We present an unusual case of a late, large pancreas allograft arteriovenous fistula and aneurysm rescued from threatened rupture or need for transplant pancreatectomy by endovascular intervention.

Case Report:

The patient is a 34-year-old woman with end-stage renal disease secondary to diabetes type 1. She underwent simultaneous kidney pancreas transplant from a 36 year old brain dead donor.

The allografts were prepared on the backtable in usual fashion. The kidney was placed in the left iliac fossa and the pancreas placed on the right with arterial anastomosis of donor iliac Y graft to right common iliac artery, portal vein to distal vena cava, and with enteric drainage to recipient jejunum. Day 1 pancreas duplex revealed normal flow without pathology. She had immediate function of both organs and was discharged home on post-operative day 10.

Four months after transplant, at time of protocol biopsy, ultrasound of the pancreas revealed preserved arterial and venous flow but the artery appeared aneurysmally dilated. CT angiogram confirmed the artery to be moderately tortuous along its course and then focally aneurysmal (A). This arterial graft aneurysm appeared to communicate with the draining vein with a jet of contrast seen as it drained into the inferior vena cava (B).

In the interventional radiology suite access to the left common femoral artery was achieved and catheter was exchanged to select the contralateral right common iliac artery with digital subtraction arteriography. The transplant artery was traversed throughout its length to the level of the fistula and the vessel then successfully embolized with a single 12 mm Vascular Plug with preserved flow proximally in the allograft (C). Interval CT angiogram confirmed embolization of the large pancreatic transplant AV fistula with excellent perfusion to the transplanted pancreas via multiple branches proximal to the plug (D).

With fortuitous, timely endovascular intervention the catastrophe of aneurysm rupture was avoided and pancreas graft salvaged with preserved glycemic control and renal function.

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