Resection of malignant tumors invading the vena cava: Perioperative complications and long-term follow-up

Article Outline

• Abstract
• Patients and methods
• Results
• Discussion
• Conclusion
• Author contributions
• References
• Copyright

Objective

Invasion of the vena cava by malignant tumors is generally considered an absolute contraindication for surgery as a result of high surgical risk. Surgical treatment with resection of the vena cava may be beneficial for selected patients. This study was performed to evaluate our experiences with resection of the vena cava for malignant tumors, with a special focus on secondary tumors involving the inferior caval vein.

Methods

A total of 35 patients underwent extended resection of malignant tumors invading the vena cava. Prosthetic repair was performed in 13 patients by using a ringed polytetrafluoroethylene graft. Preoperative risk factors, mortality and morbidity, and long-term follow-up and graft patency rates were examined.

Results

The operative mortality rate was 6%. Minor complications occurred in 12 patients (34%). The graft patency rate was 85%, and there was no graft-related perioperative morbidity. The 1-, 3-, and 5-year survival rates were 76%, 32%, and 21%, respectively, with a median survival of 29 months. Incomplete resection and cardiopulmonary risk have a significant negative effect on survival.

Conclusions

Radical resection of the vena cava is a feasible procedure in highly selected patients, with low morbidity and mortality and acceptable survival rates, especially in patients with complete resection of the tumor.

Malignant tumors concerning the vena cava are either leiomyosarcomas arising directly from the vessel wall¹ or malignancies of other origins invading the vena cava by direct extension. Primary leiomyosarcomas of the vena cava are very rare, with only approximately 300 cases reported in the world literature since 1871. Until 1996, these tumors were collected in an international registry.², ³ Other tumors necessitating vena cava resection arise mostly from the retroperitoneal tissue, the kidney, the suprarenal gland, the liver, or the lung.⁴, ⁵, ⁶, ⁷, ⁸, ⁹, ¹⁰, ¹¹, ¹², ¹³, ¹⁴ Invasion of the vena cava by these malignant tumors is generally considered an absolute or at least relative contraindication for surgery because of the high surgical risk and the poor long-term survival.⁷, ⁸, ⁹ Conservative therapies comprising chemotherapy, radiotherapy, or both have been performed, with no clear effect on survival.⁷ Because complete resection has been reported to be one of the most important positive prognostic factors for long-term survival,² surgical treatment including complete or partial resection of the vena cava should be considered even in cases of advanced cancer. Whereas the perioperative complications of vena cava resection for leiomyosarcomas have been well described,³ the benefit after resection of secondary vena cava tumors remains to a certain extent unclear. To improve understanding of this heterogeneous problem, the aim of this retrospective study was to analyze our results in resection of the vena cava for malignant tumors in a series of 35 patients with special regard to perioperative complications and factors influencing long-term survival.

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Patients and methods 

Between January 1991 and October 2006, 35 en bloc resections including either caval wall excision or resection of a circumferential caval segment were performed to achieve extirpation of advanced malignant tumors. All operations were performed at the Department of Surgery, Klinikum Großhadern, University of Munich. Included were all patients who underwent an oncologic resection for a malignant tumor or metastasis of a malignant tumor with invasion of either the superior or inferior vena cava.

There were 17 men and 18 women with a median age of 56 years (range, 17-78 years). The indication for caval resection was sarcoma in 10 patients, hepatobiliary cancer in 6 patients, primary lung cancer in 4 patients, invasion by metastasis in 7 patients, and other malignant tumors in 8 cases. Neoadjuvant therapy included chemotherapy in 11 patients, radiotherapy in 2 patients, and chemoradiotherapy in 3 patients.

Detailed medical history was evaluated, including former malignant diseases, coronary heart disease, myocardial infarction, presence of stable or unstable angina, the New York Heart Association score (in case of heart insufficiency), arterial hypertension, cardiac dysrhythmia, hypercholesterinemia, diabetes, peripheral artery disease, cerebrovascular insufficiency, chronic obstructive pulmonary disease, emphysema, smoking, abuse of alcohol, present therapy with corticosteroids or immunosuppressive drugs, and liver or kidney diseases. When necessary, standardized preoperative pulmonary function evaluation including arterial blood gas analysis, spirometry, and quantitative lung perfusion scan was performed before surgery.¹⁵ Measurements of total lung capacity and functional residual capacity were an important part of the routine pulmonary function assessment. Body plethysmography (barometric and volumetric) was performed to measure thoracic gas volume. Cardiac risk was assessed by stress electrocardiography, myocardial scintigram, or coronary angiography in patients with a history of cardiovascular diseases or present cardiovascular symptoms.

Preoperative evaluation of local extension of the tumor included abdominal ultrasound examination, nuclear magnetic resonance imaging, computerized tomography scan, positron emission tomography, or a combination of both. Conventional venograms were not routinely performed before surgery. Involvement of the vena cava was recognized before surgery in all patients. Tumor infiltration was located at the superior vena cava in 9 patients, the hepatic and suprahepatic segment of the inferior vena cava (IVC) in 14 patients, the renal segment in 7 cases, and the infrarenal segment in 5 patients.

Segmental caval resection was performed in patients who had a primary malignancy of the vena cava or tumor invasion of more than 180° of the circumference of the vessel wall. In all patients having caval resection, the vena cava was routinely reconstructed. Only in patients having long-lasting tumor compression of the caval vein with sufficient collateral circulation did we abandon the option of reconstruction. Thirteen patients underwent reconstruction of the vena cava by using ringed, rifampicin-tinctured polytetrafluoroethylene grafts (W.L. Gore & Associates, Inc, Flagstaff, Ariz). In these patients, the vena cava was clamped with straight vascular clamps, and anastomoses were performed with monofilament sutures. Total venous occlusion did not result in relevant hemodynamic problems; thus, a veno-venous bypass was not necessary in any patients who underwent segmental resection of the vena cava. In 21 cases, partial excision of the vessel wall was performed, followed by direct suturing of the vessel in 17 patients or patch repair with Dacron patches (C.R. Bard Inc, Tempe, Ariz) in 4 cases. In one patient, the vena cava segment was resected without reconstruction as a result of good collateralization.

Before clamping, patients received 80 U/kg weight, usually 5000 IU, of unfractionated heparin. Patients treated by caval wedge resection and reconstruction by direct sutures received low-dose heparin until hospital discharge. Patients with caval reconstruction using alloplastic material initially received unfractionated heparin at a therapeutic level (partial thromboplastin time of 50 to 60 seconds) and were then switched to oral anticoagulation with phenprocoumon given for 6 months. Antiplatelet agents, pneumatic compression boots, and distal arteriovenous fistulas were never used.

Patients’ long-term follow-up was performed by either the authors or the Munich cancer registry, which receives permanent updated information from all general practitioners, hospitals, chemoradiotherapy units, and registration offices in Munich. Follow-up data were available in all patients for 4 to 180 months, with a median follow-up of 19 months. Because the entire cohort (Table I, Table II) is a very heterogeneous group of patients to discuss, we additionally focused our analyses on the outcome of patients with secondary tumors of the inferior vena cava. As shown in Table III, the effect of several tumor-specific factors on survival of this subgroup was analyzed.

Table I. Characteristics, treatment, perioperative complications, and follow-up

Patient no.	Age (y) and sex	Operation	Location	Resection status	Histology	Grade	Complications	Neoadjuvant therapy	Adjuvant therapy	Follow-up (mo)
1	69M	sCR+graft	IVC-R	0	Leiomyosarcoma	2	No		R	57
2	47F	sCR+graft	IVC-R	0	Pheochromocytoma	2	minor			179
3	28M	sCR+graft	IVC-I	0	Leiomyosarcoma	1	Minor			12
4	65M	sCR+graft	SVC	0	Leiomyosarcoma		Minor	C		34
5	62M	wCR+directsuture	SVC	0	NSCLC	3	No		R	4
6	17F	sCR+graft	SVC	0	Malignant thymoma		No	R		29
7	21M	wCR+directsuture	SVC	0	GCCmetastasis		No	C		32
8	67M	wCR+patch	IVC-R	1	Liposarcoma	3	Major			0
9	49M	sCR+graft	SVC	0	NSCLC		Minor			28
10	56F	wCR+patch	IVC-H	0	Leiomyosarcoma	3	No	C		19
11	40M	sCR+graft	IVC-I	0	GCC metastasis		No	C		21
12	62F	sCR+graft	IVC-R	0	Leiomyosarcoma	3	Minor			76
13	53M	wCR+directsuture	SVC	1	NSCLC	2	No		R	17
14	67M	wCR+directsuture	IVC-H	0	HCC	2	Minor			12
15	34F	wCR+directsuture	IVC-I	1	Pheochromocytoma		No		R	60
16	46F	wCR+directsuture	IVC-H	1	Colon cancer metastasis	3	No	C		15
17	64F	wCR+directsuture	IVC-H	0	HCC	3	Minor			18
18	56F	wCR+directsuture	SVC	2	NSCLC	3	No	R	C	21
19	53F	wCR+patch	IVC-H	1	Colon cancer metastasis	3	Minor	C		12
20	72F	wCR+directsuture	IVC-R	1	SR-CA	3	No			10
21	37F	wCR+directsuture	IVC-H	1	HCC	2	No	C		9
22	65M	wCR+directsuture	IVC-H	1	HCC	3	No			4
23	76F	wCR+directsuture	IVC-H	0	Colon cancer metastasis	3	No			29
24	65F	sCR+graft	IVC-H	1	Liposarcoma	2	No		C	53
25	69M	wCR+directsuture	IVC-H	0	Rectal cancer metastasis	3	No	C		39
26	43M	wCR+directsuture	IVC-R	0	SR-CA		No	C		29
27	48M	sCR+graft	SVC	1	CUP		Minor	RC		18
28	48M	wCR+directsuture	IVC-H	0	Rectal cancer metastasis	2	Minor	RC		39
29	62M	wCR+directsuture	IVC-R	1	NSCLC metastasis	3	No	RC		8
30	77F	wCR+directsuture	IVC-H	0	CCC	2	Minor		C	32
31	55F	sCR+graft	IVC-I	0	Liposarcoma	2	No			23
32	29F	sCR	SVC	0	Malignant thymoma		Minor		R	24
33	41F	sCR+graft	IVC-I	1	Leiomyosarcoma	2	No	C		19
34	62F	sCR+graft	IVC-H	1	Leiomyosarcoma	3	No	C		10
35	78M	wCR+patch	IVC-H	1	HCC	3	Major			0

sCR, Segmental/wedge resection of the vena cava; wCR, wedge resection of the vena cava; SVC, superior vena cava; IVC, inferior vena cava (H, hepatic segment; R, renal segment; I, infrarenal segment); NSCLC, non–small-cell lung cancer; HCC, hepatocellular carcinoma; GCC, germ cell carcinoma; SR-CA, cancer of the suprarenal gland; CCC, cholangiocarcinoma; C, chemotherapy; R, radiotherapy; RC, radiochemotherapy; CUP, cancer of unknown primacy.

Table II. Results of statistical analysis of the overall mortality of all patients (n = 35)

IVC, Inferior vena cava; SVC, superior vena cava; RR, relative risk; CI, confidence interval.

Factors with a significant effect on survival in univariate calculation were entered into multivariate Cox/proportional hazard regression analysis. Complete tumor resection and absence of cardiopulmonary diseases were independent predictors of longer survival.

Table III. Results of statistical analysis of mortality with a focus on secondary abdominal tumors involving the inferior vena cava (n = 20)

Factor	Univariate			Multivariate
	RR	95% CI	P value	RR	95% CI	P value
Sex (male vs female)	1.87	0.65-6.23	.222
Age (<60 vs >60 y)	0.42	0.13-1.18	.095
Complete resection (R0 vs R1/2)	0.29	0.08-0.77	.016⁎	0.06	0.01-0.63	.019⁎
Histology
Nonsarcoma vs sarcoma	0.49	0.12-2.63	.473
Noncolon vs colon	0.81	0.25-2.54	.705
Non-HCC vs HCC	0.24	0.02-0.49	.005⁎	0.14	0.02-0.93	.043⁎
Non § vs §	2.05	0.69-6.38	.191
Metastases (M0 vs M1)	0.59	0.19-1.69	.307
Cardiopulmonary diseases	2.70	1.04-12.5	.043⁎	1.96	0.32-12.5	.476
Neoadjuvant chemoradiotherapy	0.82	0.27-2.45	.710
Symptoms
No symptoms vs any symptom	0.51	0.17-1.45	.200
No pain vs pain	0.37	0.07-0.98	.046⁎	0.06	0.01-0.63	.019⁎
Grading (1/2 vs G3/4)	0.16	0.06-0.64	.007⁎	0.06	0.01-0.66	.022⁎

HCC, Hepatocellular carcinoma; §, malignancy other than HCC, colon cancer, or sarcoma; CI, confidence interval.

Leiomyosarcomas of the inferior caval vein and all malignancies of the superior caval vein were excluded. Incomplete tumor resection, histology of hepatic cell carcinoma, dedifferentiated grading, and pain due to tumor growth proved to be independent predictors of higher mortality.

Perioperative complications appearing from the time of operation until patient discharge from the hospital were registered in a database. General complications such as dysfunction of the circulatory system, myocardial infarction, dysrhythmia, pulmonary embolism, respiratory failure, renal failure, liver failure, central nervous dysfunction, sepsis, pneumonia, and postoperative bleeding were recorded. Specific complications such as thrombosis, graft infection, and severe edema leading to an operative revision were generally classified as major complications.

Analyses of categorical variables were performed by using the χ² test. Survival curves for each prognostic variable on overall survival were estimated according to the Kaplan-Meier method.¹⁶ The terminal event was death attributable to all causes. The statistical significance of the differences in survival distributions among the prognostic groups was evaluated by the log-rank test. The statistical difference was considered to be significant if the P value was <.05. Factors reaching the level of significance in univariate analysis were entered in a multivariate calculation model by using the Cox proportional hazard analysis.¹⁷ Data were analyzed by using SigmaPlot for Windows, version 9.0 (Systat Software Inc, San Jose, Calif) and MedCalc for Windows, version 9.2.0.1 (MedCalc Software, Mariakerke, Belgium).

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Results 

The leading symptoms patients presented with were symptoms of impaired venous backflow, edema of the limbs, or hepatic venous outflow obstruction due to tumor compression in seven cases, followed by tumor-related pain in six patients, palpable abdominal tumor masses in three patients, and others (abnormal fatigue, hoarseness, weight loss, and ileus) in five patients. In the remaining 14 patients no symptoms occurred until the tumor was identified either by routine or by follow-up examinations. Eight patients had a recorded history of cardiologic or circulatory diseases. Pulmonary disease, including chronic obstructive pulmonary disease, emphysema, or retention pneumonia, was present in five patients. Dysfunction of the thyroid gland was recorded in six cases. Two patients were smokers, and three patients were addicted to alcohol at the time of operation. Seven patients had a history of malignant diseases.

The 30-day, or in-hospital, mortality was 6% (due to two perioperative deaths). There were three intraoperative complications: one patient who had a myocardial infarction and two patients with major hemorrhage. Major and minor postoperative complications were seen in 2 (death) and 12 patients, respectively.

The rate of postoperative complications was not affected by coronary heart disease, a history of myocardial infarction, the presence of stable or unstable angina, arterial hypertension, cardiac dysrhythmia, hypercholesterinemia, diabetes, chronic obstructive pulmonary disease, emphysema, a history of smoking, or abuse of alcohol.

After surgery, 16 patients were admitted to the intensive care unit. The median intensive care unit and hospital stays were 2 days (range, 1-15 days) and 13 days (range, 6-40 days), respectively.

Twenty-six patients died from tumor-related causes during the follow-up period. The overall median survival, excepting the two patients who died shortly after surgery in the hospital, was 29 months, with survival rates for 1, 3, and 5 years of 76%, 32%, and 21%, respectively. There was one long-term survivor (180 months); the patient was female, with a malignant pheochromocytoma, histopathologic stage pT4N1M0, R0 resection, and no adjuvant therapy. The patient is alive without tumor recurrence or symptoms of venous occlusion.

As shown in Table II (entire cohort; n = 35), survival was significantly enhanced in patients with complete resection (R0 vs R1/2; P = .014) and patients without cardiopulmonary diseases (P = .005), but it was not affected by histology (sarcoma vs nonsarcoma, P = .25; presence vs absence of metastases, P = .69), age (younger than 60 years vs older than 60 years; P = .26), or adjuvant treatment regimens (radiotherapy with or without chemotherapy vs no adjuvant treatment, P = .30). Neither neoadjuvant treatment nor the presence of cardiopulmonary disease showed an influence on resection status (P = .76 and P = .26, respectively). Development of postoperative complications was not affected by neoadjuvant treatment (P = .34), age (P = .95), or history of cardiopulmonary disease (P = .72). Postoperative complications led significantly to a prolonged hospital stay (P = .004) but did not affect survival (any type of complication vs no complications, P = .30).

In the subgroup of patients (n = 20) having secondary tumors of the abdomen that were treated with caval resection, multivariate analysis showed that complete tumor resection, histology other than hepatic cell carcinoma, low grade, and the absence of tumor-related pain were independent factors for longer survival (Fig 1; Table III).

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• Fig 1. 

  Subgroup analyses of mortality with a focus on secondary abdominal tumors involving the inferior vena cava (n = 20; also see Table III). Curves A to D show Kaplan-Meier survival and log-rank analyses depending on completeness of resection (A), histology (B), tumor-related pain (C), and histopathologic grading (D; grading available in only 17 patients). Circles indicate living patients at the time of follow-up.

There were no statistically significant (P = .52) differences among the median survival times of malignancies of the superior vena cava (24 months), primary leiomyosarcomas of the IVC (34 months), or secondary malignancies of the IVC (18 months). In the last subgroup, the longest survival times were seen in patients with pheochromocytomas (60 and at least 180 months), low-grade liposarcoma (at least 53 months), and metastases of rectal cancer (two patients, each with 39 months). In these patients, either resection margins were tumor free or surgical treatment was followed by adjuvant chemotherapy. The median survival time of patients who underwent caval resection due to hepatic cell carcinoma was 9 months.

In patients with caval reconstruction (n = 13), there were two occlusions of the polytetrafluoroethylene graft 1 week and 18 months after the operation (85% patency rate). No graft infection was seen in our series.

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Discussion 

Advanced tumor growth with invasion of the superior or inferior vena cava is in general considered a contraindication for surgery⁹ and leads, when untreated, to death within 3 months after recognition.⁷ Patients with such advanced and uncommon tumors (Fig 2) invading the vena cava should usually be treated by surgeons experienced in oncologic and vascular surgery. Results and experiences should be discussed at interdisciplinary tumor board meetings, which issue recommendations for individual treatment. Patients reported in this article represent 35% of all caval operations performed at our department of surgery during the last 15 years, excluding patients with intracaval tumor growth arising from renal cell cancer, who are usually treated at the department of urology.

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• Fig 2. 

  Nuclear magnetic resonance image of a patient with a leiomyosarcoma arising from the retroperitoneal tissue. Both the liver and portal vein are displaced upward. The inferior vena cava (IVC) is compressed and infiltrated by tumor.

Retroperitoneal tumors with infiltration of the large vessels are frequently considered as unresectable. Patients who had primarily unresectable disease were treated by hyperthermia and chemotherapy according to the EORTC study protocol.¹⁸ After neoadjuvant therapy, patients were re-staged to evaluate possible surgical resection. On the basis of the experience in our institution with neoadjuvant chemotherapy in combination with regional hyperthermia in selected patients with high-risk soft tissue sarcomas, approximately half of these patients (30 of 58) responded to the combined treatment, and complete surgical resection was achievable in 8 of 30 surgically treated patients, including those with multivisceral resection or vena cava reconstruction.¹⁸

Aggressive resections for these tumors have been reported in only a few studies in the world literature.¹, ³, ⁶, ⁷, ⁸, ⁹, ¹², ¹³, ¹⁹, ²⁰, ²¹, ²² These series reported a 5-year survival between 20% and 31%, with a median survival ranging from 14 to 37 months. Fueglistaler et al⁸ reported 8 patients who underwent caval and aortic resection for cancer, with a median survival of 14 months. Hardwigsen et al⁹ described 14 patients with en bloc resection of abdominal malignancies including the inferior vena cava; the median survival was 37 months, with a 3-year survival of 56%. Castelli et al⁶ reported 11 patients with a 5-year survival of 20% and a median survival of 15 months. Yoshidome et al¹⁴ described 10 patients with circumferential resection of the inferior vena cava with a 5-year survival of 20% and a median survival of 20 months. The study with the most reported cases of caval resection for cancer of different origins is by Bower et al,⁷ who reported 29 patients with a 3-year survival rate of 75% and a median survival of 37 months. The series by Miyazaki et al¹¹ reported a 5-year survival of 22% in 14 patients and a median survival of 19 months; Sarkar et al¹³ reported on approximately 10 patients with median survival of 21 months. The 5-year survival rate in this series was 21%, with a median survival of 29 months, and is, as far as dissimilarity of cancer origin permits, comparable with the international results of the studies named previously. With respect to the overall survival rate reported in this article, it must be kept in mind that our cohort represents a highly selected group of patients with good performance status, high compliance with medical advice, and a strong request for radical treatment.

According to other series,², ³, ⁷, ²³ completeness of tumor resection has, as in our study, a significant positive effect on survival. In addition, the presence of cardiopulmonary diseases leads to a highly significant declining of long-term survival. The median survival time of healthy patients (without cardiopulmonary disease) is nearly three times longer than that of patients with cardiopulmonary compromise (11.8 vs 31.7 months). This is not due to a higher rate of radical resections in healthy patients or more frequent neoadjuvant/adjuvant treatment, because neither operative risk nor chemoradiotherapy has a significant effect on the completeness of resection. In our opinion, the improved survival in patients without cardiopulmonary diseases is due to a better ability of the individual to compensate for the side effects of tumor progression and additional neoadjuvant or adjuvant chemoradiotherapy.

As shown in Table III, subgroup analysis of patients who underwent resection of the IVC due to secondary malignancy revealed completeness of resection, histology other than hepatic cell carcinoma, low grading (grade 1 or 2), and the absence of tumor-related pain to be independent predictors of increased survival. Although the differences in survival among the subgroups of superior vena cava and primary and secondary malignancies of the IVC are statistically not significant, a trend may be at least assumed. Thus, we recommend operation of primary leiomyosarcomas of the vena cava as well as surgical treatment of secondary malignancies involving the IVC, especially low-grade pheochromocytoma, liposarcoma, and metastases of colorectal cancers. Because of the depressing median survival time and high morbidity and mortality rates (2/5 patients and 1/5 patients, respectively) in our patients with hepatic cell carcinoma, the indication for operative treatment in such patients should be extensively discussed individually.

In our series, there were two major complications: one patient with a history of arterial hypertension, atrial fibrillation, and diabetes mellitus developed cardiocirculatory decompensation with consecutive lethal multiorgan dysfunction due to a massive intraoperative myocardial infarction. The second major complication occurred in a patient with a fatal hypotensive shock related to postoperative bleeding. Other studies describe mortality and morbidity rates ranging from 0% to 15%⁷, ⁹, ¹⁹ and 9% to 45%,⁶, ⁷, ⁹, ¹¹, ¹⁴ respectively. Because there is no clear description of minor and major complications, direct comparison of the individual rates is not possible. The mortality and morbidity rates in this study were 6% and 34%, respectively, and are, in consideration of the problem discussed previously, internationally comparable.

It is reported by Yoshidome et al¹⁴ that reconstruction of the vena cava may be necessary only in patients with poor preoperative collateral circulation or those who have oliguria or unstable hemodynamics during surgery. In contrast, Illuminati et al²³ and others⁴, ⁹ recommend systematic reconstruction, including a mandatory reinsertion of the right renal vein, especially in patients undergoing gross retroperitoneal resection, anticipating disruption of pre-existing venous collaterals. As a principle, we tried to reconstruct the caval vein in every patient. Primary ligation was performed in one patient because of pre-existing and long-lasting tumor compression of the caval vein with sufficient collateral circulation.

For vena cava reconstruction, ring-reinforced polytetrafluoroethylene grafts were used, with the rationale that they would resist respiratory compression and graft collapse, which may promote thrombosis.⁴, ⁹, ²³ For patch repair of the vena cava, there are no adequate reports regarding whether polytetrafluoroethylene or Dacron grafting should be preferred. Whenever possible, we recommend vein patches, ie, from the great saphenous vein, for reconstruction.

Within the group of our patients, there were no cases with bowel involvement. In such cases, we would try to avoid alloplastic material. When reconstruction is absolutely necessary because of the location or absence of adequate venous collaterals, we would recommend the use of venous interpositions with doubled segments of the great saphenous vein or the femoral vein. Additionally, omental interposition between the big vessels and the bowel may be reasonable to avoid veno-enteric fistulas.

The patency rate of the grafts was 85% (11/13 patients) in this study. The first graft occluded immediately after operation. We suppose this was most likely due to pausing the systemic anticoagulation with heparin because of postoperative bleeding. Because the patient had neither symptoms of impaired venous backflow nor signs of pulmonary embolism on axial computed tomography, we decided that thrombectomy was not necessary. Almost 15 years after the operation, the patient is healthy, without any venous problems. Oral anticoagulation was not taken longer than 6 months. The second graft occlusion appeared 18 months after the operation, when the patient experienced severe (finally lethal) septic multiorgan dysfunction arising from pneumonia.

Use of anticoagulation drugs after caval reconstruction is inconstant in the available literature. Whereas some authors⁴, ¹¹, ¹³, ²² did not recommend routine application of long-term anticoagulation or antiplatelet agents, others⁷, ⁸ systemically suggest indefinite administration of oral anticoagulation. Because there is no evidence that lifelong medication with, eg, warfarin, having known side effects, is better with respect to patency rates, we recommend the postoperative use of oral anticoagulation agents limited to 6 months. The graft patency rate in this study is comparable to those reported in international studies,⁷, ⁷, ⁸, ¹¹, ¹³, ²³, ²³ which describe patency rates ranging from 63% to 100%.

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Conclusion 

Patients with advanced tumor growth and invasion of the superior or inferior vena cava should be considered for surgical treatment, even when tumor infiltration necessitates segmental resection of the vena cava followed by graft reconstruction. Survival is significantly better in patients with complete resection, and morbidity and mortality rates are acceptable. Especially in patients with assumed microscopic radical tumor resection, surgical treatment should be considered when preoperative histopathologic analysis reveals low-grade (grade 1 or 2) tumors, histology of primary leiomyosarcoma of the vena cava, pheochromocytoma, liposarcoma, or liver metastasis from colorectal cancer.

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Author contributions 

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References 

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