Inferior vena cava resection and reconstruction for abdominal malignancies: Outcomes of limited resection versus IVC replacement

Abstract

Background: Curative (R0) resection of abdominal malignancies with inferior vena cava (IVC) invasion or tumor thrombus often requires partial or circumferential caval resection. Reconstructive options frequently require multidisciplinary surgical support and are affected by location/extent of invasion, physiologic tolerance of vascular cross-clamping, and chronic occlusion of the distal IVC. Recent application of transplant techniques to accomplish ex-vivo liver resections have expanded the potential for curative resections in patients with previously unresectable malignant invasion of the retrohepatic IVC. This study aims to review the indications, techniques, and outcomes for IVC resection and reconstruction at a single institution. Methods: A retrospective review was conducted on patients with IVC resections for treatment of abdominal malignancies between 2008-2018 at a single institution. Demographics and cancer diagnoses were recorded, as well as operative approaches and reconstructive methods. Postoperative morbidity followed to 90 days after surgery and survival was tracked until death or loss to follow-up. Results: Of the 52 patients who underwent IVC repair for tumor invasion, 32 required a type of IVC wall resection. Of those that underwent wall resection, the most common malignancies were renal cell carcinoma (n = 17), intrahepatic cholangiocarcinoma (n = 4), leiomyosarcoma (n = 4), colorectal liver metastases (n = 2). One case occurred due to hepatocellular carcinoma, retroperitoneal liposarcoma, and metastatic disease from a pancreatic adenocarcinoma, gastrointestinal stromal tumor, and small bowel neuroendocrine tumor each. IVC reconstruction was performed through primary closure in 34% (11/32) or bovine pericardial patch in 25% (8/32) for partial wall resections, and synthetic graft in 25% (8/32) for circumferential resections. Five patients (16%) underwent ligation of the infrarenal IVC without reconstruction. Resection was performed on veno-venous cardiopulmonary bypass in 25% (8/32). Three patients underwent an ex-vivo partial hepatectomy with back-table IVC resection and reconstruction followed by liver auto-transplantation, including one case as stage II of an associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) procedure. R0 resection was accomplished in 60% (3/5) for IVC ligation without reconstruction, 73% (8/11) for primary repair, and 63% (5/8) for bovine pericardial patch. Circumferential resection with synthetic graft reconstruction achieved R0 in 100% (8/8) including all three ex-vivo resections. Ninety-day major morbidity (Clavien grade 3 or greater) for IVC resections was 41% (13/32), with no increase for synthetic grafts compared to primary or patch repair (25% vs 37%, p = 0.55). Overall survival for IVC resections at 90 days, 1-year, and 2-years was 79%, 68%, and 64%, respectively. Conclusion: IVC resection with or without various techniques for reconstruction has an acceptable morbidity and provides the only opportunity for R0 resection in some locally-advanced abdominal malignancies. Circumferential resection with graft reconstruction (including ex-vivo for select patients) can achieve an excellent rate of R0 resection without increased morbidity. These complex reconstructions frequently require the technical acumen of hepatobiliary and transplant disciplines and should be performed in highly specialized centers with a multidisciplinary approach.