The use of polytetrafluoroethylene to facilitate the vascular access in recurrent melanoma to limbs

Abstract

Introduction: Melanoma with recurrent loco-regional metastases to limbs often makes difficult a second surgical approach because of the adhesions affecting the vascular access. Our aim was to evaluate whether the placement of a polytetrafluoroethylene (PTFE) membrane around vessels might facilitate a surgical re-approach.

Presentation of case: We reported a case of a 64-year-old male with a melanoma on the left foot who developed in transit metastases after LND. While performing the inguinopelvic LND we coated the iliac vessels with PTFE patch to facilitate the vascular access in case of re-intervention for a ILP. In the second surgical approach we made a cutaneous incision in the left iliac region and we proceeded through the subcutaneous tissue until detection of iliac vessels, more clearly visible because of the PTFE patch fixed around vascular walls to minimize adhesions. We removed the PTFE coating and easily performed arteriotomy and venotomy for the completion of the ILP.

Discussion: This case report seems to demonstrate the efficacy of a PTFE membrane applied in a patient around iliac vessels during inguinopelvic dissection, to reduce adhesion density. In fact this membrane provided a barrier to adhesions of the iliac vessels, decreasing the risk of vascular injury thereby facilitating a subsequent vascular access. Re-coating of the iliac vessels with PTFE could be preparatory to a better identification of the vascular structures in cases of a surgical re-approach.

Conclusion: The use of PTFE effectively simplifies the second approach to vessels in event of a melanoma metastasizing to limbs.

Fig. 1

(1.1) Operative photograph showing the technique of coating the iliac vein and artery during inguinopelvic lymph-node dissection. The PTFE membrane was hydrated in sterile saline at room temperature for 15 min; then we proceeded to cut strips about 5 cm long × 3.5 cm high for use during the surgery, with small variations in size due to the caliber of the vessels. (1.2) The vessels were lined by strip that was inserted using a synthetic monofilament of non-absorbable polypropylene suture between the two extremities of the long side, leaving a few millimeters between the membrane and the vessel. No sutures are placed between the vessel wall and the membrane.

Fig. 2

Multiple cutaneous – subcutaneous in transit metastases to left lower limb.

Fig. 3

(3.1) We exceeded the sub-cutaneous tissues searching for the iliac vessels till we identified the PTFE patch fixed around vascular walls that allowed us to detect the iliac artery and vein. Furthermore the PTFE membrane gave us the possibility to identify and use a cleavage plane obtaining a less risky approach to vessels walls. (3.2) We removed the PTFE patch in order to have an easier access to the vascular structures. We performed arteriotomy and venotomy and cannulated the vessels.