43 A challenging management of a Y graft mycotic pseudoaneurysm in a simultaneous pancreas-kidney transplant recipient

Abstract Introduction The incidence of allograft artery mycotic pseudoaneurysms after kidney and pancreas transplantation is less than 1%. Natural history of vascular mycotic aneurysms is characterized by their tendency to rupture causing major bleeding, leading to graft loss and increased mortality rate. Case Report A 45-years old patient was transferred to the intensive care unit of our hospital following a massive upper gastrointestinal bleeding, pyrexia and hemodynamic compromise. Medical background included a simultaneous pancreas-kidney transplant (SPK) back in 2020, followed by rejection and repeated pancreatic transplant (PTA) alone one year after. Abdominal computerized tomography imaging showed a thrombosed graft superior mesenteric artery, with concomitant active bleeding from the splenic limb of the arterial Y graft, due to a mycotic pseudoaneurysm ruptured into the bowel. The bleeding was initially managed with an endovascular stenting of the right common iliac artery, determining an inevitable graft ischemia. Blood cultures isolated Bacteroides sp. so, the patient was started on board spectrum antibiotics (piperacillin/tazobactam) based on the culture sensitivities. Following resuscitation, the patient went to theatre two days after for a graft pancreatectomy, including the aneurysmal Y graft. An iliac artery vascular repair was then performed. The endovascular stent was removed during the procedure. The cultures of the pancreatic graft, vessels and stent were positive for enterococcus faecium, leading to adding vancomycin to the already existed antibiotic regimen. The patient received in total four weeks of intravenous and oral antibiotics. His postoperative course was uneventful and was discharged on the 14th postoperative day. Educational Highlights Pancreatic graft arterial pseudoaneurysms is an uncommon as well as quite serious complication following a combined kidney and pancreas transplantation. Initial management of pseudoaneurysms should rely on early diagnosis while endovascular repair could be an acceptable bridging therapy along with long term antibiotics. Surgical management involve removing the infected vessels and perform arterial reconstruction aiming preservation of the graft. However, in some cases graft pancretectomy is deemed necessary to control the ongoing resistant sepsis or findings of ischemic graft.