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Abstract

We thank Dr Campo for his interest in our article. As stated, this was an unusual case because the inferior vena cava (IVC) was used to replace an injured aorta in a contaminated field. As Dr Campo correctly points out, our report showed that the IVC was capable of sustaining systemic arterial pressure and was also resistant to infection. We agree with Dr Campo that, ideally, preoperative rather than intraoperative vascular consultation would have been preferable to plan for the possibility of aortic and/or IVC replacement. If necessary, autogenous replacement using conduits such as the superficial femoral vein1Nevelsteen A Lacroix H Suy R. Autogenous reconstruction with the lower extremity deep veins: an alternative treatment of prosthetic infection after reconstructive surgery for aortoiliac disease.J Vasc Surg. 1995; 22: 129-134Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar would be the preferred method of reconstructing the aorta in the presence of infection. Another possibility is use of a saphenous spiral vein graft, although this may result in progressive dilatation of the graft.2Farret A da Ros CT Fischer CAC Mandelli JP Farret Jr., LC Suprarenal aorta reconstruction using a saphenous spiral graft: case report.J Trauma. 1994; 37: 114-118Crossref PubMed Scopus (6) Google Scholar Overall, there is no convincing evidence that a spiral vein graft is superior to other types of autogenous repair. Reconstruction with aortic allograft has also been described for aortic replacement, but this procedure is limited by the availability of aortic allografts and possible late graft deterioration.3Kieffer E Bahnini A Koskas F Ruotolo C Le Blevec D Plissonnier D. In situ allograft replacement of infected infrarenal aortic prosthetic grafts: results in 43 patients.J Vasc Surg. 1993; 17: 349-356Abstract Full Text Full Text PDF PubMed Scopus (224) Google Scholar We have no experience in the use of pericardial xenografts. In patients with testicular tumors and retroperitoneal metastases, retroperitoneal lymph node dissection remains the only treatment option after chemotherapy. Preoperative imaging for patients with locally advanced disease, however, cannot distinguish among residual cancer, necrotic tissue, or a benign teratoma. The patient in question was seen 2 days before surgery with vomiting, which was most likely due to duodenal obstruction. Surgical extirpation was his only treatment option. Although it is common for computed tomographic imaging to show an absence of a plane between the aorta and the residual tumor tissue, this plane can often be developed with sharp dissection around the aorta. Regarding the need for IVC replacement, we agree with Dr Campo's suggestion that acute IVC interruption needs to be replaced; otherwise it would lead to acute and massive fluid shifts with subsequent hypotension, renal failure, and significant venous morbidity.4Donaldson MC Wirthlin LS Donaldson GA. Thirty-year experience with surgical interruption of the inferior vena cava for prevention of pulmonary embolism.Ann Surg. 1980; 191: 367-372Crossref PubMed Scopus (37) Google Scholar In the case presented, however, the IVC was chronically compressed, and thus reconstruction of the IVC was believed to be unnecessary. This practice of removing a chronically compressed IVC during en bloc resection is well known to cancer specialists although not necessarily well documented. Finally, it is possible that removal without replacement of the chronically compressed IVC may have contributed to the patient's compartment syndrome, although we believe that this was most likely due to the ischemia reperfusion insult following a prolonged ischemic time. Certainly, after skin grafting there were no apparent sequelae to suggest chronic venous congestion.