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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.

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