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ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY
A Journal on Vascular and Endovascular Surgery
Giornale Italiano di Chirurgia Vascolare 2003 December;10(4):361-82
language: English, Italian
Surgical reconstruction of iliofemoral veins and the inferior vena cava for malignant disease
Caldarelli G. 1, Della Giovampaola C. 1, Zampieri F. 1, Salinitri G. 2, Caldarelli C. 1, Minervini R. 2
1 Vascular Surgery Section, II General Surgery Unit, Department of Surgery, University of Pisa, Pisa, Italy
2 Urology Unit, University of Pisa, Pisa, Italy
Aim. Iliofemoral veins and inferior vena caval resection and their replacement for malignancy are sometimes necessary when extensively involved. The purpose of the study is to evaluate the feasibility and the results of prosthetic venous replacement in such cases.
Methods. Seven patients (range 41-75 years) were treated over a 10-year period (1991-2001) by aggressive venous surgery to achieve complete tumor resection, with prosthetic graft replacement to re-establish venous flow. The tumors included: 2 retroperitoneal liposarcoma, 1 bladder cancer, 1 retroperitoneal fibrosarcoma, 1 inguino-pelvic lymphoma and 2 of the right kidney, all with high grading. Five patients had either an iliofemoral or an ilioiliac circular reinforced polytetrafluoroethylene (PTFE) graft; 2 patients had a vena caval replacement, of whom 1 had a circular reinforced PTFE and 1 a Dacron silver graft. The prosthetic diameter was 8-10 mm for the iliac grafts and 18-20 mm for the inferior vena cava (IVC) grafts. An adjunctive arterio-venous fistula was not used in any patient, even in the iliofemoral bypass. Chronic anticoagulation was not used in any patient. In all the patients, graft patency was evaluated during the follow-up by color flow duplex imaging, and in 1 it was determined by angio-CT scan and venogram.
Results. There was 1 death 30 days after surgery. Of the remaining 6 patients 1 had no evidence of regional recurrence or metastatic disease at 12 months and 5 died from recurrent tumor 8-30 months after surgery. The mean time to death was 23 months. At 3 months, all 6 prostheses were patent, 1 of which had partial thrombosis with preserved laminar flow; at 6 months 4 were patent and at 12 months 3 of 5 prosthesis were patent. Regarding the 8-10 mm prostheses all 5, 4 and 3 were patent at 3, 6 and 12 months, respectively.
Conclusion. Iliofemoral prosthetic reconstruction for malignancies represents a viable option to avoid venous engorgement and lower extremity swelling, at least in the early postoperative period. Resection of the IVC and its replacement allows for complete tumor resection and avoids renal failure, providing durable relief from the symptoms of venous obstruction. The mean time to death for the present patients must be considered the limit for these aggressive operations but survival may improve operating lower grading tumor patients. The intent of this aggressive management is to cure but also to provide prolonged palliation of symptoms.