Outcomes of Arterial Conduits in Vascular Reconstruction After Oncologic Resection of Locally Advanced Pancreatic Malignancies

Abstract

To determine early and midterm outcomes of various conduit types for visceral artery reconstruction after resection of locally advanced pancreatic malignancies. Retrospective review of all patients who underwent resection for pancreatic malignancy with visceral reconstruction using superficial femoral artery (SFA), great saphenous vein (GSV), splenic artery (SA), cryopreserved allograft, or prosthetic graft (PG) between 2000 and 2019. The SFA donor limbs were revascularized with expanded polytetrafluoroethylene interposition grafts. End points for visceral and donor limb arterial reconstructions are primary and secondary patency, vascular complications, and mortality. Visceral reconstruction for oncologic resection was performed in 57 patients. Reconstructed arteries included proper hepatic (n = 24), common hepatic (n = 17), superior mesenteric (n = 22), right hepatic (n = 5), and left hepatic (n = 2) with multivessel reconstructions performed in 13 patients. Of 57 visceral reconstructions, 30 were performed with autogenous SFA; 27 had no preoperative evidence of peripheral arterial disease. Median follow-up for all patients was 9 months. The 30-day visceral reconstruction complications included pseudoaneurysms in one SFA conduit (requiring gastroduodenal artery coiling and covered stent placement) and one GSV conduit (requiring covered stent placement), thrombosis in one PG conduit and one GSV conduit (both requiring open thrombectomy), and anastomotic bleed from one SA conduit (requiring operative repair). The 30-day SFA harvest donor limb complications included one hematoma, one lymphocele, and one symptomatic edema. Early mortality occurred in three patients including one SA conduit with multiorgan failure, one GSV conduit pseudoaneurysm rupture secondary to pancreatic leak and one SFA conduit of unknown cause. Midterm visceral reconstruction complications included pseudoaneurysm in 6 patients (3 SFA conduits with 2 treated, 3 GSV conduits with all treated), and graft occlusion in 10 patients (3 SFA, 4 GSV, 1 cryopreserved allograft and 2 PG). One patient underwent percutaneous angioplasty for high-grade stenosis of a SA graft. This gave a primary and secondary patency for all visceral arterial reconstructions of 81% and 84%, respectively. Midterm SFA donor limb patency was 100% with median follow-up of 8 months. Late mortality occurred in 19 patients (33%) with 11 cancer-related deaths and 5 of unknown cause or unrelated to the primary cancer. Three late mortalities occurred secondary to mycotic graft pseudoaneurysm ruptures in the setting of bile and pancreatic leaks (1 GSV, 1 PG secondary reconstruction in SFA conduit patient and 1 SFA conduit). This preliminary study suggests that superficial femoral artery can be considered feasible conduit in oncologic reconstructions with low morbidity of the donor limb. Long-term follow-up is needed to identify oncologic and patency-related outcomes.TablePrimary end points by conduit choiceConduitNo. of patientsPrimary patencySecondary patencyMajor early visceral graft complicationsAll-cause mortality, % (vascular-related, %)Median follow-up, months (range)Superficial femoral artery3090%90%n = 1 pseudoaneurysm30 (7)8 (2-39)Cryopreserved allograft988%88%n = 00 (0)4 (1-23)Great saphenous vein838%38%n = 2 (1 pseudoaneurysm, 1 thrombosis)75 (25)11 (0-25)Prosthetic graft667%83%n = 1 thrombosis67 (0)12 (1-107)Splenic artery450%50%n = 1 anastomotic bleed50 (0)26 (1-52) Open table in a new tab