Graft Pseudoaneurysm Hemorrhage in a Patient With a History of an Enteric-Drained Pancreatic Transplant: A Case Report

Abstract

Graft pseudoaneurysm is a rare but life-threatening complication in patients who have undergone pancreatic transplantation. While most of the reported post-pancreatic transplantation pseudoaneurysms present in the early postoperative period, late-onset pseudoaneurysms do occur, though much more rarely. We report a case of massive lower gastrointestinal hemorrhage in a 58-year-old female with a history of enteric-drained pancreatic transplant and donor duodenum anastomosis to recipient jejunum. This transplant occurred 7 years prior but 1 year prior the pancreatic graft failed as insulin-dependent diabetes mellitus recurred. Around the same time, a small bowel obstruction occurred requiring a small bowel resection with primary anastomosis. The bleeding episode began with the patient initially presenting in hypovolemic shock from hematochezia and an acute hemoglobin drop to 5.5 g/dL. Upper endoscopy was unremarkable, and colonoscopy revealed blood within the colon and the terminal ileum but no source could be identified. An abdominal angiogram and tagged RBC study were also unable to identify a source of gastrointestinal hemorrhage. CT angiogram of the abdomen revealed a mid-right common iliac artery pseudoaneurysm at the failed pancreatic graft site. Deployment of a covered stent across this vascular structure resulted in controlling the active extravasation into the small bowel lumen. Follow-up abdominal CT showed an excluded thrombosed pseudoaneurysm. In summary, we report this case to emphasize the diagnostic challenges associated with identifying this rare but life-threatening and at times late-onset complication of enteric-drained pancreatic transplant.