Resection of the inferior vena cava for neoplasms with or without prosthetic replacement: a 14-patient series

Abstract

Objective: To review the outcome of resection of the suprarenal or infrarenal inferior vena cava (IVC) and possible indications for prosthetic replacement.

Summary background data: Involvement of the IVC has long been considered a limiting factor for curative surgery for advanced tumors because the surgical risks are high and the long-term prognosis is poor. Prosthetic replacement of the IVC is controversial.

Methods: The authors retrospectively reviewed a 7-year series of 14 patients who underwent en bloc resection including a circumferential segment of the IVC. The tumor was malignant in 12 patients and benign in 2. The resected segment of the IVC was located above the kidneys in eight patients and below in six. Resection was performed without extracorporeal circulation in all patients.

Results: In all but one patient, IVC resection was associated with multivisceral resection, including extended nephrectomy (n = 8), major hepatic resection (n = 3), digestive resection (n = 3), and infrarenal aortic replacement (n = 2). Prosthetic replacement of the IVC was performed in eight patients cases and was more common after resection of a suprarenal (6/8) than an infrarenal segment of the IVC (2/6). One patient died of multiorgan failure. Major complications occurred in 29% of patients. Symptomatic complications of prosthetic replacement occurred in one patient (acute postoperative thrombosis, successfully treated by surgical disobstruction). Graft-related infection was not observed. Marked symptoms of venous obstruction developed in three of the six patients who did not undergo venous replacement. In patients undergoing surgery for malignant disease, the estimated median survival was 37 months and the actuarial survival rate was 67% at 1 year.

Conclusion: Multivisceral resection including a segment of IVC is justified to achieve complete extirpation in selected patients with extensive abdominal tumors. Prosthetic replacement of the IVC may be required, particularly in cases of suprarenal resection. It is a safe procedure with a low complication rate and good functional results.

Figure 1. Patient 12. Abdominal computed tomography scan (top) and nuclear magnetic resonance imaging (bottom) showing a large right retroperitoneal mass involving the retrohepatic inferior vena cava and pushing the right kidney forward (not shown), and a synchronous mass in the sinus of the left kidney. In this difficult case, the patient was informed of the possible need for bilateral nephrectomy, but conservation of the right kidney turned out to be possible.

Figure 2. Patient 14. Abdominal contrast-enhanced computed tomography scan (top) and three-dimensional reconstruction (bottom) showing a tumor in the right kidney with massive intracaval extension. Note the upper extremity of the tumor thrombus extending above the ostia of the hepatic veins. This case illustrates the limit of surgery without cardiopulmonary bypass.

Figure 3. (A) The procedure performed in each case of suprarenal inferior vena cava resection with or without venous replacement. Numbers are the same as in tables. (B) The procedure performed in each case of infrarenal inferior vena cava resection without (top) or with (bottom) venous replacement.

Figure 4. Patient 2. Preoperative cavography (left) showing a tight stenosis of the upper part of the retrohepatic inferior vena cava resulting from carcinoma of the right hepatic lobe. Note the backflow into the renal veins and one collateral lumbar vein. Despite this drainage, extended right hepatectomy with inferior vena cava resection and ligation led to intraoperative oliguria and hypotension, which were reversed by venous reconstruction. Cavography on the postoperative day 14 (right) showed a patent prosthesis. The extremities of the graft are designated by the white arrows.