529

American Journal of Roentgenology 1990.154:529-531.

Case

Report

Acute Venous Thrombosis After Pancreas Transplantation: Diagnosis with Duplex Doppler Sonography and Scintigraphy Ian Boiskin,1

Martin

P. SandIer,1

Arthur

C. Fleischer,1

and

The number of pancreas transplantations performed in selected patients with severe diabetes mellitus has increased in recent years. Technical complications after surgery are relatively common and remain a major obstacle to the success of the procedure. According to Hanto and Sutherland [1], acute venous thrombosis is the second most common cause of graft loss and usually occurs in the first week after transplantation. Successful thrombectomy has not been accomplished in any patient; infarction occurs immediately after thrombosis, and the diagnosis is not made early enough to allow revascularization. Perfusion scintigraphy is a sensitive, albeit nonspecific indicator of abnormal perfusion in the transplanted organ [2]. If the graft is not visualized, arteriography is necessary and is the procedure of choice for further evaluation. The absence of blood flow is thought to signify vascular thrombosis and warrants the removal of the allograft [i]. In a recent case [3] in which duplex Doppler sonography was used in correlation with the radionuclide perfusion study, early diagnosis of allograft renal vein thrombosis was reported. Surgical correction was done immediately, and the transplanted kidney was salvaged. We describe a case in which, using the same two procedures, we diagnosed an acute venous thrombosis in an allograft pancreas transplant.

Received September Department SandIer. 2 Department ,

AJR 154:529-531,

A. Nylander

Case

Report

A 33-year-old and

recent

for

pancreas and

nation mm

with

retinopathy was

severe

and

Hg and

cataracts

had

except

cataracts.

Serum

amylase

diabetes

in renal

transplantation. occurred when

unremarkable

was 93 mg/dl,

insulin-dependent

deterioration

and kidney of diabetes

started. Onset old,

man

progressive

for

function

admitted

Dialysis had not been the patient was 1 3 years

developed.

a blood

creatinine

mellitus

was

level

Physical

pressure was

exami-

of

210/110

8.0 mg/dI,

glucose

count

was 4.5 x

was 31 lU/I, and the WBC

i 03/MI.

The patient underwent and duodenocystostomy. iliac fossa.

The

a whole cadaveric pancreas transplantation The donor pancreas was placed in the right

accompanying

arterial

supply

vessels

(celiac

axis

and

splenic artery) and venous drainage vessels (splenic and portal veins) were anastomosed to the right common iliac artery and vein, respectively. with

During

the

same

operation,

ureteroneocystostomy

placed in the surgery. A few puran) kidney. good

left iliac

hours

a cadaveric

was

fossa.

performed.

study

A dynamic perfusion

an

showed

radioisotope to

both

the

later,

the

kidney

developed

‘31I-orthoiodohippurate

normal

function

angiogram kidney

transplantation

donor

No complications

postoperatively,

renographic

renal The

and

with

was

during (13l-Hip-

in the transplanted mTcDTPA

pancreatic

showed

transplants

(Fig.

1A). Two glucose i03/pI.

days levels Serum

remained amylase

patient’s

blood

unchanged, levels,

however,

pressure

and

the

WBC

increased

increased.

Serum

count

was

to 137

lU/I.

7.4

x

29, 1989; accepted after revision November 6. 1989.

of Radiology

and Radiological

of Transplant

Surgery.

March

William

Sciences.

Vanderbilt

University

1990 0361 -803X/90/1

543-0529

Vanderbilt Medical

University Center,

Medical

Nashville,

Center,

Nashville,

TN 37232-2405.

© American Roentgen Ray Society

TN 37232-2405.

Address

reprint

requests

to M. P.

BOISKIN

530

.

ET AL.

AJR:154,

1990

,

_ .

March

--

p

).

:

.

B

American Journal of Roentgenology 1990.154:529-531.

A

Fig. 1.-Acute venous thrombosis after pancreas transplantation. A, Radioisotopic angiogram (anterior views obtained every 1.5 sec after IV injection of 15 mCi [555 MBq] “Tc-DTPA) obtained immediately after transplantation shows perfusion of renal transplant in left iliac fossa (solid arrow) and of pancreas transplant in right iliac fossa (open arrow). B, Radioisotopic angiogram obtained 2 days after transplantation shows no perfusion in pancreas transplant (arrowhead) and normal perfusion in renal transplant (arrow). C, Duplex Doppler sonograms of pancreas transplant show short systolic inflow with marked reversal of blood flow during diastole. No venous signals were obtained.

A second transplanted

311-Hippuran

renogram

kidney.

radioisotope

perfusion

to the

pancreas

was

Duplex 5.0-MHz

kidney

seen

Doppler flow

of

renal

transplant

transplant showed Doppler waveform and

marked

reversal

function

in the

showed

No perfusion

to the

normal

the were

as

grade

flow

greatly

examination (Toshiba main, normal.

was

performed

i 00, Tustin,

segmental,

and

Examination

with

arcuate of

a

CA). Doppler the

arteries pancreas

flow

during

diastole.

This

was

inter-

portal

The

veins.

The

the

closer

and

vein

and

thrombosis

and

likely

surgical

exploration.

discolored

and

diagnoses,

During

uniformly

dark

was

be obtained flow.

to

the

anteresistive

tail

of

vena

cava,

the

and

however,

The pancreas

itself

had

iC). obstruction

and

surgery, red.

allowed more

from the splenic

inferior

normal (Fig.

that

progressively

examination

could

morphology

venous most

iliac

and showed

resistance

became

the

signals

right

patent size

Acute ered

the

vascular

waveform

No venous

appeared normal

increased

only.

in appearance

transplanted

flow within the celiac axis and splenic artery. The of the splenic artery showed short systolic inflow of blood

preted

pancreas.

transducer within

normal

angiogram

i B).

sonographic

signals

showed

transplant.

(Fig.

phased-array

arterial the

The

the

therefore

patient

the pancreas Pancreatectomy

were

underwent

considemergent

was found was

to be

performed,

AJR:i54,

March

and pathologic

examination

orrhagic

Thrombosis

organ.

VENOUS

1990

revealed was

found

THROMBOSIS

an acutely in the splenic

infarcted and

WITH

and hemportal veins.

American Journal of Roentgenology 1990.154:529-531.

Discussion Approximately 40% of pancreas grafts survive 1 year. Causes of transplant failure include technical surgical problems such as vascular thrombosis and anastomotic leaks, rejection, pancreatitis, and infection [1 ]. Currently, no definitive test is available for early diagnosis of abnormal function. Alterations in levels of blood glucose and blood and urinary amylase are late, nonspecific markers of pancreas endocrine abnormality [4]. Imaging has an important role in follow-up and can facilitate clinical management by showing vascular complications. A wide variety of techniques have been used, including sonography, CT, and radionuclide scanning [2, 5]. Perfusion scintigraphy is useful for assessing perfusion in the transplanted pancreas. mTc-DTPA is a convenient radiopharmaceutical because coexisting renal transplants can be imaged simultaneously [6]. The study is a sensitive indicator of normal function. When the results are abnormal, however, it is nonspecific [2]. When the graft cannot be visualized (and thus perfusion is absent), arteriography has been advocated as the next procedure for further evaluation [1 ]. This is, however, invasive, its specificity has not been determined, and it has the added risk of side effects associated with the use of contrast agents. Much has been published recently about the use of duplex Doppler sonography in the evaluation of renal allograft arterial flow. Increased vascular impedance that results in decreased diastolic blood flow, and even reversed flow during diastole, most commonly is associated with acute vascular rejection [7]. The findings are not specific. Other conditions, including acute renal vein obstruction, severe acute tubular necrosis, pyelonephritis, and extrarenal compression of the graft, also may be associated with high vascular impedance [3, 8]. The

PANCREAS

TRANSPLANTS

531

cause, however, usually can be recognized from the clinical history or other sonographic findings. Patel et al. [9] have recently shown the measurement of duplex arterial resistive indexes to be highly accurate in the diagnosis of pancreas transplant rejection. The diagnosis of venous thrombosis of the pancreas transplant should be based on the inability to detect venous flow and/or visualization of thrombus within distended splenic or portal veins. The absence of detectable venous flow on duplex Doppler examination, together with nonvisualization of the pancreas allograft on the radioisotopic angiogram, was thought to indicate acute venous thrombosis in our patient. Although this diagnosis was confirmed surgically, the graft could not be salvaged.

REFERENCES 1 . Hanto DW, Sutherland 2. 3. 4.

5. 6. 7.

8.

9.

DER. Pancreas transplantation:

clinical considera-

tions. Radio! C!in North Am 1987:25:333-343 Kuni CC, du Cret RP, Boudneau RJ. Pancreas transplants: evaluation using perfusion scintigraphy. AJR 1989:153:57-61 Delbeke D, Sacks GA, SandIer MP. Diagnosis of allograft renal vein thrombosis. C!in Nuc! Med 1989;14:415-420 Dafoe DC, Campbell DA, Rocher L, Schwartz R, Turcotte JA. Diagnosis of rejection in simultaneous renal/pancreas (urinary bladder drained) transplantation. Transplant Proc 1987; 19: 2345-2347 Patel B, Markivee CR. Mahanta B, Vas W, George E, Garvin P. Pancreas transplantation: scintigraphy. US, and CT. Radiology 1988:167:685-687 Shulkin BL, Dafoe DC, WahI RL. Simultaneous pancreas-renal transplant scintigraphy. AJR 1986;147:1193-1196 Rifkin MD, Needleman L, Pasto ME, et al. Evaluation of renal transplant rejection by duplex Doppler examination: value of the resistive index. AJR 1987:148:759-762 Warshauer DM, Taylor KJW, Bia MJ, et al. Unusual causes of increased vascular impedance in renal transplants: duplex Doppler evaluation. Radiology 1988;169:367-370 Patel B, Wolverson MK, Mahanta B. Pancreatic transplant rejection: assessment with duplex US. Radiology 1989;1 73:131-135