Arterial complications may be encountered in the postoperative period after small bowel transplantation and may lead to fatal outcomes in the recipient. We report our experience of two cases of living donor small bowel transplantation with early postoperative arterial complications.

(Case #1) The patient was an 18 month old girl with tufting enteropathy. She presented with chronic diarrhea which lead to complete dependence on total parenteral nutrition. She received a 100 cm long small bowel graft from her 34 year old mother. Arterial anastomosis was done in end-to-side fashion to the recipient’s infrarenal aorta. End-to-side venous anastomosis was done to the recipient’s superior mesenteric vein. Serial endoscopic biopsy showed signs of acute rejection on postoperative day 8. Anti-rejection therapy was initiated with daclizumab. On postoperative day 13, endoscopic findings showed mucosal erythema with absent bowel motility. Abdominal CT scan taken on the next day revealed severely decreased, albeit sustained arterial flow to the small bowel graft. Follow-up endoscopy showed progressive necrosis of the allograft mucosa and follow-up CT scan revealed absent arterial flow to the small bowel graft. Surgical removal of the allograft was done on postoperative day 33. Complete thrombotic occlusion of the graft artery was noticed. The patient died due to uncontrolled sepsis 3 days after the surgery.

(Case #2) The patient was a 10 month old boy with short bowel syndrome after extensive small bowel resection due to small bowel volvulus. She received a 100 cm long small bowel graft from her 30 year old mother. Arterial anastomosis was done in end-to-side fashion to the recipient’s infrarenal aorta. End-to-side venous anastomosis was done to the recipient’s infrarenal vena cava. Postoperative serial endoscopy and biopsy revealed normal-appearing small bowel mucosa and no evidence of acute rejection. Routine follow-up CT scan taken on postoperative day 17 showed a 3 cm-sized lobulated contrast-enhancing structure. Pseudoaneurysm at the arterial anastomosis site was suspected and surgical repair was undertaken. A bleeding site was observed at the arterial anastomosis. Primary closure of this site was not possible due to the severely friable nature of the vessels. A new arterial inflow was constructed with the splenic artery. The patient progressed to severe sepsis postoperatively and surgical removal of the allograft was attempted on the next day. Intraoperative findings showed occlusion of the arterial anastomosis and extensive infarction of the entire small bowel graft. However, graft removal could not sufficiently control the progression of sepsis and the patient died 2 days later.