Introduction: Severe graft pancreatitis (GP) although uncommon after multivisceral transplantation (MVT) may be associated with necrosis of the gland, infection of necrotic debris and bleeding secondary to erosion of infected necrosis into surrounding vasculature. For MVT the anatomic proximity of graft pancreas to the aortic conduit (AC) poses unique challenge when affected by infection and necrosis as local control of a mycotic aneurysm (MA) by embolization or surgical ligation would lead to ischemia of the transplanted viscera.

Case 1: A 40 year old female underwent MVT. Postoperatively, she developed severe GP and intra-abdominal abscesses and had persistent bacterial and fungal sepsis. On day 28, she developed massive intra-abdominal bleed. At emergent laparotomy, aortogram showed irregularities in the AC concerning for MA. An intra-aortic balloon was placed to control hemorrhage with excision of the involved area and primary anastomosis of the conduit. Three days later she had recurrent massive bleeding from multiple sites along the remaining length of the AC which could not be controlled and the patient succumbed.

Case 2: 44 year old male received MVT. His early post operative course was complicated GP and infected peripancreatic collections. On day 26 he developed massive intra-abdominal hemorrhage which on exploration was noted to be coming from the donor AC. The AC appeared thinned and had blackish discoloration consistent with MA. Vascular surgery colleagues deployed 2 endovascular stents in the celiac axis and superior mesenteric artery to bypass the weakened segment while maintaining blood flow in both the major graft vessels. The space between the stents and wall of the AC was then filled with coils. He had no graft dysfunction although further aneurysmal changes of the proximal AC (Fig1) a few weeks later required extension of the stents from the previously placed stents all the way to his native aorta. He is now more than 1 month after the revision without evidence of infection or extension of the MA, with resolution of the GP and good graft function.

Conclusion: Graft pancreatitis following MVT can lead to fatal hemorrhage from erosion of infected necrosis into the vascular inflow to the graft. Endovascular stenting of the AC vessels (celiac and SMA) offers a potential treatment option in this situation. This is likely a safer and durable solution than attempt at surgical revision of the anastomosis in the presence of infection.