Management of a ruptured mycotic pseudo-aneurysm following pancreas-kidney transplantation

Abstract

Simultaneous pancreas kidney transplantation (SPK) is accepted as a therapy for patients with type 1 diabetes and coexisting renal failure. Mycotic pseudoaneurysm formation is a life-threatening complication of transplantation, despite this however, little has been published with regards to its occurrence following SPK transplantation. We describe the case of a 35 year old patient who 18 days after receiving a SPK transplant developed an iliac-enteric fistula, following mycotic pseudoaneurysm formation. An emergency laparotomy was required to manage a life threatening gastrointestinal hemorrhage, which necessitated graft pancreatectomy. Resection of the diseased segment of recipient iliac artery onto which the allograft was anastomosed was also required. The patient went on to develop a vascular leak, managed initially by endovascular stenting. With the development of subsequent sepsis and a further leak, operative management was required to remove the infected stent and achieve hemostasis. Immunosupression was withdrawn in an attempt to tackle the ensuing life-threatening sepsis. The patient showed signs of improvement over the following weeks, but unfortunately, developed signs of recurrent sepsis and increasing, unremitting discomfort over the kidney allograft. On re-exploration the allograft was found to be heavily infected, with the concurrent progressive renal failure, the decision was made to remove the allograft. This case highlights important considerations when managing mycotic pseudoaneurysms in transplant recipients. Stent placement to manage such complications may not be a long lasting solution and where stent deployment is used close follow-up of patients is mandatory.