Replacement Of Inferior Vena Cava Research Articles

Polytetrafluoroethylene expanded prosthesis as replacement of the inferior vena cava in renal cell carcinoma with caval thrombus

To assess the outcomes of inferior vena cava replacement with polytetrafluoroethylene expanded prosthesis in patients with renal cell carcinoma and caval thrombosis. All patients who underwent radical nephrectomy with inferior vena cava replacement by polytetrafluoroethylene expanded prosthesis for renal cancer associated with inferior vena cava thrombosis and a suspicion of inferior vena cava wall invasion from January 2000 to June 2011 were considered for this study. Demographic data, postoperative course, graft patency and survival data were evaluated. A total of 26 patients (median age 59.5 years, range 19.9-85.6 years) were included in the analysis. The median tumor diameter was 10 cm (range 5-14 cm). Histological invasion of the wall of the inferior vena cava was found in 16 (61.5%) cases. The median follow up was 28 months (range 1-136). A graft thrombosis occurred in five (19.2%) patients within the first year. Four of these patients died before the end of the second year. Patency of the inferior vena cava graft at 6 and 12 months was 88% and 79%, respectively. Overall survival probability at 3 years was 64%. Prosthetic replacement of the inferior vena cava can be carried out when invasion of the wall of the inferior vena cava is suspected. The postoperative complication rate in this subset of high-risk patients undergoing radical nephrectomy seems acceptable, and the patency of the prostheses is good in most of the cases.

Replacement of Vena Cava up to the Right Atrium during Living Donor Liver Transplantation for Echinococcus alveolaris.

Management of advanced stage of Echinococcus alveolaris is a very difficult procedure. Surgical treatment like resection and liver transplantation is accepted procedure nowadays. Here we presented a case report of Echinococcus alveolaris which invaded the inferior vena cava up to the right atrium and surrounding tissues. This patient underwent living donor liver transplantation with replacement of inferior vena cava up to the right atrium with cryopreserved cadaveric aortic graft. This procedure is very difficult but it is a life-saving chance for patients in advanced cases of Echinococcus alveolaris.

Primary Ewing Sarcoma of the Kidney with Inferior Vena Cava Invasion

Ewing sarcoma is typically a skeletal based tumor of presumed neuroectodermal origin. Primary Ewing sarcoma of the kidney is exceedingly rare and is usually found in young adults. We report a case of primary Ewing sarcoma with inferior vena cava (IVC) invasion that was managed successfully with radical nephrectomy and partial replacement of IVC using bovine pericardial patch.

Surgical resection and inferior vena cava reconstruction for treatment of the malignant tumor: technical success and outcomes.

The purpose of this study was to review patients who underwent inferior vena cava (IVC) resection with concomitant malignant tumor resection and to consider the operative procedures and the outcomes. Between 2000 and 2012, 41 patients underwent resection of malignant tumors concomitant with surgical resection of the IVC at our institute. The records of these patients were retrospectively reviewed. Primary tumor resections included nephrectomy, hepatectomy, retroperitoneal tumor extirpation, lymph node dissection, and pancreaticoduodenectomy. The IVC interventions were partial resection in 23 patients and total resection in 18 patients. Four patients underwent IVC replacement. Operation-related complications included pulmonary embolism, acute myocardial infarction, deep vein thrombosis, leg edema and temporary hemodialysis. There were no operative deaths. The mean follow-up period was 24.9 months (range: 2-98 months). The prognosis depended on the type and stage of the tumor. Resection and reconstruction of the IVC can be performed safely if the preoperative evaluations and surgical procedures are performed properly. The IVC resection without reconstruction was permissive if the IVC was completely obstructed preoperatively, but it may also be considered in cases where the IVC is not completely obstructed.

No-Touch En Bloc Right Lobe Living-Donor Liver Transplantation with Inferior Vena Cava Replacement for Hepatocellular Carcinoma Close to Retrohepatic Inferior Vena Cava: Case Report

Current studies have shown that living-donor liver transplantation (LDLT) for hepatocelluar carcinoma (HCC) satisfying the Milan criteria does not compromise patient survival or increase HCC recurrence compared with deceased-donor liver transplantation (DDLT). For patients with HCC beyond the Milan criteria, however, worse outcomes are expected after LDLT than after DDLT, despite insufficient data to reach a conclusion. Regarding operative technique, LDLT might be a less optimal cancer operation for HCC located at the hepatic vein confluence and/or paracaval portion. The closeness to the wall of the retrohepatic inferior vena cava (IVC) is greater than in conventional DDLT, rendering it difficult to perform a no-touch en bloc total hepatectomy. An LDLT, which must preserve the native IVC for the piggyback technique during engraftment, may lead to tumor remnants. To reduce recurrences after LDLT, we successfully performed a no-touch en bloc total hepatectomy including the retrohepatic IVC and all 3 hepatic veins. IVC replacement with an artificial vascular graft together with a modified right-lobe LDLT was performed for a patient having advanced HCC close to the hepatic vein confluence and paracaval portion. There was no artificial vascular graft-related complication, such as thrombosis or infection. Despite the limitations of LDLT, requiring the piggyback technique for graft implantation, IVC replacement using an artificial graft led us to perform a no-touch en bloc total hepatectomy as with a conventional DDLT.

The use of biological grafts for reconstruction of the inferior vena cava is a safe and valid alternative: results in 32 patients in a single institution

BackgroundResection and reconstruction of the inferior vena cava (IVC) is occasionally required in the surgical treatment of intra‐abdominal tumours. IVC reconstruction can be performed with biological or synthetic graft material, with most centres preferring synthetic grafts. In spite of the potential advantages of biological grafts in terms of handling characteristics, and safety, very limited data are available about their use in patients requiring an IVC resection. MethodsMedical records of 32 patients who underwent an IVC resection and reconstruction from 1990 and 2011 with autogenous peritoneo‐fascial (N = 22) and bovine pericardial (N = 10) grafts were reviewed. ResultsA tangential resection with patch repair was performed in 10 patients, whereas in the remaining 22 it was necessary to resect and replace a segment or all of the retrohepatic IVC. A concomitant liver resection was performed in 14 patients, nephrectomy in 10 and pancreaticoduodenectomy in 2 patients. There were no acute or late complications related to graft thrombosis or infection. Three patients died as a consequence of multi‐organ failure. Overall survival at 1 and 5 years was 78% and 48%, respectively. ConclusionsThe preferential use of synthetic grafts in IVC replacement is not evidence based. Selection of an appropriate prosthetic graft for IVC reconstruction should be based on the safety and its handling features. The use of biological grafts for IVC repair is a valid alternative to current synthetic materials and may in fact be superior in terms of biocompatability, ease of handling, reduced rate of infection and improved long‐term patency without permanent anticoagulation.

Liver resection with concomitant inferior vena cava resection: experiences without veno-venous bypass

Liver resection offers the chance of a cure for liver cancer. However, when extended hepatectomies were performed in combination with resection of the inferior vena cava (IVC), the procedures were reported to have a surgical mortality rate in excess of 5 %. While most of these operations were performed with the use of veno-venous bypass, this study presents our experience performing the procedure without the bypass. Data were collected from a prospectively maintained database. A retrospective evaluation of a consecutive series of concomitant IVC and liver resections was performed. Five hundred and seventy-five liver resections were performed between June 2008 and November 2011. Eleven patients (1.9 %) underwent concomitant IVC and liver resections. One patient required segmental IVC replacement, and four IVC defects were closed using a bovine pericardial patch without bypass. Only one patient had histologically confirmed IVC invasion. There was no postoperative mortality. Nine postoperative complications occurred in five patients. No complications in terms of IVC patency were seen. Five patients had disease recurrence, one of whom died within 12 months of surgery. Concomitant liver and IVC resection is safe without using a bypass procedure, with acceptable short-term results. Meticulous technique, careful patient selection and a specialized anesthetic team are key to obtaining low postoperative morbidity and mortality rates and an acceptable oncological outcome.

Combined resection of a tumor and the inferior vena cava: report of two cases

Tumor resection and caval tumor thrombectomy, with or without cavotomy and inferior vena cava (IVC) replacement are sometimes performed in patients with renal cell carcinoma (RCC) extending into the IVC or liver tumors invading the IVC. Two such cases were treated. Case 1: a 68-year-old female was transferred with a diagnosis of right RCC with tumor thrombus extending into the IVC. A plication was performed to prevent extension into the right atrium before the nephrectomy and cavotomy with removal of the tumor thrombus was accomplished, because the IVC was almost completely obstructed and the hemodynamics were stable during cross-clamping of the IVC. Case 2: a 37-year-old female was transferred with a diagnosis of a giant metastatic liver tumor. A trisegmentectomy with resection of the invaded IVC and IVC replacement was performed while the abdominal aorta was cross-clamped to maintain the hemodynamics. Therefore, abdominal aortic cross-clamping was convenient to maintain the hemodynamics when the IVC replacement was performed during IVC cross-clamping.

Nutcracker syndrome due to left-sided inferior vena cava compression and treated with superior mesenteric artery transposition

Left renal vein hypertension secondary to left renal vein compression has been described as a cause of persistent hematuria in nutcracker syndrome. Malformation of the inferior vena cava (IVC), although rare and frequently asymptomatic, may also result in left renal vein hypertension, with resultant hematuria when it is severely compressed. We report a 20-year-old man with persistent hematuria due to compression of left-sided IVC. The patient was successfully treated by means of superior mesenteric artery (SMA) transposition and division of the fibrous bundle at the origin of the SMA. His postoperative course was uneventful. Compression of the left IVC is a unique form of nutcracker syndrome. SMA transposition, together with division of a fibrous bundle at the origin of the SMA if present, is a safe and effective surgical procedure for this special entity.

Multidisciplinary treatment and long-term outcomes in six patients with leiomyosarcoma of the inferior vena cava

PurposeLeiomyosarcoma (LMS) of the inferior vena cava (IVC) is a rare primary soft tissue sarcoma. Few reports have detailed the tumor features, treatment strategies, and long-term outcomes in IVC LMS patients. The present report describes the treatment and long-term outcomes of six patients with IVC LMS.MethodsWe reviewed six consecutive cases of IVC LMS treated at the University of Ulsan College of Medicine, Asan Medical Center from August 1998 to June 2010.ResultsThe patients comprised five females and one male, and had a median age of 44 years (range, 25 to 64 years). All tumors were suprarenal. The tumors were located between the hepatic and renal veins (i.e., middle segment; n = 5 [83%]), or above the hepatic veins (i.e., upper segment; n = 1 [17%]). Prosthetic IVC replacement using polytetrafluoroethylene grafts was performed in five patients, and the remaining patient underwent only tumor resection and IVC ligation. There were no intraoperative or postoperative deaths. The mean tumor size was 9.3 cm (range, 5 to 20 cm), and five of the six tumors were high grade. The mean follow-up period was 80 months (range, 6 to 118 months). The median survival period was 94 months. Recurrence occurred in all patients. Distant recurrence resulted in three patients undergoing lung resection and three patients undergoing thigh muscle resection.ConclusionIVC LMS is a rare but serious disease. Although surgical resection combined with chemoradiotherapy was not completely curative, it resulted in long-term patient survival, even in patients with advanced tumors.

Aggressive combined resection of hepatic inferior vena cava, with replacement by a ringed expanded polytetrafluoroethylene graft, in living‐donor liver transplantation for hepatocellular carcinoma beyond the Milan criteria

We present the cases of two patients with hepatocellular carcinoma (HCC) beyond the Milan criteria (MC) who underwent living-donor liver transplantation (LDLT) combined with aggressive hepatic venacaval resection and replacement of the hepatic inferior vena cava (IVC) by an artificial vascular graft. The aim of the resection and replacement of the hepatic IVC was to resect completely a latent cancer adjacent to the hepatic IVC and to avoid micrometastasis via the hepatic veins during increased manipulation of the native liver with HCC. First, the hepatic hilus was dissected and the infrahepatic IVC was encircled. After minimum mobilization of the liver, the common orifice of the middle and left hepatic veins and suprahepatic IVC was encircled. Venovenous bypass (VVB) was started to stabilize systemic hemodynamics. After cross-clamping of the infrahepatic and suprahepatic IVC, the IVC was divided at the site just below the confluence of the common orifice of the middle and left hepatic veins and its infrahepatic site. Then, all retroperitoneal attachments of the right lobe were dissected and the native liver was resected with the retrohepatic IVC. The IVC was replaced by a ringed expanded polytetrafluoroethylene (e-PTFE) graft. Infrahepatic venous recirculation ended the VVB. An extended left-lobe graft was implanted. The e-PTFE grafts were covered with the greater omentum to avoid infection. The operations were completed safely. The postoperative courses were free of complications related to the reconstruction of the hepatic IVC. One patient developed recurrence in the left adrenal gland. LDLT combined with hepatic venacaval resection and replacement by an e-PTFE graft for HCC beyond the MC could be safe and feasible under VVB. Further studies are needed to confirm to what extent this procedure could prevent post-transplant recurrence in HCC beyond the MC.

Venous Resection in Urological Surgery

Complete removal of retroperitoneal and pelvic tumors may require resection or ligation of major retroperitoneal, pelvic and mesenteric venous structures. We provide an overview of venous anatomy and collateral drainage, and review the veins that can be safely resected. We reviewed major anatomical texts, and performed a directed MEDLINE literature search of retroperitoneal, pelvic and mesenteric venous anatomy. Resection and reconstruction of these vessels were also reviewed with an emphasis on collateral blood flow and post-resection sequelae. The infrarenal inferior vena cava, iliac veins, left renal vein, lumbar veins, inferior mesenteric vein and splenic vein may be resected or ligated without reconstruction. Resection of the right renal vein results in renal demise in the majority of instances. The portal vein may not be resected without reconstruction. Venous reconstruction may be performed with autologous or synthetic graft material. Most major veins in the body can be safely resected or ligated with minimal sequelae. However, it is imperative to understand venous anatomy and collateral blood flow to minimize intraoperative and postoperative complications.

Results of Endoluminal Occlusion of the Inferior Vena Cava During Radical Nephrectomy and Thrombectomy

BackgroundThe surgical management of renal tumours with thrombi in the inferior vena cava (IVC) has become the gold standard treatment. ObjectiveTo evaluate endoluminal occlusion of the IVC during radical nephrectomy with either retrohepatic (level II) or suprahepatic (level III) caval tumour thrombus. Design, setting, and participantsFrom January 2000 to October 2007, 28 consecutive patients with renal cell carcinoma presenting a thrombus level II or III were treated with endoluminal occlusion of the free IVC cranial. Surgical procedureThe occlusion balloon was positioned under transesophageal echography (TEE) control through a cavotomy performed at the level of the renal vein ostium. Thrombectomy and radical nephrectomy were then performed. MeasurementsOperative time, perioperative bleeding, and pre- and postoperative complications were assessed. Overall patient survival time, disease-free survival, and development of metastasis were assessed. Results and limitationsCaval thrombectomy was performed successfully in all patients. IVC replacement with an expanded polytetrafluoroethylene graft or patch closure after lateral cavectomy was performed in 10 and 4 patients, respectively. Average operative time was 160min (range: 120–210). There was no perioperative mortality. The complications were one splenectomy and one early thrombosis of the IVC. Mean length of follow-up was 22.1 mo (range: 3–90). There was no local or IVC tumour recurrence. Cause-specific death and metastasis occurred in six (21.4%) and nine patients (32.1%), respectively. Thirteen patients (46.4%) are disease-free. ConclusionsEndoluminal occlusion of the IVC with TEE monitoring for level II and III thrombus avoided a suprahepatic or subdiaphragmatic approach of the IVC. Segmental resection and reconstruction of the IVC could also be performed in case of adherent thrombi.

Combined Resection of the Liver and the Inferior Vena Cava for Hydatid Disease

Hydatid disease can result in cystic liver disease. If a conservative treatment fails, these cysts require resection. Involvement of the inferior vena cava requiring resection for hydatid disease is unusual. We present a case of hydatid disease with complete caval obstruction and resultant portal hypertension that required combined liver resection and inferior vena cava replacement.

Utilization of autologous vein graft for replacement of the inferior vena cava in living-donor liver transplantation for obliterative hepatocavopathy

Obliterative hepatocavopathy (OHC) is a subtype of Budd-Chiari syndrome in which stenosis or obstruction of the retrohepatic inferior vena cava (IVC) is observed. Although IVC replacement is necessary in OHC patients, there are hardly any graft vessels available for IVC reconstruction during living-donor liver transplantation (LDLT). Here, we describe a novel technique of IVC reconstruction using only the autologous blood vessels in an OHC patient during LDLT. In this case, sufficient drainage of the hepatic outflow and reconstruction of the venous return from the lower half of the body were simultaneously required. Therefore, we substituted the retrohepatic IVC with the suprarenal IVC of the recipient, and we reconstructed the IVC continuity by using the autologous internal jugular vein and external iliac vein. The operation was safe, and the postoperative venous drainage from the hepatic tributaries was in good condition. This procedure might be an option for IVC replacement during LDLT.

Combined liver and inferior vena cava resection for hepatic malignancy

The experience from a single center, in combined liver and inferior vena cava (IVC) resection for liver tumors, is presented. Twelve patients underwent a combined liver resection with IVC replacement. The median age was 45 years (range 35-67 years). Resections were carried out for hepatocellular carcinoma (n = 4), colorectal metastases (n = 6), and cholangiocarcinoma (n = 2). Liver resections included eight right lobectomies and four left trisegmentectomies. The IVC was reconstructed with ringed Gore-Tex tube graft. No perioperative deaths were reported. The median operative blood transfusion requirement was 2 units (range 0-12 units) and the median operative time was 5 hr. Median hospital stay was 10 days (range 8-25 days). Three patients had evidence of postoperative liver failure, resolved with supportive management. Two patients developed bile leaks, resolved conservatively. With a median follow up of 24 months, all vascular reconstructions were patent and no evidence of graft infection was documented. Aggressive surgical management of liver tumors, offer the only hope for cure or palliation. We suggest that liver resection with vena cava replacement may be performed safely, with acceptable morbidity, by specialized surgical teams.

Should the inferior vena cava be reconstructed after resection for malignant tumors?

Background Caval replacement after circumferential resection of the inferior vena cava remains controversial. The aim of the current study is to determine whether or not inferior vena cava replacement should be performed. Methods We reviewed 36 cases undergoing resection of the inferior vena cava concomitant with resection of malignant neoplasms. Our criteria for circumferential resection of the inferior vena cava were half or more of the circumference of the vessel wall invaded by tumor, a primary tumor of the caval wall, or massive intraluminal tumor thrombus suspected of adhering to the caval wall. We detailed 10 patients undergoing circumferential resection of the inferior vena cava. Results Most of patients who did not undergo replacement of the inferior vena cava showed no sign of swelling of the lower limbs, but one showed persistent leg edema with oliguria. This patient had poor development of collateral circulation and mild obstruction of the inferior vena cava before surgery. Two patients who underwent replacement of inferior vena cava had no venous sequelae, although they had poor development of collateral circulation before surgery. Conclusion Caval replacement after circumferential resection of the inferior vena cava may be necessary in patients who have preoperative poor development of collateral circulation or who have oliguria or unstable hemodynamics intraoperatively.

Leiomyosarcoma of the retrohepatic portion of the inferior vena cava: Clinical presentation and surgical management in five patients

Leiomyosarcoma (LMS) is a rare primary soft tissue sarcoma arising from the inferior vena cava (IVC). For LMS involving the retrohepatic portion of IVC there are limited published data about tumor features, surgical strategies, and IVC replacement. Clinical data, surgical procedures, and pathologic features of five consecutive patients referred for IVC-LMS, in 5 years, were reviewed. A complete surgical resection of the tumor was performed in each patient and IVC replacement used expanded polytetrafluoroethylene grafts. Abdominal pain (n = 4) and palpable flank mass (n = 3) were the most frequent signs. To assure a complete tumoral exeresis, adjacent organ resection included hepatectomy (n = 4), extended right nephrectomy (n = 3), and right adrenalectomy (n = 1). Prosthetic IVC reconstruction was performed in four patients, three times associated with arteriovenous fistula. Median postoperative stay was 18 days. No prosthetic-related complication was observed, venous insufficiency sequela did not occur. Tumoral clearance was achieved in all patients, and direct tumoral involvement of the liver was less frequent than for kidney. Three patients died at a median followup of 34 months, two are alive and disease-free at 34 and 44 months. LMS of the IVC is characterized by locally advanced status at the time of diagnosis. A radical tumoral resection associated with liberal use of venous prosthetic replacement may offer a chance for cure and good quality of life in palliative situations.

Urgent inferior vena cava replacement with an autologous pericardium tube graft

Urgent inferior vena cava replacement with an autologous pericardium tube graft

LIVING-RELATED LIVER TRANSPLANTATION AND VENA CAVA RECONSTRUCTION AFTER TOTAL HEPATECTOMY INCLUDING THE VENA CAVA FOR HEPATOBLASTOMA1

In most cases of total hepatectomy (TH) required for hepatoblastoma (HB), the retrohepatic inferior vena cava (IVC) has to be removed with the native liver for complete tumor excision. Because the liver graft procured by living donation has no IVC, a reconstruction of the recipient IVC is needed. We report our experience with living-related liver transplantation (LRLT) and IVC replacement in such cases. Between May 1998 and December 1999, four children underwent TH, including IVC and LRLT with IVC replacement for otherwise irresectable HB after chemotherapy (SIOPEL 2 and 3 protocols). IVC reconstruction used an allogenic iliac vein procured from a cadaveric donor (bank graft) in two cases and an internal jugular vein procured from the donor parent in two cases. Median age and weight at surgery were 17 months (range 10-60) and 9.6 kg (range 8.3-17.9). In the living donors, there were two complications of the procurement: one intra-abdominal biliary collection and one subcutaneous abscess. In all four children, complete excision of the tumor could be achieved without any intra-operative complication. One patient died 5 months after LRLT due to lung metastases. Three patients were alive and well with no evidence of tumor recurrence 13-24 months after surgery. Reconstructed IVC was patent in two patients, and asymptomatic thrombosis occurred 2 years after operation in one patient. Total hepatectomy including the retrohepatic IVC is not a technical obstacle to LRLT. Therefore, scheduled surgery, at the best time after chemotherapy, can be considered in all patients with otherwise irresectable HBs.