VASCULAR GRAFT THROMBOSIS AFTER PANCREATIC TRANSPLANTATION - UNIVARIATE AND MULTIVARIATE OPERATIVE, AND NONOPERATIVE RISK FACTOR-ANALYSIS

BACKGROUND: Vascular thrombosis is still the leading cause of nonimmun ologic, technical pancreatic transplant graft failures. The paucity of published data-coupled with our large institutional experience with p ancreatic transplantation in all recipient and transplant categories, using a wide spectrum of surgical techniques-provided the impetus for a retrospective study of graft thrombosis risk factors. STUDY DESIGN F our hundred thirty-eight patients with pancreatic transplants (45 perc ent simultaneous pancreas-kidney [SPK], 23 percent pancreas-after-kidn ey [PAK], and 32 percent pancreatic transplants alone [PTA]) and with Type I insulin-dependent diabetes mellitus were studied retrospectivel y. Of 438 pancreatic transplants, 90 percent were bladder-drained and 10 percent were enteric-drained. Ninety-three percent were from cadave r donors, 90 percent were whole-organ grafts, and 20 percent were retr ansplantations. Quadruple immunosuppression was given. For bladder-dra ined, whole-organ transplantations (n=378), we performed Cox regressio n analyses to study the impact on pancreatic graft thrombosis of donor , recipient, mode of preservation, and surgical variables. RESULTS: Th e overall thrombosis rate was 12 percent (5 percent arterial, 7 percen t venous). For cadaver, bladder-drained, whole-organ pancreatic transp lants, the thrombosis incidence was highest in PAK recipients (20 perc ent). The PAK category was also found to be an independent risk factor for thrombosis by stepwise Cox regression analysis. In separate stepw ise Cox regression analyses for each category, other identified risk f actors for thrombosis included the following: donor age (PAK, PTA); ca rdiocerebrovascular cause of donor death (SPK, PAK); the use of an aor tic Carrel patch (SPK); arterial pancreatic graft reconstruction using a splenic artery to superior mesenteric artery anastomosis (SPK, PTA) or an interposition graft between the splenic artery and the superior mesenteric artery (PTA); portal vein extension graft (PAK); left-side d implantation into the recipient (PAK); and graft pancreatitis (defin ed as hyperamylasemia exceeding five days post-transplant [PAK, PTA]). CONCLUSIONS: Older donors or those who died of cardiocerebrovascular disease should not be considered for any recipient category. Preservat ion time needs to be minimized and strategies need to be developed to decrease graft pancreatitis. Surgically, left-sided implantation and a rterial reconstructions other than the Y-gaft also increase risk, as d o portal vein extensions. Renal transplants alone in prospective PAK r ecipients with Type I diabetes mellitus should, therefore, always be i mplanted left-sided to allow for right-sided pancreatic graft placemen t.