Inferior vena cava resection and reconstruction for retroperitoneal tumor excision

Abstract

Objective: This study reviews the results of en bloc resection of the inferior vena cava (IVC) for malignant tumor excision and reconstruction.

Methods: A prospective database was reviewed. IVC resection was categorized as suprarenal, perirenal, infrarenal, or extensive (>one segment resected). Repairs were divided into primary, patch, or circumferential. Tumor type, perioperative morbidity, mortality, and graft patency were recorded.

Results: Between 1990 and 2011, 47 patients (21 women; mean age, 56; range, 35-89 years) underwent IVC resection for en bloc tumor excision. Sarcomas were most common (36 [77%]: 30 primary IVC). Eleven patients had primary IVC repair, nine patch repair (two autogenous), and 27 had circumferential replacement with a polytetrafluoroethylene ringed graft. Extensive IVC reconstruction in 18 patients included the entire IVC, with renal (RV) and hepatic vein reimplantation in eight; suprarenal and perirenal in six (seven RVs reimplanted); and infrarenal and perirenal in four (four RVs reimplanted). Nine single-segment IVC replacements were infrarenal. Morbidity was 10.6%: one each with bowel obstruction, chyle leak, renal failure with complete recovery (left RV reimplant, right nephrectomy), reoperation for bleeding, and IVC graft thrombosis. Morbidity did not differ by type of reconstruction. There was no mortality. Follow-up ranged from 1.5 to 216 months (18 years) with a mean of 3.5 years. Computed tomography or duplex scans were available in 28 of 47 patients and in 15 of 27 patients in group 3 at a mean follow-up of 36 and 20 months, respectively. One IVC graft thrombosis was documented at 10 months after chemotherapy/sepsis. Tumor recurrence caused three graft stenoses. Cumulative 5-year patency in group 3 was 80% (imaging) and 92% (clinical). Lower extremity edema was universally avoided. Cumulative 5-year survival for the series was 45% ± 8.5%. Mean long-term survival was 5.8 ± 0.56 years (range, 4 months-17 years), with a significant difference between primary or patch (mean, 6.5 years) and circumferential or extensive repair (mean, 4.2 years; P < .005). Cumulative (47% vs 52%) and mean (3.1 vs 3.6 years; P > .12) survival was similar between patients with single-segment and extensive IVC resection and replacement.

Conclusions: IVC resection and reconstruction for en bloc tumor excision is safe, even when extensive repairs are necessary. Replacement of the IVC with prosthetic graft avoids extremity venous complications and likely contributes to quality of survival. Survival depends on tumor behavior and degree of IVC involvement, where primary and patch repair has a better prognosis than circumferential resection.