Inferior Vena Cava Reconstruction Using a Ringed Polytetrafluoroethylene Interposition Graft and Inferior Vena Cava Filter Placement Following Resection of Renal Cell Carcinoma With a Tumor Thrombus Directly Infiltrating the Inferior Vena Cava

Background Renal cell carcinoma (RCC) with tumor thrombus (TT) may extend into and, in rare cases, actually invade the inferior vena cava (IVC). Techniques of IVC reconstruction after removal of the RCC, TT, and infiltrated portion of the IVC have not been well documented. Methods A ringed polytetrafluoroethylene (PTFE) interposition graft along with an IVC filter placed within the graft (to prevent the development of pulmonary emboli) was used for patients who underwent surgical resection of RCC with TT extending into and directly invading the wall of the IVC. Demographic information about these patients along with their pathology reports, surgical procedures, and patency of the PTFE graft was obtained and described. Results Four male patients were identified as having RCC and TT with histologic invasion of the IVC requiring IVC dissection and replacement with a PTFE graft (as described above); their TT levels were II, IIIa, IIIc, and IV, respectively. Patient ages were 58, 65, 58, and 51 years and tumor sizes were 7.5, 7.5, 15.0, and 6.5 cm, respectively. These patients were followed for 36, 24, 32, and 48 months, respectively. At last follow-up, each patient had a patent IVC graft, and none of them developed any pulmonary emboli post-operatively. Conclusions Ringed PTFE interposition graft along with an IVC filter deployed inside the graft appears to be a safe vascular conduit for IVC reconstruction after surgical resection of RCC with TT directly invading the IVC.

Iatrogenic Inferior Vena Cava Resection Requiring Reconstruction

This is a report of an iatrogenic inferior vena cava (IVC) segmental resection and reconstruction utilizing bovine pericardium. A 48-year-old female patient presented for a planned right nephrectomy by the urology service secondary to xanthogranulomatous pyelonephritis. This was complicated by inadvertent resection of an 8 cm segment of the infrarenal IVC. Postoperatively, the patient did not tolerate IVC ligation due to severe lower extremity edema. She then underwent reconstruction with a bovine pericardium conduit as an interposition graft. The post-operative course was complicated by pulmonary embolism requiring percutaneous intervention. This report addresses the utility of bovine pericardium for IVC reconstruction in an infected field.

Leiomyosarcoma of the Inferior Vena Cava: Surgical Management and Clinical Results

Leiomyosarcoma of the inferior vena cava (IVC) is a rare lesion with less than 300 cases reported. Optimal management and long-term outcomes are not well described. From August 1984 to June 2004, eight patients with leiomyosarcoma of the IVC were treated at our institution. Clinical and pathologic data, surgical management, and outcomes were assessed. Eight cases were identified (4 males) with a median age of 52 (range 29–66). Presenting symptoms included abdominal pain (n = 5, 63%), lower extremity edema (n = 2, 25%), and palpable mass (n = 2, 25%). Tumor location was between the renal and iliac veins (low) (n = 4, 50%), between the hepatic and renal veins (middle) (n = 3, 38%), and above the hepatic veins with right atrial extension (high) (n = 1, 12%). Two patients with preoperative IVC occlusion were managed with tumor excision and IVC ligation. Three patients had primary repair of the IVC after tumor excision. A polytetrafluorothylene (PTFE) tube graft was used for IVC reconstruction in three cases. There was no postoperative mortality. Postoperative morbidity included deep venous thrombosis (DVT) (n = 1), lower extremity edema (mild n = 1; moderate n = 1), GI bleed (n = 1), and chronic renal insufficiency (n = 1). One patient is currently receiving adjuvant chemotherapy. Four patients received chemotherapy after recurrence, and one received palliative radiation therapy as well. Median survival to this point was 60 months with a median follow-up of 39 months. The 5-year overall survival and disease-free survival was 31 per cent for both (CI 0.1–1.0). The type of IVC reconstruction had no effect on survival ( P = 0.22). Recurrence was discovered in four patients (50%) at a median time of 14 months. Resection of leiomyosarcoma of the IVC should be attempted whenever feasible. The management of the IVC can be managed with primary repair, ligation, or prosthetic graft. Long-term survival is possible if complete resection can be achieved.

Complete resection of leiomyosarcoma of the suprarenal inferior vena cava without caval replacement

Objective: To successfully treat leiomyosarcoma of the suprarenal segment of the inferior vena cava (IVC) by section without caval replacement. Methods: Multiple occlusive clamps were used to maintain haemodynamic stability. Measurement of the stump pressure of the distal IVC and both renal veins was employed to evaluate venous congestion. Results: Use of these techniques allowed avoidance of suprarenal IVC reconstruction in our patient, who had well-developed collateral veins. Conclusions: Our experience indicates that reconstruction is not always mandatory.