Concomitant arterial and venous reconstruction with resection of lower extremity sarcomas

Limb salvage can now be achieved in many cases of lower extremity sarcoma. Obtaining disease-free margins may require resection of adjacent vascular structures. We present our experience with a consecutive series of patients undergoing resection of lower extremity sarcomas en block with the artery and vein, focusing on the mid- and long-term outcomes of their vascular reconstruction.

Records were reviewed retrospectively for patient age, tumor location and type, procedure, and early and late outcomes. Between 1991 and 2004, 10 children (mean age 12 years, range 6-18 years) and 9 adults (mean age 48 years, range 24-73 years) underwent wide resection of lower extremity sarcomas to include the involved arterial and venous segments. All children had bone sarcomas, and because of their skeletal immaturity, they were treated with rotationplasty--a type of intercalary amputation that removes the distal thigh, knee, and proximal tibia while preserving the distal leg and foot. In rotationplasty, the distal residual limb is preserved, rotated 180 degrees, and attached to the thigh, positioning the ankle at the level of the former knee joint. In these cases, the residual vessels were reconstructed by primary anastomosis. All of the adults except one had soft tissue sarcomas; the resected vessels were reconstructed with contralateral saphenous vein. In all cases, the operative approach included shunting of artery and vein during tumor removal and orthopedic reconstruction.

The mean follow-up was 5.7 years. Three patients died of metastatic disease, and one died from a postoperative pulmonary embolism. No patient had local recurrence. Two patients ultimately required above-knee amputation: one child for tissue loss secondary to reperfusion injury, and one adult because of graft thrombosis secondary to progression of peripheral arterial disease. Two patients required early re-exploration for perioperative graft thrombosis. Both required replacement of saphenous vein conduits with polytetrafluoroethylene (PTFE) prosthetic graft; one of the PTFE grafts became infected.

Limb salvage can be achieved in the majority of patients who have lower extremity sarcomas even when en bloc resection includes the artery and vein. Intraoperative shunting can limit ischemia and is especially useful when immediate vascular repair is delayed by orthopedic reconstruction. The long-term patency rate of the reconstructed vessels is high. Saphenous vein is the preferred conduit when it is of adequate caliber.