Customized femoral vein grafts for inferior vena cava reconstruction Nirvana Sadaghianloo, MD, a,b Matthieu Durand, MD, a,c Emmanuel I. Benizri, MD, PhD, a,d Serge Declemy, MD, a,b Elixène Jean-Baptiste, MD, PhD, a,b and Réda Hassen-Khodja, MD, a,b Nice, France After extended en-bloc resection of a retroperitoneal neoplasm, prosthetic grafts can efficiently replace the inferior vena cava. However, in cases of concomitant biliary or bowel surgery, there is a risk of infection, and autogenous materials typically used present with size match. We present a method of autogenous graft con- struction using the femoral vein for replacement of the inferior vena cava, with an alternate configuration for renal vein implantation. (J Vasc Surg: Venous and Lym Dis 2014;2:200-3.) Involvement of the inferior vena cava (IVC) has long been considered a limiting factor for the resection of retro- peritoneal tumors. While en bloc multivisceral resection, including a segment of the IVC, has been proposed in selected patients to achieve complete tumor excision, 1,2 there is still controversy regarding the need and technique for reconstruction following IVC resection. For cases of extended involvement, some authors have proposed IVC ligation without reconstruction. Others have advocated complete resection followed by reconstruction using pros- thetic material. 3,4 When radical resection also involves a biliary procedure or bowel resection, however, the risk of prosthetic graft infection becomes a serious concern, and autogenous material may be favored. 5 Few successful cases of autogenous replacement of the IVC have been re- ported, mainly because the size match between graft and IVC makes surgery challenging. 6-12 We present a method of IVC replacement with a custom-made autogenous graft using the femoral vein (FV), with two representative cases. The first shows an infrarenal replacement; the second shows reimplantation of a renal vein onto the graft using an alternate configuration. CASE REPORT Operative procedure: General outline. Procedures were performed by experienced surgeons after consulting with a multi- disciplinary cancer team and receiving the patient’s written consent. Surgery was proposed in order to obtain negative surgical margins. Preoperatively, clinical examination and Duplex scanning of both lower limb vessels was performed to rule out a bifid FV, occlusive lesions, or venous insufficiency and to assess the diame- ters of the FV (minimal size, 5 mm). All patients were operated on under general anesthesia in the dorsal decubitus position, with one lower extremity abducted on the operated side. The operative technique began with exploration of the abdomen and tumoral en bloc resection by the visceral or urological team. As soon as resectability and risk of contamination were confirmed, the vascular team started harvesting 18 to 20 cm of the FV from the thigh (below the profunda femoris vein), through an incision that extended from the traditional incision points of the common femoral and above-knee popliteal vessels, as thoroughly described elsewhere in the literature. 13 In particular, the sartorius muscle was reflected laterally at the upper part of the incision and medially at the distal part of the incision. The graft was then customized in order to match the patient’s anatomy and interposed between two healthy segments of the IVC. This vascular step should precede visceral reconstruction, if necessary. No temporary arteriovenous fistula was created. Finally, aspiration drainage was placed in the abdominal and thigh incisions before closure. Postoperative prescriptions included 4000 UI of enoxaparin daily for 15 days (in order to prevent venous thromboembolism) and elastic stockings on the operated lower limb for 3 months. Both patients were discharged to home. Configuration 1: Infrarenal replacement. The patient was a 45-year-old man who had undergone right orchiectomy and adjuvant chemotherapy for a testicular teratoma 15 years prior. In the context of sudden abdominal pain, an abdominal computed tomography (CT) scan showed a retroperitoneal 7.5-cm tumor involving the right kidney, the head of the pancreas, and the IVC (Fig 1, A). A CT-guided biopsy confirmed that the mass was a metastatic development of the testicular teratoma. The team of visceral surgeons began en bloc resection with cephalic duodeno- pancreatectomy and right nephrectomy. Complete resection was achieved by removing a 9-cm-long segment of infrarenal IVC and the affluent right renal vein. The vascular surgeons created a 2-cm diameter and a 9-cm-long tube graft with the harvested FV. The FV was opened longitudinally, then divided into two rectangular pieces of 3 9 cm, which were ultimately joined by two side-by- side continuous sutures (5-0 Prolene). The customized graft was From the University of Nice Sophia Antipolis, a and the Department of Vascular Surgery, b Department of Urology, c and Department of General Surgery and Digestive Cancerology, d University Hospital of Nice. Author conflict of interest: none. Reprint requests: Professor Réda Hassen-Khodja, MD, Department of Vascular Surgery, Saint-Roch Hospital, 5 Rue Pierre Devoluy, 06000 Nice, France (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relation- ships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 2213-333X/$36.00 Copyright Ó 2014 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvsv.2013.08.010 200
Transcript
FromVSu
AuthRepVN
Theshre
2213Cophttp
200
Customized femoral vein grafts for inferior venacava reconstructionNirvana Sadaghianloo, MD,a,b Matthieu Durand, MD,a,c Emmanuel I. Benizri, MD, PhD,a,d
Serge Declemy, MD,a,b Elixène Jean-Baptiste, MD, PhD,a,b and Réda Hassen-Khodja, MD,a,b Nice, France
After extended en-bloc resection of a retroperitonealneoplasm, prosthetic grafts can efficiently replace theinferior vena cava. However, in cases of concomitantbiliary or bowel surgery, there is a risk of infection, andautogenous materials typically used present with size
the University of Nice Sophia Antipolis,a and the Department ofascular Surgery,b Department of Urology,c and Department of Generalrgery and Digestive Cancerology,d University Hospital of Nice.or conflict of interest: none.rint requests: Professor Réda Hassen-Khodja, MD, Department ofascular Surgery, Saint-Roch Hospital, 5 Rue Pierre Devoluy, 06000ice, France (e-mail: [email protected]).editors and reviewers of this article have no relevant financial relation-ips to disclose per the Journal policy that requires reviewers to declineview of any manuscript for which they may have a conflict of interest.-333X/$36.00yright � 2014 by the Society for Vascular Surgery.://dx.doi.org/10.1016/j.jvsv.2013.08.010
match. We present a method of autogenous graft con-struction using the femoral vein for replacement of theinferior vena cava, with an alternate configuration for renalvein implantation. (J Vasc Surg: Venous and Lym Dis2014;2:200-3.)
Involvement of the inferior vena cava (IVC) has longbeen considered a limiting factor for the resection of retro-peritoneal tumors. While en bloc multivisceral resection,including a segment of the IVC, has been proposed inselected patients to achieve complete tumor excision,1,2
there is still controversy regarding the need and techniquefor reconstruction following IVC resection. For cases ofextended involvement, some authors have proposed IVCligation without reconstruction. Others have advocatedcomplete resection followed by reconstruction using pros-thetic material.3,4 When radical resection also involvesa biliary procedure or bowel resection, however, the riskof prosthetic graft infection becomes a serious concern,and autogenous material may be favored.5 Few successfulcases of autogenous replacement of the IVC have been re-ported, mainly because the size match between graft andIVC makes surgery challenging.6-12
We present a method of IVC replacement with acustom-made autogenous graft using the femoral vein(FV), with two representative cases. The first shows aninfrarenal replacement; the second shows reimplantationof a renal vein onto the graft using an alternateconfiguration.
CASE REPORT
Operative procedure: General outline. Procedures wereperformed by experienced surgeons after consulting with a multi-disciplinary cancer team and receiving the patient’s writtenconsent. Surgery was proposed in order to obtain negative surgical
margins. Preoperatively, clinical examination and Duplex scanningof both lower limb vessels was performed to rule out a bifid FV,occlusive lesions, or venous insufficiency and to assess the diame-ters of the FV (minimal size, 5 mm). All patients were operatedon under general anesthesia in the dorsal decubitus position,with one lower extremity abducted on the operated side. Theoperative technique began with exploration of the abdomen andtumoral en bloc resection by the visceral or urological team. Assoon as resectability and risk of contamination were confirmed, thevascular team started harvesting 18 to 20 cm of the FV from thethigh (below the profunda femoris vein), through an incision thatextended from the traditional incision points of the commonfemoral and above-knee popliteal vessels, as thoroughly describedelsewhere in the literature.13 In particular, the sartorius muscle wasreflected laterally at the upper part of the incision and medially atthe distal part of the incision. The graft was then customized inorder to match the patient’s anatomy and interposed between twohealthy segments of the IVC. This vascular step should precedevisceral reconstruction, if necessary. No temporary arteriovenousfistula was created. Finally, aspiration drainage was placed in theabdominal and thigh incisions before closure. Postoperativeprescriptions included 4000 UI of enoxaparin daily for 15 days (inorder to prevent venous thromboembolism) and elastic stockingson the operated lower limb for 3 months. Both patients weredischarged to home.
Configuration 1: Infrarenal replacement. The patient wasa 45-year-old man who had undergone right orchiectomy andadjuvant chemotherapy for a testicular teratoma 15 years prior. Inthe context of sudden abdominal pain, an abdominal computedtomography (CT) scan showed a retroperitoneal 7.5-cm tumorinvolving the right kidney, the head of the pancreas, and the IVC(Fig 1, A). A CT-guided biopsy confirmed that the mass wasa metastatic development of the testicular teratoma. The team ofvisceral surgeons began en bloc resection with cephalic duodeno-pancreatectomy and right nephrectomy. Complete resection wasachieved by removing a 9-cm-long segment of infrarenal IVC andthe affluent right renal vein. The vascular surgeons created a 2-cmdiameter and a 9-cm-long tube graft with the harvested FV. TheFV was opened longitudinally, then divided into two rectangularpieces of 3 � 9 cm, which were ultimately joined by two side-by-side continuous sutures (5-0 Prolene). The customized graft was
Fig 1. Configuration 1: Abdominal computed tomography (CT) angiogram. A, At the time of diagnosis, witha retroperitoneal tumor mass involving the inferior vena cava (IVC). B, At 1-year follow-up, with a patent vein graft.
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERSVolume 2, Number 2 Sadaghianloo et al 201
then interposed between two segments of the IVC, with contin-uous suture (Fig 2). The total duration of the procedure was435 minutes. No transfusion was required perioperatively. Apancreatic fistula occurring during the hospitalization period wassuccessfully managed nonoperatively without any prolongedinfectious complications. The patient recovered with a patent IVCat discharge (day 15) and at 1-year follow-up (Fig 1, B). His lowerlimb remained asymptomatic, without any leg swelling or signs ofvenous insufficiency.
Configuration 2: Perirenal replacement. The patient wasa 71-year-old woman presenting with low back pain. A CT scanshowed a retroperitoneal 8-cm tumor involving the right kidney,the right renal vein, and the perirenal IVC. There were alsoosteolytic lesions in T8 and the left iliac bones, as well as non-
Fig 2. Artistic views of the venous reconstruction in configopened longitudinally, and the graft was constructed so as to
neoplasic cystic lesions in the liver. The patient was eligible foren bloc tumoral resection followed by adjuvant chemotherapy.The urologists commenced the procedure with radical nephrec-tomy. They encountered a 2-cm tumor affecting the transversecolon and the right liver, which was resected by the generalsurgeon, while the team of vascular surgeons began harvesting theFV. Once en bloc resection was achieved and the colon repaired,the IVC was reconstructed with the FV-customized graft asdescribed in configuration 1 (Fig 2). In this particular case, thesuture lines were intentionally oriented side-by-side, and the leftcontinuous suture was interrupted in order to leave a hole toreceive the left renal vein (Figs 2, 3). The total duration of theprocedure was 320 minutes. Perioperatively, 600 mL of red bloodcell were transfused. The patient was discharged home at day 8,
urations 1 and 2: The harvested femoral vein (FV) wasmatch the patient’s anatomy.
Fig 3. Configuration 2: Operative view of the femoral vein (FV) graft construction and inferior vena cava (IVC)replacement. A, Two continuous sutures were performed to join the two rectangular pieces of the FV graft. B, A holewas left to receive the renal vein. C, The FV graft received the renal vein. D, The final operative view.
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS202 Sadaghianloo et al April 2014
and later recovered without any infectious complications, lowerlimb swelling, or sign of venous insufficiency. Pathologists diag-nosed an urothelial carcinoma. The follow-up CT scan showeda patent graft at 1 month.
DISCUSSION
The multidisciplinary approach to treating retroperito-neal neoplasms enabled us to extend the indications fortumor resection, such that involvement of the major vesselsis no longer a limiting factor. Ligation of the IVC aftercircumferential resection can be well-tolerated in patientswith a fully occluded IVC and limited tumor extension.However, in cases of partial caval obstruction or whenthe tumor excision is likely to interrupt collateral veins,lack of reconstruction may lead to lower limb edema,deep vein thrombosis, and/or renal failure.2,5,14 In thissetting, while prosthetic grafts have proved their effective-ness in IVC replacement, autogenous material may bepreferred in cases of potential contamination with concom-itant bowel or biliary surgery.5 This is where selection ofa size-matched autogenous material becomes challenging.
Many authors have reported the use of the FV asa possible candidate for major vessel reconstruction.15
Indeed, the FV provides some consistent advantages. First,harvesting the FV and building the graft does not prohib-itively lengthen operating time, since vascular and resectionsteps can be conducted simultaneously, using two surgicalteams. We found an increased operative time of approxi-mately 30 minutes, similar to findings of a previous report.9
Second, the FV provides a thick, long, and wide graft mate-rial,16 particularly as compared with the great saphenous
vein or the jugular vein, which can be deficient, particularlyin terms of length.
Thirdly, harvesting the FV is generally well tolerated,even though postoperative edema and leg heaviness havebeen reported. Wells et al studied the harvest of 86 FVsand reported that the presence of collateral venous chan-nels between the popliteal vein stump and the profundafemoris vein helped prevent clinical venous complicationsfrom arising later.17 For this reason, in our practice, weligate the FV above the popliteal vein and recommendpatients wear elastic stockings for up to 3 months afterthe procedure. We also plan a postoperative examinationat 15 days, including clinical and Doppler examination toeliminate asymptomatic deep vein thrombosis. Graftthrombosis may increase symptoms of venous hypertensionin the donor leg.The conformability of the FV-constructedgraft is the most interesting aspect of this technique. Itallows the creation of a customized graft perfectly fittedto the patient’s anatomy. Miller et al first described a retro-hepatic vena cava replacement using a tailored FV.6 DuBayet al later reported of a similar “panel graft” technique forreconstruction of the infrarenal vena cava.10 In bothdescriptions, before performing the lower anastomosis,the graft was folded back on itself to obtain the lengthrequired. On this particular point, we would rather suggestpre- and peroperative measurement to harvest the exactlength of FV. DuBay et al also inverted the two rectangularpanels of FV upside down before joining them intoa cylinder, a precaution that we did not find necessary inour practice. Despite these slight differences, our firstconfiguration technically approaches their description and
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERSVolume 2, Number 2 Sadaghianloo et al 203
tends to confirm feasibility and efficacy. However, theyfurther advised to align the sutures anteriorly and posteri-orly when renal veins have to be implanted into the graft.Since that implies making new holes, we rather advocateinterrupting the lateral suture line, leaving a free hole toreceive the renal vein. This technique for perirenal venacava reconstruction was depicted in our second configura-tion and can be used to reimplant either one or both renalveins with reduced suture time.
CONCLUSIONS
The customized FV-constructed graft is an effectivematerial for peri- or infrarenal IVC replacement in casesof extended retroperitoneal neoplasms, where a contami-nated environment limits the use of prosthetic grafts.
The authors thank Benjamin Maes (University of NiceSophia Antipolis) for his professional artistic drawings ofthe technique, and Professor Alan Dardik and James Tier-ney (Yale University, New Haven, Conn) for revision ofthe manuscript.
REFERENCES
1. Lodge JP, Ammori BJ, Prasad KR, Bellamy MC. Ex vivo and in situresection of inferior vena cava with hepatectomy for colorectal metas-tases. Ann Surg 2000;231:471-9.
2. Hardwigsen J, Baque P, Crespy B, Moutardier V, Delpero JR, LeTreut YP. Resection of the inferior vena cava for neoplasms with orwithout prosthetic replacement: a 14-patient series. Ann Surg2001;233:242-9.
3. Bower TC, Nagorney DM, Cherry KJ Jr, Toomey BJ, Hallett JW,Panneton JM, et al. Replacement of the inferior vena cava for malig-nancy: an update. J Vasc Surg 2000;31:270-81.
4. Quinones-Baldrich W, Alktaifi A, Eilber F, Eilber F. Inferior vena cavaresection and reconstruction for retroperitoneal tumor excision. J VascSurg 2012;55:1386-93.
5. Quinones-Baldrich W, Farley S. Techniques for inferior vena cavaresection and reconstruction for retroperitoneal tumor excision. J VascSurg: Venous and Lym Dis 2013;1:84-9.
6. Miller CM, Schwartz ME, Nishizaki T. Combined hepatic and venacaval resection with autogenous caval graft replacement. Arch Surg1991;126:106-8.
7. Bower TC, Nagorney DM, Toomey BJ, Gloviczki P, Pairolero PC,Hallett JW Jr, et al. Vena cava replacement for malignant disease: isthere a role? Ann Vasc Surg 1993;7:51-62.
8. Yamamoto H, Hayakawa N, Ogawa A, Sakamoto E, Nagino M,Kamiya J, et al. Segmental resection and reconstruction of the inferiorvena cava with an autogenous vein graft. Br J Surg 1997;84:51.
9. McKay A, Motamedi M, Temple W, Mack L, Moore R. Vascularreconstruction with the superficial femoral vein following majoroncologic resection. J Surg Oncol 2007;96:151-9.
10. DuBay DA, Lindsay T, Swallow C, McGilvray I. A cylindrical femoralvein panel graft for caval reconstructions. J Vasc Surg 2009;49:255-9.
11. Song TK, Harris EJ, Raghavan S, Norton JA. Major blood vesselreconstruction during sarcoma surgery. Arch Surg 2009;144:817-22.
12. Munene G, Mack LA, Moore RD, Temple WJ. Neoadjuvant radio-therapy and reconstruction using autologous vein graft for the treat-ment of inferior vena cava leiomyosarcoma. J Surg Oncol 2011;103:175-8.
14. Daylami R, Amiri A, Goldsmith B, Troppmann C, Schneider PD,Khatri VP. Inferior vena cava leiomyosarcoma: is reconstructionnecessary after resection? J Am Coll Surg 2010;210:185-90.
15. Brahmanandam S, Clair D, Bena J, Sarac T. Adjunctive use of thesuperficial femoral vein for vascular reconstructions. J Vasc Surg2012;55:1355-62.
16. Hagino RT, Bengtson TD, Fosdick DA, Valentine RJ, Clagett GP.Venous reconstructions using the superficial femoral-popliteal vein.J Vasc Surg 1997;26:829-37.
17. Wells JK, Hagino RT, Bargmann KM, Jackson MR, Valentine RJ,Kakish HB, et al. Venous morbidity after superficial femoral-poplitealvein harvest. J Vasc Surg 1999;29:282-9.
