrasound examination, and arteri-ography of the abdominal aorta and iliac and visceral arteries did not reveal a bleeding source. She was discharged. Two months later, another episode of massive upper and lower gastrointestinal tract bleeding occurred. She was readmitted and collapsed within a few hours. At emergency operation, a rupture was found of the arterial anastomosis site into the tip of the Roux-en-Y loop previously used for enteric drainage. Bacterial Cultures The bacteria cultured from the rupture sites are listed in the Table. Results of cultures were negative in patient 4 but were considered to be falsely negative because there was communication with the intestine. Surgical Treatment All patients underwent ligation of the proximal and distal common iliac artery. In all but patient 4, crossover femoral-femoral bypass was performed immediately. In patient 4, the extremity seemed well perfused, and the limb was not revas-cularized. Ten months later, she developed intermittent clau-dication in the left leg. At the time of this writing, she is scheduled for arterial bypass. The patients are all alive and well and are currently receiv-ing exogenous insulin. Renal function, if it was present be-fore, was not adversely affected by the complication (Table). COMMENT Since the advent of immunosuppression with cyclosporine, I-year graft survival has improved and is currently reported to be 50% or more.'·B Breakdown of the constructed anasto-moses for exocrine drainage has been common and has often been ascribed to the proteolytic activities of the pancreatic juices, or less often to infections. Both factors could have contributed to the aneurysm for-mation and rupture in our four patients. The bacteria cultured from the rupture site in three patients were indigenous to the gastrointestinal tract, and in the patient with a negative culture, the rupture was into the intestine. Thus, we classi-fied all of the pseudoaneurysms as mycotic. Mycotic aneurysm and rupture may be a relatively specific complication of whole pancreas transplantation. Although Carrel patches to the iliac vessels are almost always used for kidney transplantation at the University of Pittsburgh, only one mycotic aneurysm was observed after 1375 cadaveric Arterial Mycotic Aneurysm - Tzakis et al Reprinted from the Archives of Surgery June 1989, Volume 124 Copyright 1989. American Medical Association Clinical Characteristics of Patients With Arterial Aneurysms After Pancreatic Transplantation* Time Between Aneurysm Rupture, Time of Pancreas Time After Patient! Kidney Transplant Pancreas Transplant Age, y/Sex Transplant and Removal Graft Removal 1/301M Previous 1Smo Sd (rejection) 21281M Previous 2.Smo , wk (10 nonfunctional (rejection) transplants) 3/36/M Simultaneous 10 d 2.Smo (venous thrombosis) 4/241F None 3wk 14 mo (pancreatitis) *LeIA indicates left common iliac artery. renal transplantations between 1981 and 1988. In contrast, mycotic aneurysms developed after 4 of our 17 whole pancreas transplantations between 1983 and 1986. At the University of Iowa, Iowa City, aneurysm rupture was seen in 3 of 80 cases (Robert Corry, MD,oral communication, September 1988). The same incidence of 3 in 80 cases has been seen at the Karolinska Institute in Stockholm (Carl G. Groth, MD, oral communicaton, September 1988). In all 10 cases of the Pitts-burgh-Iowa City-Stockholm collection, exocrine pancreatic drainage had been into the gastrointestinal tract. This compli-cation was not seev in 3 other patients in our series who had failed grafts removed. Two of these patients' grafts were grossly infected. A fourth patient has had a failed graft left in situ for3 years without this complication. Intraperitoneal placement of the pancreatic allograft offers a theoretical advantage of having the arterial anastomosis exposed to the peritoneal cavity rather than the closed extra-peritoneal space. Patient 4 had the only intraperitoneal pan-creas graft in our series. Whether this frightening complication will be minimized with the increasingly popular techniques of exocrine drainage into the less contaminated bladde~I9 remains to be seen. Walstra et apo have reported a successfully treated mycotic aneurysm after bladder drainage, which has also been ob-served with a fatal outcome (D. N ghiem, MD, oral communi-cation, June 1988) The most important lesson from this cumulative experience is the necessity for a high index of suspicion in the event of wound complications, unexplained shock syndromes, gastro-intestinal tract hemorrhage, or unexplained abnormalities with examination performed physically or by imaging tech-niques. Appropriate surgical care then can be planned, some-times electively instead of under the catastrophic circum-stances that existed in all of our cases. In our patient 4, in whom a wound infection with Candida stellatoidea and Can-dida albicans was documented at the time the pancreas was removed for pancreatitis, prophylactic ligation of the common iliac artery was seriously considered but not done. This proved to have been an error when the aneurysm ruptured into the intestine more than 1 year later. This study was supported by the Veterans Administration, Pittsburgh. Pa; grants DK-29961 and RROO05625 from the National Institutes of Health, Bethesda, Md; and the E. Clarence Rice Fellowship of the American Diabetes Association, Washington, DC (Dr Carroll), ArchSurg-VoI124, June 1989 Arterial Site Current Findings Culture Results Repair Status Pseudoaneurysm Citrobacter Femoral-femoral, Alive and well; of LelA freundii, bypass functional BacterOides ligation kidney me/aninogenicus, of LelA transplant Enterobacter aerogenes, Clostridium subtermindi Pseudoaneurysm Bacteroides Femoral-femoral, Alive and well; of LelA fragilis, Fusobac- bypass ligation dialysis terium nucleatum of LelA Pseudoaneurysm Cfreundii, Femoral-femoral, Alive and well; of LelA microaerophilic bypass ligation functional philic strept of LelA kidney Viridans transplant Pseudoaneurysm Negative Ligation of Alive and well; of LelA LelA native renal function References 1. Sutherland DR. Pancreas transplant registry: history and analysis of cases 1966-1986. Pancreas. 1987;473-488. 2_ Groth CG, Tyden G, Segmental pancreatic transplantation with enteric exocrine drainage. In: Groth CG, ed. Pancreatic Transplantation. Philadel-phia, Pa: WB Saunders Co; 1988:99-112, 3. Sollinger HW, Kalayoglu M, Hoffman RM, Deierhoi MH, Belzer FO, Quadruple immunosuppressive therapy in whole pancreas transplantation, Transplant ?roc. 1987;19:2297-2299. 4. LandgrafR, LandgrafL, Burg M, et al. Longterm follow-up of segmental pancreas transplantation in type I diabetics_ Transplant ?roc. 1986;18:1118-1124, 5. Corry RJ, Nghiem D, Schulak J, Budtel WD, Gonwa TA. Surgi-cal treatment of diabetic nephropathy with simultaneous pancreati-coduodenal and renal transplantation, Surg Gynecol Obstet. 1986;162: 547-555, 6, Starzl TE, Tzakis AG, Pancreatico-duodenal transplantation with enteric exocrine drainage, In: Groth CG, ed. Pancreatic Transplantation. Philadel-phia, Pa: WE Saunders Co; 1988:113-129. 7. Starzl TE, Iwatsuki S, Shaw BW, et aL Pancreaticoduodenal transplanta-tion in humans. Surg Gynecol Obstet, 1984;159:265-272, 8. Corry RJ_ Pancreatic-duodenal transplantation with urinary tract drain-age_ In: Groth CG, ed. Pancreatic Transplantation. Philadelphia, Pa: WB Saunders Co; 1988:147-153. 9, Sollinger HW, Kalayoglu M, Hoffman R, et aL Experience with pancrea-ticocystostomy in 24 consecutive pancreas transplants. Transplant ?roc. 1985;17(suppI2):141-143. 10. Walstra BJ, Jorning PG, Kootstra G, van HoofJP, Janevski BK. Pancre-as transplantation complicated by a mycotic false aneurysm: diagnostic fea-tures, J MedlmG{}ing. 1988;2:133-136. Editorial Comment This concise article describes a devastating complication (mycotic aneurysm at the arterial suture line) that has occurred with surpris-ingly high frequency in patients with pancreatic transplantation at the University of Pittsburgh, There have also been a significant number of identical complications reported by the Iowa City and Stockholm groups. The common denominator in all of these cases has been drainage of the pancreatic secretions into the gastrointestinal tract. There is little general recognition even in the transplant com-munity as to the prevalence of this complication, even though the danger of gastrointestinal tract contamination in the immunosup-pressed patients is well known. The authors' recommendation for a high index of suspicion of this complication and for its aggressive treatment by ligation of the iliac artery and extra-anatomic bypass is well taken, as is their suggestion that ligation of the artery should even be considered prophalactically in instances where contamina-tion of the suture line is recognized. CLYDE F. BARKER, MD Philadelphia, Pa Arterial Mycotic Aneurysm-Tzakis et al 661 Printed and Published in the United States of America 

Arterial Mycotic Aneurysm and Rupture: A Potentially Fatal Complication of Pancreas Transplantation in Diabetes Mellitus

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Arterial mycotic aneurysm and rupture: A potentially fatal complication of pancreas transplantation in diabetes mellitus

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Arterial Mycotic Aneurysm and Rupture: A Potentially Fatal Complication of Pancreas Transplantation in Diabetes Mellitus

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