Outcome of peripheral venous reconstructions during tumor resection

Peripheral venous reconstruction surgery may be necessary for appropriate oncologic resection; however, the operative approach and surgical outcomes are not well described. We report our experience with these complex reconstructions to identify best practice.

We retrospectively reviewed all adult patients who underwent peripheral vein reconstruction for tumor resection at Mayo Clinic, Rochester (2000-2015). Patients were classified into three subgroups by the location: iliac (IL), lower extremity (LE), and upper extremity (UE). Location, type of reconstruction, operative morbidity, as well as long-term patency, limb salvage, recurrence-free survival, and overall survival were recorded.

We identified 27 patients (11 women and 16 men), with a mean age of 55 ± 15 years, who underwent 28 operations involving vein reconstruction during tumor resection. One patient underwent two vascular reconstructions for recurrent malignant fibrous histiocytoma. Concomitant artery reconstruction was required in 16 (57%). The most commonly treated tumors were rectal cancer (n = 4) and liposarcoma (n = 3). Reconstructions were IL in 19 (68%), LE in 6 (21%), and UE in 3 (11%). Venous reconstructions consisted of 7 vein grafts (25%), 17 polytetrafluoroethylene prosthetic grafts (61%), 1 cryograft (4%), and 3 isolated patch angioplasties (11%). Two additional patch angioplasty procedures were performed in conjunction with vein grafts (1 polytetrafluoroethylene, 1 vein graft). There were no 30-day deaths. The mean hospital length of stay was 13.5 ± 10.5 days. Medications prescribed at discharge were aspirin in 15 patients (54%) and warfarin in 16 (57%). Surgical complications included renal failure (n = 5), respiratory complication (n = 3), surgical site infection (n = 5), graft infection (n = 3), and lymph leak (n = 5). The median follow-up was 4.4 years (range, 17 days-14.1 years). At 2 and 5 years, overall primary patency was 61% (95% confidence interval [CI], 41%-87%) and 61% (95% CI, 36%-87%), respectively, and overall freedom from graft thrombosis was 87% (95% CI, 69%-100%) and 87% (95% CI, 64%-100%), respectively. Graft thrombosis occurred in five patients (18%; 4 IL, 1 LE), of which four were prosthetic and one was a patch site. These were managed by thrombolysis (n = 1), thrombectomy (n = 1), and medical management (n = 3). Two patients (7.1%) underwent ipsilateral amputation at 3 and 314 days for compartment syndrome and metastatic pain. The overall survival rate was 74% (95% CI, 50%-87%) at 2 years and 56% (95% CI, 32%-75%) at 5 years. Death was predominantly from cancer-associated morbidities. Overall recurrence-free survival was 75% (95% CI, 57%-97%) at 2 years and 56% (95% CI, 31%-92%) at 5 years.

In selected patients fit for advanced tumor resection, reconstruction of IL and extremity veins is a safe and durable, with excellent limb salvage. Vein and prosthetic reconstructions both appear effective; however, infectious complications and graft thrombosis remain important complications when selecting a prosthetic conduit.