Outcomes of oncovascular reconstruction in patients with extremity sarcomas

Although surgical resection is the primary treatment for patients with extremity sarcomas owing to chemoradiation resistance, the feasibility of these procedures is challenged by the involvement of critical vasculature. Given the small scale of prior studies, we aimed to describe long-term outcomes of these joint procedures to guide future management decisions.

We conducted a retrospective chart review of patients with upper and lower extremity sarcomas who underwent surgical resection with vascular reconstruction at a tertiary referral center between 2001 and 2024. Primary end points included overall vascular patency, long-term mortality, and intervention-free survival. Secondary outcomes included 30-day mortality, complications, and reinterventions. Descriptive statistics were used to calculate the frequency, median, mean, standard deviation, and interquartile range. Survival and vascular reintervention-free survival probabilities were calculated using Kaplan-Meier estimates.

Fifty vascular interventions (30 arterial/20 venous; 86% lower extremity) were performed during tumor resection in 25 patients (mean age, 44.4 ± 21.0 years; 52% female). One-half (48%) were for recurrent disease, 64% had prior chemoradiation, and 30% had stage 4 disease. The most common pathologies were synovial sarcoma (16%) and chondrosarcoma (16%). Despite a Clavien-Dindo grade II+ complication rate of 76%, there were no mortalities within 30 days. However, three patients experienced graft thrombosis within 30 days, requiring reintervention to regain patency; one of those patients underwent major amputation owing to ischemia severity. The median overall survival was 5.3 years with 20% experiencing local recurrence, 16% distant metastases, and 28% with both. During the follow-up period (median, 805 days; interquartile range, 325-1918 days), there were no further amputations or vascular graft infections. Vascular reintervention-free survival at 1 year was 90.5%. Five patients (20%) underwent vascular reintervention beyond 30 days: two required vascular reconstruction for local recurrence and three to achieve primary-assisted patency. Dacron/polytetrafluorethylene conduits of the iliac, femoral, and popliteal arteries had a 100% patency during follow-up, as did femoral vein reconstruction with autologous conduits. Femoral vein reconstruction with cryopreserved conduits had a 1-year primary-assisted patency of 66.7%. Femoral artery reconstruction with great saphenous vein/femoral vein demonstrated 85.7% assisted primary patency at 1 year and 75% at 4 years.

This study highlights promising outcomes of vascular reconstruction in patients with extremity sarcomas. Overall, extremity arterial reconstructions after tumor resection had excellent patency and durability resulting in high rates of limb preservation. Despite the complexity and high rates of postoperative complications, the low failure-to-rescue rate reflects the importance of multidisciplinary teamwork in caring for these high-acuity patients.