Inferior Vena Cava Reconstruction Research Articles

Parietal peritoneum as a vascular substitute for the reconstruction of donor inferior vena cava in living donor liver transplantation

Living donor liver transplant is technically more difficult than deceased-donor liver transplant because of the shorter and narrower vascular stumps and presence of multiple biliary ducts in partial liver grafts. Division of the vascular structures quickly and precisely is a prerequisite to decrease ischemia time as well as to prevent narrowing in donor vascular structures. Intraoperative vascular complications of donor hepatectomy are under-reported. Here, we report a case of inadvertently cut donor inferior vena cava (IVC) during the division of right hepatic vein (RHV) leading to narrowing of IVC which was repaired successfully using a parietal peritoneal patch from the falciform ligament.

Leiomyosarcoma of inferior vena cava (IVC): do we really need to reconstruct IVC post resection? Single institution experience.

Inferior vena cava (IVC) leiomyosarcomas (LMS) are a rare group of retroperitoneal tumors. R0 surgical resection is the only curative modality of treatment. IVC resection for retroperitoneal sarcoma is a complex surgery with no definitive guidelines for reconstruction. Retrospective review of all patients who underwent surgical resection of primary leiomyosarcoma of the IVC requiring resection from 2010 to 2020 at our tertiary care center was performed. Among 24 patients who required IVC resection for LMS, only 7 (29%) required reconstruction of IVC. According to Clavien-Dindo classification, there was one grade 3 or more morbidity and 1 post-operative mortality. Seventeen patients underwent R0 resection whereas 7 patients had R1 resection on final histopathology. At a median follow-up of 25months (range 8-91months), the median OS was 40months with median DFS of 28months. Two patients presented with local recurrence while 13 patients developed systemic recurrence on follow-up. Careful preoperative multidisciplinary planning can make IVC resection without reconstruction feasible with acceptable perioperative morbidity, mortality, and oncological outcomes for IVC LMS.

Hepatic Vein and Inferior Vena Cava Reconstruction during Hepatic Surgery Resection for Cancer

Invasion of tumor in the liver requires surgical interventions that may reduce the effects or may eliminate the tumor-affected cells. The renewal of the hepatic vein and inferior vena cava has enabled most specialized oncologists and medical specialists to use advanced diagnostic methods in the treatment of the liver tumors. Liver resection has prolonged the lives of many patients and the invention of live donor organ transplants has effectively enabled the use of liver resection in most cancer centers across the world. By reviewing data from 10 articles, 21 surgical analyses were investigated and analyzed for the risks involved in the applications of reconstructions of hepatic vein and inferior vena cava in the surgical liver resection. The postoperative complications and the indications of reconstructions were mentioned. The results indicated that with these surgical procedures, complications are still involved but may be successful for particular patients.

Medium-term outcomes after inferior vena cava reconstruction for acute and chronic deep vein thrombosis and retroperitoneal fibrosis

ObjectiveIn the present study, we evaluated the technical and clinical outcomes after endovascular inferior vena cava (IVC) reconstruction in patients with nonmalignant obstruction. MethodsThe preoperative, procedural, and follow-up medical records and imaging studies were retrospectively reviewed for 59 consecutive patients who had undergone endovascular IVC reconstruction for nonmalignant obstruction from February 2014 to January 2019. The patients were classified into three groups according to the quality of their infrainguinal inflow vessels. The outcomes measured were the primary, primary-assisted, and secondary patency rates, reintervention rates, and symptomatic resolution. ResultsThe indications for treatment were post-thrombotic syndrome (n = 41), acute deep vein thrombosis (n = 12), and retroperitoneal fibrosis (n = 6). The median patient age was 37 years, 11 months, 71.2% were men, and 32.2% had a diagnosis of thrombophilia, with no significant difference in these demographics between the three inflow groups. The median follow-up duration was 2 years, 3 months (range, 6 months to 6 years, 5 months). The whole-cohort primary patency was 91.2%, 71.0%, and 24.1% at 1, 3, and 5 years, respectively. Secondary patency was 76.7% at 1 year and 66.4% at both 3 and 5 years. Inflow group A (no post-thrombotic disease in the femoral or deep femoral veins) demonstrated significantly higher primary patency compared with group B (stenotic disease in one or two infrainguinal inflow veins; P = .009) and significantly higher secondary patency than for both groups B (P = .008) and C (all three infrainguinal inflow veins had stenosed or femoral and/or deep femoral vein occlusion was present; P = .04). In post-thrombotic syndrome patients, the Villalta scores had decreased from a mean of 14.2 to 8.1 at 1 year and 6.8 at 2 years, and the Venous Insufficiency Epidemiological and Economic Study Quality of Life score had improved from a mean of 19.8 to 54.1 and 57.3 at 1 and 2 years, respectively. In the patients with acute deep vein thrombosis, the Villalta score was 2.8 at 1 year and 0 at 2 years. In the patients with retroperitoneal fibrosis, the Venous Insufficiency Epidemiological and Economic Study Quality of Life score had improved from a mean of 25.3 at baseline to 44 at 6 months. ConclusionsEndovascular IVC reconstruction for nonmalignant obstruction can achieve good patency and clinical improvement, although the outcomes were poorer for patients with post-thrombotic disease of the femoral and deep femoral veins.

V11-04 ROBOTIC-ASSISTED LAPAROSCOPIC RIGHT RADICAL NEPHRECTOMY WITH RIGHT IVC THROMBECTOMY AND REPAIR WITH BOVINE GRAFT

You have accessJournal of UrologyRenal Oncology II (V11)1 Sep 2021V11-04 ROBOTIC-ASSISTED LAPAROSCOPIC RIGHT RADICAL NEPHRECTOMY WITH RIGHT IVC THROMBECTOMY AND REPAIR WITH BOVINE GRAFT Rohan Sawhney, Mubashir Billah, Mutahar Ahmed, and Michael Stifelman Rohan SawhneyRohan Sawhney More articles by this author , Mubashir BillahMubashir Billah More articles by this author , Mutahar AhmedMutahar Ahmed More articles by this author , and Michael StifelmanMichael Stifelman More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002073.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Extension of renal cell carcinoma (RCC) into the inferior vena cava (IVC) has been reported in 3-7% of patients. Definitive treatment is surgical resection with a 5-year cancer-specific survival of 32%. Various treatment choices exist including open radical nephrectomy with IVC thrombectomy, hybrid robot-assisted laparoscopic (RAL) radical nephrectomy with limited subcostal for IVC thrombectomy and complete RAL radical nephrectomy with IVC thrombectomy. In all cases one must be prepared to reconstruct the vena cava to prevent narrowing. We present a unique case of RCC with subhepatic IVC thrombosis that was treated entirely robotically and utilized a bovine patch to reconstruct the vena cava. METHODS: A 77-year-old male presented with gross hematuria, an eGFR of 42 and MRI revealing a heterogenous ill-defined mass in the upper pole of the right kidney, level 2 IVC thrombosis, and numerous pulmonary parenchymal metastases. CT guided renal biopsy confirmed clear cell RCC and the patient was treated pre-operatively with immunotherapy. This video will review pertinent steps to performing a robotic IVC thrombectomy with bovine patch. In addition, we will review our single institution experience with complete RAL radical nephrectomy with IVC thrombectomy. RESULTS: The video outlines our technique for robotic radical nephrectomy, IVC thrombectomy and placement of bovine graft. Reviewing our retrospective and prospective data renal cancer databases, we completed 18 IVC thrombectomies, of which 3 were done completely robotically. Of the 9 requiring a bovine patch, 4 were done open, 4 were done as a hybrid technique and 1 was done robotically. Our data for complete robotic IVC thrombectomy is summarized in Table 1. CONCLUSIONS: Management of Level 1 and 2 IVC thrombus can be safely performed through a hybrid technique or completely robotically technique. No matter the technique, one must be prepared for IVC reconstruction. Our experience suggests that complete robotic IVC thrombectomy and reconstruction with bovine graft is feasible in select patients. We recommend having a vascular surgeon close by and anesthesia ready with blood products if necessary. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e858-e859 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rohan Sawhney More articles by this author Mubashir Billah More articles by this author Mutahar Ahmed More articles by this author Michael Stifelman More articles by this author Expand All Advertisement Loading ...

Inferior Vena Cava Reconstruction Using a Ringed Polytetrafluoroethylene Interposition Graft and Inferior Vena Cava Filter Placement Following Resection of Renal Cell Carcinoma With a Tumor Thrombus Directly Infiltrating the Inferior Vena Cava.

BackgroundRenal cell carcinoma (RCC) with tumor thrombus (TT) may extend into and, in rare cases, actually invade the inferior vena cava (IVC). Techniques of IVC reconstruction after removal of the RCC, TT, and infiltrated portion of the IVC have not been well documented. Methods A ringed polytetrafluoroethylene (PTFE) interposition graft along with an IVC filter placed within the graft (to prevent the development of pulmonary emboli) was used for patients who underwent surgical resection of RCC with TT extending into and directly invading the wall of the IVC. Demographic information about these patients along with their pathology reports, surgical procedures, and patency of the PTFE graft was obtained and described. Results Four male patients were identified as having RCC and TT with histologic invasion of the IVC requiring IVC dissection and replacement with a PTFE graft (as described above); their TT levels were II, IIIa, IIIc, and IV, respectively. Patient ages were 58, 65, 58, and 51years and tumor sizes were 7.5, 7.5, 15.0, and 6.5cm, respectively. These patients were followed for 36, 24, 32, and 48months, respectively. At last follow-up, each patient had a patent IVC graft, and none of them developed any pulmonary emboli post-operatively. Conclusions Ringed PTFE interposition graft along with an IVC filter deployed inside the graft appears to be a safe vascular conduit for IVC reconstruction after surgical resection of RCC with TT directly invading the IVC.

Leiomyosarcoma of Inferior Vena Cava involving the Liver– A rare case report

Sarcomas are very rare tumours and 10-30% are located in retro peritoneum. Out of all the sarcoma cases only 1% cases are of Leiomyosarcoma. We reported a case of 60 year female came with chief complaints of pain abdomen and loss of weight. On palpation there was tenderness in the right hypochondrium and was evaluated. MRI abdomen showed a well-defined heterogenous mass of size 8.8 ×7.9×8.2cm noted in the suprarenal location which was compressing inferiorvenacava (IVC) and also showed displacement of IVC with focal intraluminal extension with possibility of Leiomyosarcoma of IVC or retro peritoneum or hepato renal region. Section from trucut biopsy of Liver showed loss of normal liver architecture by pleomorphic spindle tumour cells arranged in bundles. Cells showing marked nuclear pleomorphism with enlarged irregular nucleus with many mononucleate and multi nucleate gaint cells suggestive of malignant spindle cell neoplasm. Immuno Histochemistry (IHC) staining was showed diffuse positivity for smooth muscle Actin, Desmin. Treatment was initiated with adjuvant chemotherapy. Later IVC reconstruction along with resection of supra renal mass was done. Keywords: Leiomyosarcoma of inferiorvenacava (IVC), Malignant spindle cell neoplasm of Liver.

Novel use of the falciform ligament for reconstruction of the inferior vena cava and its tributary.

Tumor invasion into the inferior vena cava (IVC) and hepatic vein (HV) is challenging in cancer surgery with curative intent. Appropriate techniques for venous reconstruction are essential. We have described in detail a novel technique of fashioning an interposition tube graft using the falciform ligament to reconstruct the IVC and HV. The falciform ligament maintains all the benefits of an autologous tissue graft, with the added advantage of its flexibility in customizing graft dimensions. Its use in IVC and HV reconstruction has rarely been reported. The short-term outcomes with this tube graft are promising.

Transposition of the Inferior Vena Cava (IVC) in a Patient with an Infrarenal Abdominal Aortic Aneurysm (AAA)

Computed tomography angiography in a 65 year old complaining of right sided abdominal pain with a palpable expansile mass revealed a 5 cm abdominal aortic aneurysm (AAA) and hydronephrotic right kidney secondary to calculus. Transposition of the inferior vena cava (IVC) was noted (A, white arrow). The confluence of the common iliac veins gives rise to the IVC at the level of L5 vertebral body. The left sided IVC crosses the aorta at the level of the left renal vein obscuring the aneurysm neck (B, white arrow). This anomaly has a prevalence of 0.3% and is significant at open repair as IVC transection and reconstruction may be required. Endovascular repair negates this challenge.Image 1

Reversal of cardiopulmonary exercise intolerance in patients with post-thrombotic obstruction of the inferior vena cava

BackgroundIt is unclear whether cardiopulmonary exercise intolerance in patients with chronic obstruction of the inferior vena cava (IVC) is reversible following endovascular IVC reconstruction. MethodsIn 17 patients (mean age 45 ± 15 years, 71% men) with post-thrombotic syndrome due to IVC obstruction and preserved left ventricular ejection fraction (mean 58 ± 3%), we performed cardiopulmonary exercise testing before and 3 months after IVC reconstruction (mean 4.1 ± 1.5 implanted stents). The median time from latest episode of deep vein thrombosis to intervention was 150 (interquartile range 102–820) days. ResultsAt baseline, 12 (71%) patients reported New York Heart Association (NYHA) class II or III symptoms, 76% did not achieve >85% of predicted oxygen uptake at peak exercise (mean 61.8 ± 13.7%). After IVC reconstruction, the following changes were observed at anaerobic threshold: work rate increased by 14.6 W, 95%CI (−0.7; 30.0), oxygen uptake increased by 1.8 ml/kg, 95%CI (0.3; 3.3). Oxygen pulse increased by 1.95 ml per beat, 95%CI (1.12; 2.78), corresponding to a mean relative increase of 22.5%, 95%CI (12.4; 32.7) (p < 0.001). The following changes were observed at peak exercise: work rate increased by 48.1 W, 95%CI (27.8; 68.4), oxygen uptake increased by 6.4 ml/kg, 95%CI (3.8; 9.1). Oxygen pulse increased by 2.68 ml per beat, 95%CI (1.60; 3.76), corresponding to a mean relative increase of 29.4%, 95%CI (17.7; 41.2) (p < 0.001). At follow-up, 5 (29%) patients remained in NYHA class II. ConclusionsIn patients with chronic IVC obstruction, cardiopulmonary exercise intolerance as a result of impaired cardiac filling is at least partially reversible following endovascular IVC reconstruction. Study registrationURL: https://clinicaltrials.gov. Unique identifier: NCT02433054.

Reconstruction of the inferior vena cava: different strategies

Purpose: Resection and reconstruction of the inferior vena cava (IVC) is an unusual and challenging procedure. Malignant disease invading or obstructing IVC is the most frequent entity, while nonmalignant is rare and differential diagnostic is difficult. Methods: We report two cases required resection and reconstruction of IVC. Results: A 31-year-old man with left lower extremity paresthesias. His work-up revealed a large (9x3 cm) mass at the right renal hilum involving the IVC and right renal vein (RV) with complete thrombosis of bilateral external and common iliac veins (CIV), as well as the infrarenal IVC. The tumor contacted the aorta in greater than 90 degrees, as well as the third portion of the duodenum. Surgical intervention: through a midline laparotomy, we attained complete control of the IVC (above and below) as well as left RV and bilateral CIV. The IVC was transected at its origin. After thrombectomy of both iliac veins, no relevant venous flow was observed, therefore we sutured the lower IVC stump. We then divided the left RV and the IVC above the RV level, extracting the tumor en-bloc with the IVC and the right kidney. Finally, we anastomosed the left RV to a “cone” cavoplasty of the remaining IVC stump. Histologically, it was a large (11x4.5 cm) benign mesenchymal tumor involving the right renal hilum, with the diagnosis of calcifying fibrous tumor, a rare benign tumor. During follow-up after 6 years patient develops post-thrombotic syndrome of the lower limbs and subcutaneous venous collateral circulation, but without any evidence of tumor recurrence. On the other hand, we present a 39-years-old male with history of left nephrectomy after inferior vena cava and left RV thrombosis when he was one month old. He came for outpatient consultation due to recurrent deep vein thrombosis and thrombophlebitis. CT scan revealed absence of the infrarenal IVC with prominent collateral veins in multiple pathways. Due to unfavorable response to medical treatment, a surgical approach was offered. IVC reconstruction was performed with cadaveric vein graft, from the remaining iliac veins to the junction of the IVC with the right RV. At 2 years of follow up, the patient presented partial clinical improvement, nevertheless, an MRI scan showed thrombosis of the graft. Conclusion: Transplant and Hepato-Pancreato-Biliary surgeons are familiarized with IVC approach, but surgical treatment is usually difficult and may require a major vascular reconstruction.

Resection of the inferior vena cava in different neoplasm

Purpose: The involvement of the inferior vena cava (IVC) in advanced abdominal tumors is a surgical challenge, given the high postoperative morbidity and poor long-term prognosis. IVC reconstruction is not always required due to the formation of collateral veins. Our goal was to analyze our experience, perioperative management, and results. Methods: We retrospectively evaluated short and long-term results of surgical resections of tumors with associated inferior vena cava resection performed in our facilities between 2012 and 2020. Results: 15 patients were selected for our retrospective study: 1 with renal carcinoma, 4 with sarcoma, 7 with colorectal metastases, 2 with adrenal tumors, and 1 with hepatocellular carcinoma. 7 were male with an average age of 59.06 years. The postoperative severe complications (Dindo-Clavien ≥ IIIa) affected 40% of patients and the mortality rate was 13.3%. Partial resection with primary repair was performed in 7 patients (46.7%), with patch reconstruction in 1 (6.7%), thrombectomy in 2 (13.3%), and vascular reconstruction with prosthesis in 5 patients (33.3%). The average follow-up was 30.62 months. The 1, 3 and 5-year OS rates were 100%, 91% and 43%, respectively; excluding the postoperative mortality. The mean DFS was 11.53 months. The 1, 3 and 5-year DFS rates were 46%, 18% and 18%, respectively. Graft thrombosis occurred in 3 patients (20%) during follow-up. Six patients were prescribed follow-up anticoagulation. Conclusion: IVC resection, though a technically demanding procedure, can be safely performed to achieve complete tumor resection with relative survival improvement and acceptable mortality and morbidity rates in selected patients.

Postoperative complications of ex vivo liver resection combined with autologous liver transplantation in treatment of advanced hepatic alveolar echinococcosis at high altitude and related prevention and treatment strategies

Objective To investigate the postoperative complications of ex vivo liver resection combined with autologous liver transplantation in the treatment of end-stage hepatic alveolar echinococcosis at high altitude and related prevention and treatment strategies. Methods Surgical data and follow-up data were collected from 11 patients with end-stage hepatic alveolar echinococcosis who underwent autologous liver transplantation in Qinghai People's Hospital from January 2013 to March 2019, and intraoperative and postoperative conditions were analyzed. Results All 11 patients underwent autologous liver transplantation successfully, without intraoperative death, among whom 2(18.18%) underwent hemi-extracorporeal hepatectomy and 9 (81.82%) underwent total extracorporeal hepatectomy. For the reconstruction of the retrohepatic inferior vena cava, 2 patients (18.18%) underwent reconstruction with the autologous great saphenous vein, 4 patients (36.36%) underwent reconstruction with artificial vessels, and the autologous retrohepatic inferior vena cava was preserved in 5 patients (45.45%). For biliary reconstruction, 8 patients (72.73%) underwent choledochoenterostomy and 3 (27.27%) underwent choledochocholedochostomy. The main postoperative complications of the 11 patients included bleeding in 2 patients (18.18%), bile leakage and abdominal infection in 4 patients (36.36%), bilioenteric anastomotic stenosis in 1 patient (9.09%), thrombus in 2 patients (18.18%), pulmonary infection and pleural effusion in 2 patients (18.18%), and echinococcosis recurrence in 1 patient (9.09%). Of all 11 patients, 2 (18.18%) died during the perioperative period, and the other 9 patients (81.82%) were improved and discharged. Conclusion Bleeding, biliary complications, and infection are the main causes of death in patients undergoing autologous liver transplantation at high altitude. An accurate understanding of surgical indication, careful multidisciplinary evaluation before surgery, superb operation during surgery, standardized surgical procedures, and fine perioperative management are the key to reducing perioperative mortality, avoiding and reducing postoperative complications, and achieving good long-term survival in patients undergoing autologous liver transplantation.

Reuse of liver allograft from a brain-dead recipient: a case report

We report our first case of deceased-donor liver transplantation (LT) using a reuse liver graft after the first LT. The recipient was a 38-year-old female with fulminant hepatic failure from toxic hepatitis. She had a history of herb intake and her liver function deteriorated progressively. She was enrolled as the Korean Network for Organ Sharing (KONOS) status 1 and the model for end-stage liver disease score was 34. The donor was a 42-year-old male patient who fell into brain death after LT for alcoholic liver cirrhosis. Donation of multiple organs including the transplanted liver graft was performed 10 days after the first LT operation. Since the liver graft appeared to be normal and frozen-section liver biopsy showed only mild fatty changes, we decided to reuse the liver graft. A modified piggy-back technique of the suprahepatic inferior vena cava reconstruction was used. Other surgical procedures were comparable to the standard deceased-donor LT procedures. The explant liver pathology revealed submassive hepatic necrosis, which was compatible with toxic hepatitis. The peak of serum liver enzyme levels were aspartate transaminase 1,063 IU/L and alanine transaminase 512 IU/L at posttransplant day 3. Since the pretransplant general condition of the recipient was very poor, hospital stay was prolonged and she was discharged 51 days after LT operation. She is currently doing well for 3 years to date. Experience in our case and the literature review suggest that a reuse liver graft can be regarded as one of the marginal grafts which can be transplantable to the LT candidates requiring urgent LT.

Multidisciplinary Oncovascular Surgery is Safe and Effective in the Treatment of Intra-abdominal and Retroperitoneal Sarcomas: A Retrospective Single Centre Cohort Study and a Comprehensive Literature Review

Radical excision of retroperitoneal or intra-abdominal soft tissue sarcomas may necessitate vessel resection and reconstruction. The aim of this study was to assess surgical results of retroperitoneal or intra-abdominal sarcomas involving major blood vessels. This was a retrospective single centre cohort study and a comprehensive review of literature. Patients with retroperitoneal or intra-abdominal sarcomas treated by the oncovascular team in Helsinki University Hospital from 2010 to 2018 were reviewed for vascular and oncological outcomes. A comprehensive literature review of vascular reconstructions in patients with retroperitoneal sarcoma was performed. Vascular reconstruction was performed in 17 patients, 11 of whom required arterial reconstructions. Sixteen of the operations were sarcoma resections; the post-operative diagnosis for one patient was thrombosis instead of the presumed recurrent leiomyosarcoma. Early graft thrombosis occurred in two venous and one arterial reconstruction. Late thrombosis was detected in three (18%). The median follow up was 27 (range 0–82) months. Of the patients with sarcoma resections 5 (31%) died of sarcoma and further 4 (25%) developed local recurrence or new distant metastases. The comprehensive review of literature identified 37 articles with 110 patients, 89 of whom had inferior vena cava reconstruction only. Eight arterial reconstructions were described. Late graft thrombosis occurred in 14%. The follow up was 0–181 months, during which 57% remained disease free and 7% died of sarcoma. Vascular reconstructions enable radical resection of retroperitoneal and intra-abdominal sarcomas in patients with advanced disease. The complex operations are associated with an acceptable rate of serious peri-operative complications and symptomatic thrombosis of the repaired vessel is rare. However, further studies are needed to assess the performance of the vascular reconstructions in the long term.

Inferior vena cava reconstruction with a superficial femoral vein graft after resection of a venous leiomyosarcoma

Leiomyosarcoma is a rare malign neoplasm, representing about 5–7% of all tissue sarcomas while inferior vena cava leiomyosarcomas accounts for only 1%. This paper presents the case of a 74 years old patient that was diagnosed with an abdominal venous leiomyosarcoma involving the inter-renal segment of the inferior vena cava. Tumor was treated by complete in bloc resection. Reconstruction of the vascular axis was performed with an autologous venous tube graft achieved with segments of the right superficial femoral vein. Recurrent free survival and freedom from local or systemic recurrence was observed at 2 years after the intervention thanks to the aggressive radical surgical management.

Current Controversies in Inferior Vena Cava Filter Placement: AJR Expert Panel Narrative Review

Despite inferior vena cava (IVC) filter practice spanning over 50 years, interventionalists face many controversies in proper utilization and management. This article reviews recent literature and offers opinions on filter practices. IVC filtration is most likely to benefit patients at high risk of iatrogenic pulmonary embolus during endovenous intervention. Filters should be used selectively in patients with acute trauma or undergoing bariatric surgery. Retrieval should be attempted for perforating filter and fractured filter fragments when imaging suggests feasibility and favorable risk-to-benefit ratio. Antibiotic prophylaxis should be considered when removing filters with confirmed gastrointestinal penetration. Anticoagulation solely because of filter presence is not recommended except in patients with active malignancy. Anticoagulation while filters remain in place may decrease long-term filter complications in these patients. Patients with a filter and symptomatic IVC occlusion should be offered filter removal and IVC reconstruction. Physicians implanting filters may maximize retrieval by maintaining physician-patient relationships and scheduling follow-up at time of placement. Annual follow-up allows continued evaluation for removal or replacement appropriateness. Advanced retrieval techniques increase retrieval rates but require caution. Select cases may require referral to experienced centers with additional retrieval resources. The views expressed should help guide clinical practice, future innovation, and research.

Current trends in vena cava reconstructive techniques with major liver resection: a systematic review.

Historically, invasion of the inferior vena cava (IVC) represented advanced and often unresectable hepatic disease. With surgical and anesthetic innovations, IVC resection and reconstruction have become feasible in selected patients. This review assesses technical variations in reconstructive techniques and post-operative management. A comprehensive literature search was performed according to PRISMA. Inclusion criteria were (i) peer-reviewed articles in English; (ii) at least three cases; (iii) hepatic IVC resection and reconstruction (January 2015-March 2020). Primary outcomes were reconstructive technique, anti-thrombotic regimen, post-operative IVC patency, and infection. Secondary outcomes included post-operative complications and malignant disease survival. Fourteen articles were included allowing for investigation of 351 individual patients. Analysis demonstrated significant heterogeneity in surgical reconstructive technique, anti-thrombotic management, and post-operative monitoring of patency. There was increased utilization of ex vivo approaches and decreased use of venovenous bypass compared with previously published reviews. This review of literature published between 2015 and 2020 reveals persistent heterogeneity of hepatic IVC reconstructive techniques and peri-operative management. Increased utilization of ex vivo approaches and decreased use of venovenous bypass point towards improved operative techniques, peri-operative management, and anesthesia. In order to gain evidence for consensus on management, a registry would be beneficial.

Surgical approach, management, and oncologic outcomes of primary leiomyosarcoma of the inferior vena cava: An institutional case series

Leiomyosarcoma of the inferior vena cava (IVC) is a rare tumor arising from the smooth muscle of vessel walls. Surgery is the only potential curative treatment. Given its rarity, optimal surgical, and oncologic management is not well described. We review our institutional series of primary leiomyosarcomas treated with resection and IVC reconstruction over the last decade. Retrospective chart review of all patients who underwent surgical resection of primary leiomyosarcoma of the IVC from November 2009 to March 2020 at a single tertiary care center was performed. Among the eight patients treated, the majority were female (87.5%) with a median age of 52 years (range, 44-63). Tumor was located in the infrarenal IVC in five patients (62.5%). IVC was reconstructed using a ring-enforced PTFE graft in six patients (75%). All but one patient had an intermediate (grade 2) or high grade (grade 3) tumor, and all resections achieved grossly negative margins. The 1- and 3-year disease-free survival was 85.7% and 64.3%, respectively. There were no disease-specific deaths during a median follow-up of 36 months (interquartile range, 10-51 months). With a well-coordinated multidisciplinary approach, primary leiomyosarcoma of the IVC can be safely resected with good long-term survival.

Inferior Vena Cava Leiomyosarcoma: What Method of Reconstruction for Which Type of Resection?

Inferior vena cava leiomyosarcoma (IVCL) is a rare tumor with a poor prognosis, and its surgical resection remains a challenge. To date, surgery is the only potentially curative treatment for IVCL with a 5-year survival rate of 55%. The main challenge is to combine oncological surgery with clear margins and vascular reconstruction of the inferior vena cava (IVC). In this review, we discuss the different approaches to vascular reconstruction after IVCL resection, using a prosthetic or autologous patch, direct suture or simple ligation without IVC reconstruction. The reconstruction of IVC depends of tumor location and its extension. We recommend no reconstruction if venous collaterality is well-established. When vascular reconstruction is required, we prefer prosthetic PTFE graft. These patients should be referred to high-volume centers with a multidisciplinary team of sarcoma surgeons with cardiothoracic, vascular and hepatic specialties.