Vascular Involvements in Cholangiocarcinoma: Tips and Tricks

Abstract

Cholangiocarcinoma (CCA) is an aggressive malignancy of the biliary tract. To date, surgical treatment remains the only hope for definitive cure of CCA patients. Involvement of major vascular structures was traditionally considered a contraindication for resection. Nowadays, selected cases of CCA with vascular involvement can be successfully approached. Intrahepatic CCA often involves the major hepatic veins or the inferior vena cava and might necessitate complete vascular exclusion, in situ hypothermic perfusion, ex situ surgery and reconstruction with autologous, heterologous or synthetic grafts. Hilar CCA more frequently involves the portal vein and hepatic artery. Resection and reconstruction of the portal vein is now considered a relatively safe and beneficial technique, and it is accepted as a standard option either with direct anastomosis or jump grafts. However, hepatic artery resection remains controversial; despite accumulating positive reports, the procedure remains technically challenging with increased rates of morbidity. When arterial reconstruction is not possible, arterio-portal shunting may offer salvage, while sometimes an efficient collateral system could bypass the need for arterial reconstructions. Keys to achieve success are represented by accurate selection of patients in high-volume referral centres, adequate technical skills and eclectic knowledge of the various possibilities for vascular reconstruction.

Keywords: cholangiocarcinoma; liver; outcomes; resection; vascular involvement; vascular reconstruction.

Figure 1

Different IVC clamping strategies depending on infiltration site. (A) Lateral IVC clamping below hepatocaval confluence: this strategy can be readily advantageous when involvement is <60–120° circumferentially and <2–3 cm longitudinally. (B) Total IVC clamping below hepatocaval confluence: this permits venous return from the liver and does not require hepatic ischaemia (C) Side clamping at hepatocaval confluence is a strategy to permit venous return from one side of the liver, despite “very high” neoplastic infiltration. (D) Total vascular exclusion necessitates complete IVC clamping above the hepatocaval confluence, concurrent Pringle manoeuvre and hepatic ischemia. Abbreviations: IVC, inferior vena cava.

Figure 2

Reconstructive options after IVC resection. (A) Direct suture is possible when resection involved less than 120° of the IVC wall. Transverse repair (not depicted) may be used to lower chances of stenosis for long longitudinal defects. (B) Patch repair can be used when less than 180° of the IVC has been resected. Peritoneal, biological and synthetic options exist. (C) End-to-end anastomosis can be fashioned for circumferential IVC resection <3 cm in length. (D) Interpositional grafts are the preferred option for defects longer than 3 cm and autologous, cadaveric and synthetic grafts have been used.

Figure 3

Hypothermic perfusion strategies. (A) In situ hypothermic perfusion: total vascular exclusion is in place and a perfusion cannula is inserted in the portal vein. A cavotomy is also performed, to be used for venting. (B) Ante situm technique: total vascular exclusion is in place, hypothermic perfusion is used and the vena cava has been sectioned below the superior clamp. (C) The liver can now be rotated anteriorly towards the surgical team, to perfectly expose the caval plane. (D) Resection is completed and reconstruction requires grafting of the IVC and hepatic vein re-implantation. (E) Ex situ technique: TVE and hypothermic perfusion are followed by PV, hepatic artery and biliary division and subsequent complete hepatectomy with IVC resection. (F) Reconstruction requires IVC grafting and portal and arterial anastomosis. Biliary anastomosis is also required (not depicted).

Figure 4

Resection and reconstruction for hilar cholangiocarcinoma involving portal vein or hepatic artery. (A) Hilar cholangiocarcinoma involving the portal bifurcation. (B) Resection has been performed, with portal end-to-end anastomosis. (C) Hilar cholangiocarcinoma involving the right hepatic artery. (D) Resection and reconstruction with end-to-end anastomosis between the right hepatic artery stump and the proper hepatic artery. Reconstruction is also possible using a rotating arterial graft with any of the named arteries in the picture. Finally, reconstruction with a radial artery graft or a saphenous vein graft is also possible (not depicted).