Prosthetic replacement of the inferior vena cava for malignancy

Purpose: Invasion of the inferior vena cava (IVC) by tumor is generally considered a criterion of unresectability. This study was designed to review the outcomes of a strategy of aggressive resection of the vena cava to achieve complete tumor resection coupled with prosthetic graft placement to re-establish caval flow. Methods: Retrospective review of patients treated at a university referral center. Ten patients (mean age 54; eight females, two males) underwent tumor resection that involved circumferential resection of the IVC and immediate prosthetic replacement with ringed polytetrafluoroethylene (PTFE) grafts ranging in diameter from 12 to 16 mm. Results: Seven patients had replacement of the infrarenal IVC, two of their suprarenal IVC, and one had reconstruction of the IVC bifurcation. Four of the 10 patients received preoperative chemotherapy, and none received radiotherapy. The most common (7/10) pathologic diagnosis was leiomyosarcoma arising from the IVC or retroperitoneum. Additional diagnoses included teratoma (one), renal cell carcinoma (one), and adrenal lymphoma (one). There were no perioperative deaths, and one complication (prolonged ileus) occurred. Mean length of stay was 8.1 days. Anticoagulation was not routinely used intraoperatively or postoperatively. Follow-up (mean duration = 19 months) demonstrated that survival was 80% (8/10) and 88% (7/8) of patients were free of venous obstructive symptoms. Conclusion: Resection of the IVC with prosthetic reconstruction allows for complete tumor resection and provides durable relief from symptoms of venous obstruction. (J Vasc Surg 1998;28:75-83.)     

Prosthetic replacement of the infrahepatic inferior vena cava for leiomyosarcoma

HYPOTHESIS: Resection of the infrahepatic inferior vena cava associated with prosthetic graft replacement for caval leiomyosarcoma is an acceptable procedure to obtain prolonged and good-quality survival. DESIGN: A consecutive sample clinical study with a mean follow-up of 40 months. SETTING: The surgical department of an academic tertiary center and an affiliated secondary care center. PATIENTS: Eleven patients, with a mean age of 51 years, who have primary leiomyosarcoma of the infrahepatic inferior vena cava. INTERVENTIONS: All of the patients underwent radical resection of the tumor en bloc with the affected segment of the vena cava. Reconstruction consisted of 10 cavocaval polytetrafluoroethylene grafts and 1 cavobiliac graft. An associated right nephrectomy was performed in 2 cases. The left renal vein was reimplanted in the graft in 3 cases. MAIN OUTCOME MEASURES: Cumulative disease-specific survival, disease-free survival, and graft patency rates expressed by standard life-table analysis. RESULTS: No patients died in the postoperative period. The cumulative (SE) disease-specific survival rate was 53% (21%) at 5 years. The cumulative (SE) disease-free survival rate was 44% (19%) at 5 years. The cumulative (SE) graft patency rate was 67% (22%) at 5 years. CONCLUSION: Radical resection followed by prosthetic graft reconstruction is a valuable method for treating primary leiomyosarcoma of the infrahepatic inferior vena cava.     

Prosthetic replacement of the inferior vena cava. Current controversies

A ringed polytetrafluoroethylene (PTFE) graft is currently the most widely used replacement for the inferior vena cava, although clinical studies comparing this technique with non-ringed prostheses are lacking. There is no consensus on the need to use an anticoagulant or associate a temporary distal arteriovenous fistula to increase venous flow. At present, the best therapeutic strategy cannot be determined. We present a case of retroperitoneal sarcoma infiltrating the infrarenal vena cava, right colon and ureter that was surgically treated in our hospital. En bloc resection was performed and the vena cava was reconstructed using a non-ringed PTFE graft associated with systemic anticoagulation.     

Prosthetic replacement of the inferior vena cava after resection of a pheochromocytoma

A 52-year-old man had an extensive right adrenal pheochromocytoma with invasion of the pararenal inferior vena cava (IVC). Tumor resection required en bloc resection of the infrahepatic IVC. The right kidney was not involved with tumor. Reconstruction of the IVC was performed with an externally supported, expanded polytetrafluoroethylene graft with reimplantation of the right renal veins into the prosthesis. Postoperative patency of the IVC graft and renal veins was confirmed by venacavography and color-flow duplex scanning. This latter technique has been used to document interval patency of the IVC graft 3, 6, and 12 months after surgery. (J VASC SURG 1994;19:169-73.)     

Prosthetic replacement of the inferior vena cava in renal cell carcinoma surgery.

An aggressive surgical approach is needed in cases of renal cell carcinoma with extension into the vena cava, since caval extension is not such a bad prognostic indicator as previously believed. Improvements in peri- and intra-operative management have enabled the resection of the tumor thrombus at all levels of the caval extension with acceptable morbidity and mortality. In cases where there is direct major invasion of the venal caval wall, we recommended complete resection of the involved segment and re-establishment of caval continuity using a polytetrafluorethylene (PTFE) interposition graft. Two cases, in whom segmental caval resection was necessary, are reported. The pre- and intra-operative considerations are discussed together with support for the use of PTFE as the graft of choice.     

Prosthesis replacement of the inferior vena cava

The development of reconstructive venous surgery has been hampered by the lack of suitable graft materials. Fourteen carbon fibre grafts (phi: 8 mm), 30 glutaraldehyde treated ovine collagen grafts and 29 polytetrafluoroethylene (PTFE) grafts were used to replace a 35 mm segment of infrarenal inferior vena cava in pigs. Prostheses were removed 1 hour and 7, 14, 28, 56 and 112 days after implantation. All specimens were examined by light and scanning electron microscopy. The 112 day patency rate was 67% for ovine collagen grafts, while all carbon and PTFE grafts thrombosed. The difference was statistically significant (p less than 0.01). During the first hour after implantation, a thick (800-900 microns) thrombotic layer deposited on the inner surface of carbon grafts. This layer possibly caused the subsequent complete occlusion of the tubular segments. A thin neointima (less than 200 microns) developed on the flow surface of ovine collagen prostheses. This favoured complete endothelialization of the graft inner surface as soon as four weeks after surgery. In conclusion, glutaraldehyde treated ovine collagen would represent the first sound material to be used as venous substitute.     

Surgical reconstruction of iliofemoral veins and the inferior vena cava for nonmalignant occlusive disease

PURPOSE: Venous reconstructions are rarely performed, and factors affecting long-term results of bypass grafts implanted in the venous system are not well defined. In this report we updated our experience. METHODS: The clinical data of all patients who underwent venous reconstruction for iliofemoral or inferior vena caval (IVC) occlusion due to nonmalignant disease between January 1985 and June 1999 were retrospectively reviewed. Patients were classified, and outcomes were compared according to the guidelines of the Joint Vascular Societies. RESULTS: Forty-two patients, 23 males and 19 females (mean age, 40 years; range, 16-81), underwent 44 venous reconstructions. Thirty-six patients had limb swelling or venous claudication, 38 had pain, and 14 had healed or active ulcers. The cause of obstruction was congenital in two and acquired in 40 (deep vein thrombosis, 25; trauma, 5; retroperitoneal fibrosis, 4; IVC occlusion devices, 4; others, 2). Eighteen patients underwent saphenous vein crossover grafts (Palma procedure), 17 had expanded polytetrafluoroethylene (ePTFE) grafts implanted (femorocaval, 8; iliocaval, 5; crossfemoral, 3; cavoatrial, 1), 6 patients had spiral vein grafts (5 iliac/femoral and 1 cavoatrial), and 1 underwent femoral vein patch angioplasty. Clinical follow-up averaged 3.5 years (median, 2.5), and graft follow-up with imaging studies averaged 2.6 years (median, 1.6). Seven patients were lost to follow-up. The secondary 3-year patency rate for all reconstructions was 62%. Palma procedures had a 4-year patency rate of 83%. The secondary patency rate of iliocaval and femorocaval ePTFE bypass grafts at 2 years was 54%. The secondary patency was lower in patients with an arteriovenous fistula (P =.023). All ePTFE grafts had a 45% patency rate at 2 years, not significantly different from saphenous vein grafts (83%, P =.16). Clinical scores improved with graft patency (median, 0.0 vs 1.5; P =.044). CONCLUSIONS: Venous reconstructions for iliofemoral or IVC obstruction offer 3-year patency rates of 62%. The Palma procedure with autologous saphenous vein had the best long-term patency, whereas long-term success with ePTFE was moderate. The use of an arteriovenous fistula to improve graft patency remains controversial.     

Leiomyosarcoma of renal vein and inferior vena cava

A case of leiomyosarcoma of the right renal vein and inferior vena cava causing total obstruction of the vena cava is reported. This rare condition was treated successfully after two previous operations had deemed it unresectable. Treatment consisted of a right nephrectomy and resection of the vena cava and ligation of the left renal vein. Because of the slow growth of the well-differentiated leiomyosarcoma, there was no problem with venous return from the left kidney, and the patient recovered promptly without evidence of renal function impairment. Postoperatively, she received chemotherapy consisting of doxorubicin (Adriamycin) and vincristine. She is well and free of tumor over four years postoperatively. The good result, in this case, is attributed to complete surgical excision and multimodal therapy.     

Prosthetic replacement for the thoracic vena cava: an experimental study

The superior vena cava (SVC) and thoracic inferior vena cava (IVC) were replaced in 46 dogs with autologous vein, knitted Dacron, glutaraldehyde-fixed porcine pericardium, unsupported polytetrafluorethylene (PTFE), and externally stented PTFE. After 30 days, patency rates were determined by contrast venography and were 100%, 9%, 50%, 75%, and 100%, respectively. The patency rates of Dacron and glutaraldehyde-fixed pericardium are considered unacceptable when compared to autologous vein (p less than 0.05). Stented PTFE exhibited a patency rate equal to that of autologous vein at 30 days, minimal graft reaction, excellent incorporation by host fibroblasts, and a smooth neointima. The external spiral support added to PTFE enchanced the thromboresistance of this graft in the thoracic venous system. Long-term follow-up is required to determine if the stented PTFE prosthesis remains comparable to autologous vein as a venous conduit.     

下腔静脉与肝静脉的外科应用解剖

在３２例成人尸体上进行腔静脉与肝静脉的应用解剖学的研究，观测了右肾上腺静脉、左膈下静脉、主肝静脉的长度、横径、注入角度和部位及主肝静脉的汇合类型和下腔静脉各段长度。结果表明，术中阻断肝上膈下下腔静脉，有８４．４％的人可经腹部切口完成，另１５．６％者可能需开胸在心包内阻断下腔静脉，下腔静脉下阻断，有８７．５％可在网膜孔后分离阻断，１２．５％需行下腔静脉肝后段分离阻断。在游离肝右叶时，需注意可能出现的     

Prosthetic replacement of the superior vena cava treated with antiplatelet agents

The effects of cepharanthin and dipyridamole depot capsules (RAD) on the fate of Teflon fluorocarbon resin grafts used for replacement of the canine superior vena cava were studied. After short-term observation of 11 implanted grafts, 57 adult mongrel dogs underwent superior vena caval replacement with these Teflon grafts. Cepharanthin (2 mg/kg daily) and RAD (10 mg/kg daily) were administered after surgery to 28 and 14 animals, respectively. Dogs were killed at 12 days to 6 months after graft implantation. Fifteen dogs served as controls. In the cepharanthin-treated group, three grafts exhibited luminal obstruction with severe intimal hyperplasia, but smooth, semitransparent thin neointima was recognized in 25. The endothelial cell lining of the neointima exhibited excellent spread 2 months after implantation. Although one graft was obstructed with hyperproliferative fibrosis in the RAD-treated group, a well-developed neointima with complete coverage of endothelial cells was confirmed in 14 dogs. With regard to the rate of occurrence of luminal obstruction, these data were significantly different from those of the control group, which suggests that intimal hyperplasia can be reduced by treatment with antiplatelet agents.     

Right inferior phrenic vein indicating the right hepatic vein confluence into the inferior vena cava

BACKGROUND: Limiting backflow bleeding from the hepatic veins is a priority when performing hepatectomy. However, hepatic vein encirclement is difficult, especially in re-resection. We verified the presence and trajectory of the right inferior phrenic vein (RIPV), which could be a useful anatomic landmark to guide surgeons in targeting the extrahepatic right hepatic vein (RHV) before dissection. METHODS: Between May 2001 and January 2005, 100 consecutive patients with liver tumors were enrolled and underwent hepatectomy: 77 patients underwent surgery for tumors located in the right hemiliver. RESULTS: RIPV was detected in all but 1 patient (99%), and its trajectory was always guided toward the extrahepatic RHV. The only patient in whom RIPV was not detected had undergone prior liver resection and interstitial therapies for colorectal cancer liver metastases. CONCLUSIONS: Apart from exceptional conditions, detection of the RIPV is always feasible and allows safe surgical dissection while approaching the extrahepatic RHV before hepatic resection.     

Perinatal inferior vena cava thrombosis and absence of the infrarenal inferior vena cava

We report a case of infrarenal absence of the inferior vena cava (IVC) presenting as a major iliofemoral deep venous thrombosis in an adolescent. This is the first report of infrarenal IVC absence in which IVC thrombosis has been demonstrated in the perinatal period. We propose an association between perinatal IVC thrombosis and subsequent infrarenal IVC absence. In addition, the case demonstrates the importance of assessment for anatomical anomalies in patients presenting with apparently idiopathic deep venous thrombosis.     

Insertion of the inferior vena cava filter followed by iliofemoral venous thrombectomy for ischemic venous thrombosis

An elderly man, with ischemic venous thrombosis of the left lower extremity, underwent insertion of the inferior vena cava filter through the right internal jugular vein, followed by left iliofemoral venous thrombectomy with the Fogarty balloon catheter, both with fluoroscopic guidance. The inferior vena cava filter was inserted before venous thrombectomy to prevent pulmonary embolism from dislodged clots during the latter procedure.     

Utilization of autologous vein graft for replacement of the inferior vena cava in living-donor liver transplantation for obliterative hepatocavopathy

Obliterative hepatocavopathy (OHC) is a subtype of Budd-Chiari syndrome in which stenosis or obstruction of the retrohepatic inferior vena cava (IVC) is observed. Although IVC replacement is necessary in OHC patients, there are hardly any graft vessels available for IVC reconstruction during living-donor liver transplantation (LDLT). Here, we describe a novel technique of IVC reconstruction using only the autologous blood vessels in an OHC patient during LDLT. In this case, sufficient drainage of the hepatic outflow and reconstruction of the venous return from the lower half of the body were simultaneously required. Therefore, we substituted the retrohepatic IVC with the suprarenal IVC of the recipient, and we reconstructed the IVC continuity by using the autologous internal jugular vein and external iliac vein. The operation was safe, and the postoperative venous drainage from the hepatic tributaries was in good condition. This procedure might be an option for IVC replacement during LDLT.