Introduction: The incidence of pancreas graft thrombosis has reduced significantly in the last decade but when it occurs often causes the loss of the pancreas graft.  
Materials and methods: Retrospective review of our series of pancreas transplants performed between 2014 and 2023. 
Results: 52 pancreas transplants were performed between 2014 and 2023.  Nine patients have been diagnosed with partial thrombosis of the splenic vein on doppler ultrasonography on the first postoperative day. All of them responded well to oral anticoagulation. One patient developed almost complete thromboses of the splenic vein and partial thromboses of the portal vein. An endovascular approach was decided on her. 
Case Report: A 20-year-old woman with an history of total pancreatectomy performed previously in 2015 for a giant solid pseudopapillary neoplasm was placed on the national waiting list for a pancreas transplant alone (PTA) in 2020 after completing 5-years of oncology follow up. The patient underwent a deceased-donor PTA in October 2022. Pancreatic venous drainage was achieved with primary anastomosis of the donor’s portal vein to the recipient's inferior cava vein, with no venous extension graft. Following our protocol, doppler ultrasonography was performed on the 1st postoperative day, revealing partial thrombosis of graft’s splenic vein. She was placed on continuous heparin infusion with no progression of splenic vein thrombosis.  She was discharged on the 8th postoperative day with rivaroxaban plus aspirin. However, 30 days after pancreas transplant, she presented abdominal pain and increased amylase level. Computer tomography angiography revealed complete splenic vein thrombosis and partial portal vein thrombosis. Direct venography was performed through the internal jugular vein. Percutaneous mechanical thrombectomy was performed using Angioject catheter (6F hydrodynamic device). The lysis of the thrombus and restoration of flow in the splenic vein and portal vein was documented on immediate follow up direct venography.  

The patient was discharged on the 4th postoperative day with apixaban and aspirin. At 3 months follow up, Doppler EUS revealed no graft thrombosis. 

Conclusions: Portal vein thrombosis remains a challenging problem in pancreas transplantation. There are many protocols for early thromboprophylaxis but when thromboses occurs early recognition and treatment are key in order to salvage the pancreas graft. In cases when intravenous or oral anticoagulation does not restore normal portal flow an endovascular approach is a good option.