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Newton DH, Chen SL, Wu K, Fraker D, Guzzo TJ, Roses RE, Foley PJ, Fairman RM, Jackson BM. Technique and Outcomes of Concomitant Aortic and Caval Resection and Reconstruction for Retroperitoneal Tumors. Ann Vasc Surg 2024; 98:251-257. [PMID: 37805168 DOI: 10.1016/j.avsg.2023.07.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 07/16/2023] [Accepted: 07/17/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND Major vascular involvement is often considered a contraindication to resection of malignant tumors, but in highly selected patients, it can be performed safely, with results that are highly dependent upon the tumor biology. Resection of both the aorta and inferior vena cava (IVC) is a rare undertaking, requiring both favorable tumor biology and a patient fit for a substantial surgical insult; nevertheless, it provides the possibility of a cure. METHODS Patients requiring resection and reconstruction of both the aorta and IVC from 2009 through 2019 at 2 university medical centers were included. Patient characteristics, operative technique, and outcomes were retrospectively collected. RESULTS We identified 9 patients, all with infrarenal reconstruction or repair of the aorta and IVC. All cases were performed with systemic heparinization and required simultaneous aortic and caval cross-clamping for tumor resection. No temporary venous or arterial bypass was used. Since arterial reperfusion with the IVC clamped was poorly tolerated in 1 patient, venous reconstruction was typically completed first. Primary repair was performed in 1 patient, while 8 required replacements. In 2 patients, aortic homograft was used for replacement of both the aortoiliac and iliocaval segments in contaminated surgical fields. In the remaining 6, Dacron was used for arterial replacement; either Dacron (n = 2) or polytetrafluoroethylene (n = 4) were used for venous replacement. Patients were discharged after a median stay of 8 days (range: 5-16). At median follow-up of 17 months (range 3-79 months), 2 patients with paraganglioma and 1 patient with Leydig cell carcinoma had cancer recurrences. Venous reconstructions occluded in 3 patients (38%), although symptoms were minimal. One patient presented acutely with a thrombosed iliac artery limb and bilateral common iliac artery anastomotic stenoses, treated successfully with thrombolysis and stenting. CONCLUSIONS Patients with tumor involving both the aorta and IVC can be successfully treated with resection and reconstruction. En bloc tumor resection, restoration of venous return before arterial reconstruction, and most importantly, careful patient selection, all contribute to positive outcomes in this otherwise incurable population.
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Affiliation(s)
- Daniel H Newton
- Department of Surgery, Virginia Commonwealth University, Richmond, VA.
| | - Samuel L Chen
- Department of Surgery, University of California, Irvine, Irvine, CA
| | - Kainuo Wu
- Department of Surgery, Virginia Commonwealth University, Richmond, VA
| | - Douglas Fraker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Thomas J Guzzo
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Robert E Roses
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Paul J Foley
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ronald M Fairman
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
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Zheng C, Xu G, Li W, Weng X, Yang H, Wang Z, Zhang S. Clinical outcomes after vascular reconstruction using synthetic grafts for limb salvage in patients with lower extremity sarcoma: a single-center retrospective experience. Front Oncol 2023; 13:1199556. [PMID: 37664022 PMCID: PMC10471183 DOI: 10.3389/fonc.2023.1199556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/31/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction Limb-salvage surgery has become the mainstream approaches for the treatment of sarcoma in the lower extremity. In cases where the sarcoma infiltrates the primary vessel, concurrent resection of the vessels and vascular reconstruction are required to ensure sufficient resection and preservation of limb function. The objective of this study is to assess the clinical outcomes of patients who underwent vascular reconstruction utilizing synthetic grafts for limb salvage, specifically in terms of postoperative complications and limb functional status. Methods Between September 2016 and October 2021, 15 consecutive patients who underwent 15 arterial and 3 venous reconstruction procedures were included in this retrospective study. Incidence of postoperative morbidity, graft patency, rate of limb salvage, and overall survival of patients were analyzed. Results The median follow-up was 12.5 months (range, 4.5-72.0). Graft thrombosis occurred in 5 patients (33.3%) and graft occlusion occurred in 3 patients (20.0%). The median overall survival was 28.0 months with the estimated 2-year and 5-year overall survival of 57.8% and 43.4% respectively. The 1-year and 2-year estimated patency rates of arterial reconstructions were 82.3% and 62.1%, respectively. None of the included patients with limb amputation were observed as a consequence of severe vascular complications, while two patients underwent amputation due to the repeat recurrence, resulting in a limb salvage rate of 86.7%. Conclusion Our results show that the combination of vascular reconstruction and oncologic resection is a feasible option for preserving limbs in cases of musculoskeletal sarcoma with vessel involvement in the lower extremity. When vascular reconstruction surgery is performed, synthetic substitutes can be effectively used with low perioperative morbidity and an acceptable rate of limb salvage.
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Affiliation(s)
- Chuanxi Zheng
- Department of Musculoskeletal Tumor Surgery, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Gang Xu
- Department of Musculoskeletal Tumor Surgery, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Wei Li
- Department of Musculoskeletal Tumor Surgery, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Xin Weng
- Department of Pathology, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Hongwei Yang
- Department of Vascular Surgery, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Zuhui Wang
- Department of Vascular Surgery, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Shiquan Zhang
- Department of Musculoskeletal Tumor Surgery, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
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Postoperative anticoagulation in vascular reconstructions associated with malignancies. Ann Vasc Surg 2022; 86:219-228. [DOI: 10.1016/j.avsg.2022.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 03/20/2022] [Accepted: 04/05/2022] [Indexed: 11/22/2022]
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Sheaffer WW, Davila VJ, Mendes BC, Meltzer AJ, Stone WM, Soh IY, Truty MJ, Nagorney DM, Money SR, Bower TC. Surgical and reconstructive outcomes in primary venous leiomyosarcoma. J Vasc Surg Venous Lymphat Disord 2021; 10:901-907. [PMID: 34352417 DOI: 10.1016/j.jvsv.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 07/22/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Primary venous leimyosarcomas (PVL) are rare and pose challenges in surgical management. This study evaluates the clinical outcomes and identifies predictors of survival in our surgical series of PVL. METHODS A retrospective review was performed of patients who had resection of PVL at three centers between 1990-2018. Patient demographics, comorbidities, intraoperative data, survival, and graft related outcomes were recorded. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression. RESULTS Seventy patients with a diagnosis of PVL were identified between 1990 and 2018. Fifty-four patients (77%) had PVL of the IVC and 16 (23%) had peripheral PVL. Mean follow up for the series was 55.0 months (range 1-217 months). Fifty one patients (96%) with IVC PVL needed caval reconstruction and 3 (4%) had resection only. There were no deaths within thirty days of surgery. Five patients (9%) required early re-intervention including one (2%) IVC stent. Sixteen peripheral PVL were identified. Eight patients (50%) had venous reconstructions performed and 8 (50%) had the vein resected without reconstruction. There were no deaths within thirty days. Five year survival was 57.5% for IVC PVL and 70.0% for peripheral PVL . Kaplan-Meier survival analysis for IVC and peripheral PVL revealed no difference in overall survival (p = 0.624) at 5 years. CONCLUSIONS PVL is a rare and aggressive disease even with surgical resection. We found no difference in survival between IVC and peripheral lesions suggesting aggressive management is warranted for PVL of any origin. Management of PVL requires a multidisciplinary approach to provide patients with the best long term outcomes.
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Affiliation(s)
- William W Sheaffer
- Mayo Clinic Arizona Division of Vascular Surgery, 5777 E Mayo Boulevard, Phoenix, AZ 85054.
| | - Victor J Davila
- Mayo Clinic Arizona Division of Vascular Surgery, 5777 E Mayo Boulevard, Phoenix, AZ 85054
| | - Bernardo C Mendes
- Mayo Clinic Rochester Division of Vascular Surgery, 200 First St. SW, Rochester, MN 55905
| | - Andrew J Meltzer
- Mayo Clinic Arizona Division of Vascular Surgery, 5777 E Mayo Boulevard, Phoenix, AZ 85054
| | - William M Stone
- Mayo Clinic Arizona Division of Vascular Surgery, 5777 E Mayo Boulevard, Phoenix, AZ 85054
| | - Ina Y Soh
- Mayo Clinic Arizona Division of Vascular Surgery, 5777 E Mayo Boulevard, Phoenix, AZ 85054
| | - Mark J Truty
- Mayo Clinic Rochester Department of General Surgery Subspecialties, 200 First St. SW, Rochester, MN 55905
| | - David M Nagorney
- Mayo Clinic Rochester Department of General Surgery Subspecialties, 200 First St. SW, Rochester, MN 55905
| | - Samuel R Money
- Mayo Clinic Arizona Division of Vascular Surgery, 5777 E Mayo Boulevard, Phoenix, AZ 85054
| | - Thomas C Bower
- Mayo Clinic Rochester Division of Vascular Surgery, 200 First St. SW, Rochester, MN 55905
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Nooromid MJ, Thomas MA, Yoon DY, Eskandari MK, Peabody TD, Rodriguez HE. Outcomes of Sarcoma Resections Requiring Vascular Surgical Assistance: A Single-Center Experience. Vasc Endovascular Surg 2020; 54:579-585. [PMID: 32744174 DOI: 10.1177/1538574420942334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective: To describe the types of intervention and determine patency and survival after arterial and venous reconstruction after surgical excision of sarcomas. Methods: Between November 2001 and July 2015, 42 patients with sarcomas and vascular involvement underwent surgical oncologic resection followed by arterial or venous reconstruction or preservation of the native vascular bundle. Univariate, multivariate, and Kaplan-Meier survival analyses were performed on abstracted data, which included demographics, risk factors, oncologic and vascular treatment modalities, postoperative complications, graft patency, and survival outcomes. Results: A total of 42 sarcomas required vascular assistance for oncologic removal. The majority of sarcomas were malignant fibrous histiocytoma (23.8%), and the most common anatomic location was the retroperitoneum (48%). A total of 12 revascularizations procedures were performed, including 5 arterial, 3 venous, and 2 concomitant arterial and venous. In 32 cases, a vascular surgeon was needed for vessel ligation, repair, or mobilization. The overall 2- and 5-year survival was 77.7% and 26.2%, respectively, with no significant survival difference between patients who underwent revascularization compared to those without revascularization. There was a 100% patency rate in all cases at last follow-up, regardless of the type of vascular reconstruction (median 18 months, range 1-29 months). On multivariate analysis, chronic obstructive pulmonary disease (COPD; P = .002) and positive surgical margins (P = .003) were associated with decreased survival. Most cases were performed in the last 5 years of the study (n = 27, 64.3%). Conclusions: Vascular reconstruction is feasible after surgical oncologic resection of sarcomas with good mid-term patency and limb preservation. Factors independently associated with mortality included COPD and positive surgical margins.
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Affiliation(s)
- Michael J Nooromid
- Division of Vascular Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael A Thomas
- Division of Vascular Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Dustin Y Yoon
- Division of Vascular Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark K Eskandari
- Division of Vascular Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Terrance D Peabody
- Department of Orthopedic Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Heron E Rodriguez
- Division of Vascular Surgery, 24560Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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