Bleeding and thrombosis in intestinal transplantation; data from 145 consecutive adult transplants

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Background: Cambridge University Hospitals NHS Foundation Trust provides an adult intestinal/multivisceral transplant service to the United Kingdom. These patients can have complex thrombotic histories and are at risk of bleeding and thrombosis posttransplant. Objectives: We describe our experience of (a) bleeding and thrombosis posttransplant, (b) transplantation for acute abdominal vascular catastrophe, and (c) use of direct oral anticoagulants (DOACs) posttransplant. Methods: A retrospective study of recipients of intestinal transplants at our center between 2007 and June 2023 was conducted. Results: Of 138 recipients (who received 145 grafts), 96 (70%) had a history of thrombosis pretransplant. Of the 145 grafts, 138 (95%) received blood products in the immediate operative period (up to 24 hours postoperatively; day +1) and 6 of 145 (4%) had an intraoperative thrombosis. Major bleeding and thrombosis rates from day +2 to +92 posttransplant were 38.0% (95% CI, 30.0%-46.0%) and 26.1% (95% CI, 19.1%-33.5%), respectively. Bleeds were predominantly gastrointestinal, surgical site, or intra-abdominal. The majority of thromboses (32 of 38 [84%]) were venous (especially catheter associated). No particular relationship between thrombotic and bleeding complications was observed. Eight recipients were transplanted as salvage procedures due to abdominal vascular catastrophe with generally favorable results, although in 3 recipients, no etiology was identified, and anticoagulant failures were seen. Five received DOACs posttransplant, and adequate peak drug levels were seen without bleeding or thrombotic complications. Conclusion: Patients who undergo intestinal transplant are at high risk of bleeding and thrombosis posttransplant. Intestinal transplant was used successfully as a salvage treatment for acute abdominal vascular catastrophe. DOACs were used in selected posttransplant patients. Further multicenter studies are required.

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