1DepartmeMedicine, S~ao

2Departmedies de l’AppaFrance.

3University

CorrespondGastroenteroloRua Dr. En�eaCEP 05403-90

Ann Vasc Surhttp://dx.doi.or� 2014 Elsevi

Manuscript re

2013; publishe

1048

End-to-End Renal Vein Anastomosis toPreserve Renal Venous Drainage FollowingInferior Vena Cava Radical Resection due toLeiomyosarcoma

Raphael L.C. Araujo,1 S�ebastien Gaujoux,2,3 Luiz Augusto Carneiro D’Albuquerque,1

Alain Sauvanet,2,3 Jacques Belghiti,2,3 and Wellington Andraus,1 S~ao Paulo, Brazil; Clichy

and Paris, France

Background: When retrohepatic inferior vena cava (IVC) resection is required, for example, forIVC leiomyosarcoma, reconstruction is recommended. This is particularly true when the renalvein confluence is resected to preserve venous outflow, including that of the right kidney.Methods: Two patients with retrohepatic IVC leiomyosarcoma involving renal vein confluencesunderwent hepatectomy with en bloc IVC resection below the renal vein confluence. IVC recon-struction was not performed, but end-to-end renal vein anastomoses were, including a prostheticgraft in 1 case.Results: The postoperative course was uneventful with respect to kidney function, anastomosispatency assessed using Doppler ultrasonography and computerized tomography, and transientlower limb edema.Discussion: End-to-end renal vein anastomosis after a retrohepatic IVC resection including therenal vein confluence should be considered as an alternative option for preserving right kidneydrainage through the left renal vein when IVC reconstruction is not possible or should beavoided.

INTRODUCTION

Inferior vena cava leiomyosarcoma (IVCL) is a rare

retroperitoneal vascular tumor that has primarily

nt of Gastroenterology, University of Sao Paulo School ofPaulo, Brazil.

nt of Hepato-Pancreato-Biliary Surgery, Pole des Mala-reil Digestif (PMAD), AP-HP, Beaujon Hospital, Clichy,

Paris 7 Denis Diderot, Paris, France.

ence to: Wellington Andraus, MD, PhD, Department ofgy, University of Sao Paulo School of Medicine, Brazil,s de Carvalho Aguiar, 255-9� andar-sala 9113/9114,0, S~ao PaulodSP, Brazil; E-mail: wellington@usp.br

g 2014; 28: 1048–1051g/10.1016/j.avsg.2013.08.027er Inc. All rights reserved.

ceived: May 12, 2013; manuscript accepted: August 31,

d online: December 16, 2013.

been described in clinical case reports. Complete

surgical resection is the best therapeutic choice but

is technically challenging given the need to preserve

venous drainage. To date, no clear consensus for

reconstruction exists, but when the renal conflu-

ence is resected, vein reconstruction has been advo-

cated to avoid acute renal failure.1,2

In cases of retrohepatic IVCL, IVC reconstruction

is typically recommended and can be combined

with reimplantation of both renal veins whenever

possible, avoiding acute renal failure. This is partic-

ularly true for the right kidney, which has a short

vein without collaterals, precluding renal function

preservation in cases of simple ligation. Reconstruc-

tion of the IVC is not always required, because

gradual occlusion of the IVC allows the develop-

ment of venous collaterals.2 For retrohepatic IVCL,

IVC reconstruction can be omitted in cases with

complete and chronic IVC obstruction with impor-

tant collaterals. Renorenal anastomosis has been

Fig. 1. Preoperative computed tomography scan images.

(A and B) Case 1: a retroperitoneal tumor arising from a

thrombosed inferior vena cava and invading the liver

anteriorly. (C) Case 2: tumor from a thrombosed vena

cava invading the pancreatic head and the liver anteriorly

and (D) extending to the level of the renal vein confluence.

Vol. 28, No. 4, May 2014 Renal vein anastomosis and IVC 1049

described as an alternative to renal vein reim-

plantation into the reconstructed IVC in a case of

suprarenal leiomyosarcoma.3 However, renorenal

anastomosis has not been appliedwithout reimplan-

tation in cases of IVC removal. Here we describe 2

patients who underwent IVC resection without

reconstruction and end-to-end renal vein anasto-

mosis to preserve right renal venous outflow

through left renal vein collaterals.

METHODS

Two patients with level II IVCL (i.e., involving the

retrohepatic IVC from the renal veins to the hepatic

veins) were included. Both cases presented with

complete chronic IVC obstruction with collateral

development. Intraoperative Doppler assessments

were performed for both cases before and after IVC

resection including the renal vein confluence. No

IVC prosthetic replacement was performed after

the IVC resection, but to preserve the right kidney

venous drainage through the left kidney venous

drainage, end-to-end renal vein anastomoses were

performed, and the patency was again verified by

intraoperative Doppler.

Case 1

A 43-year-old woman without a significant past

medical history presented with abdominal pain.

The preoperative work-up showed a 12-cm

biopsy-proven IVCL involving segment I and the

retrohepatic IVC from the renal vein confluence

to the hepatic vein confluence. The IVC was

thrombosed below the end of the renal vein, with

the development of collateral circulation (Fig. 1).

A right hepatectomy including segment I and en

bloc retrohepatic IVC resection was performed.

The vena cava resection started just below the

hepatic vein confluence and ended 2 cm below

the renal vein confluence. No prosthetic replace-

ment was performed, but end-to-end renal vein

anastomosis resulted in an adequate renal flow

from the right to left kidney as observed using

intraoperative Doppler ultrasonography. The post-

operative course was marked only by transient

ascites without renal failure and moderate bilateral

leg edema, and the patient received preventive

anticoagulation therapy for 6 months. A pathologic

examination revealed a grade 2 moderately differ-

entiated leiomyosarcoma with negative margins.

Three years after the initial procedure, during

hospitalization for diagnostic hysteroscopy, acute

bilateral iliac and femoral vein thrombosis occurred

that required long-term anticoagulation therapy

and compression stocking. No postthrombotic

syndrome was observed over the long term. After

57 months of follow-up, the patient was alive

with preserved renal function and without tumor

recurrence.

Fig. 2. A graphic illustration summarizing the surgical

procedures performed for both cases. (A) Case 1 perform-

ing direct end-to-end renal vein anastomosis and (B)

Case 2 using the polytetrafluoroethylene prosthesis to

allow the renal vein anastomosis.

1050 Araujo et al. Annals of Vascular Surgery

Case 2

A 40-year-old woman presented with upper

abdominal and back pain in addition to obstructive

jaundice (total bilirubin of 205 mmol/L). Preoperative

computed tomography identified a retroperitoneal

heterogeneous mass (8.9 � 5.6 � 7.9 cm) arising

froma thrombosed IVC thatwas invading the pancre-

atic head. A preoperative biliary stent was not used.

The patient underwent segment I hepatectomy, pan-

creaticoduodenectomy, and IVC resection associated

with bilateral partial renal vein resections. The IVC

was resected from 1 cm below the hepatic vein

confluence and extended to 4 cm below the renal

vein confluence with IVC ligation. No IVC recon-

struction was performed because of chronic IVC

obstruction and a concomitant complex surgical pro-

cedure. An end-to-end renal vein anastomosis was

performedusing a10-mmdiameter expandedpolyte-

trafluoroethylene graft (Fig. 2). Transient renal

dysfunction and mild leg edema were observed in

the postoperative course. The patient recovered

normal renal function and was discharged on oral

anticoagulant therapy. The pathology results showed

IVCLwithnegativemargins.At2months,Dopplerul-

trasonography confirmed adequate right-to-left flow

through the renal vein anastomosis. The patient died

6months later from unexplained hemorrhagic shock

while still taking oral anticoagulation medication.

DISCUSSION

We herein describe an alternative technique to IVC

graft replacement following IVC resection including

the renal vein confluence. In the setting of chronic

IVC obstruction, 2 patients who underwent IVC

resection for IVCL underwent end-to-end renal

vein anastomosis. This technique allowed easy and

complete restoration of the right venous flow to

the left venous flow and preserved the function of

both kidneys.

IVCL is a rare retroperitoneal tumor, and its

management is primarily based on case reports and

small series.1,4e6 IVCLs represent a clear indication

for IVC resection, especially for level II lesions,2 but

IVC reconstruction is not always possible. The poten-

tial benefits of IVC replacement are the prevention

of leg edema and preservation of venous kidney

drainage. However, IVC reconstruction with graft

could represent increased risk of complications

such as infection, thrombosis, and pulmonary embo-

lism arising from deep vein thrombosis.6 In general,

the IVC reconstruction should be avoided in cases

of simultaneous deep lower limb or iliac venous

thrombosis or septic procedures.7,8 In a series of 21

resected IVCLs, 11 patients underwent IVC resection

without cava reconstruction1 without significant

postoperative morbidity; minimal lower extremity

edema was reported in 2 patients.

The main concerns with IVC resection without

reconstruction are based on disruption of collaterals

ligated with an oncologic approach, increasing

the risk of lower limb edema.9 Nevertheless, the

situation is more complex when the renal vein

confluence requires resection. Indeed, when recon-

struction is not performed, the right kidney needs to

be sacrificed because of its lack of collateral circula-

tion to the superior vena cava system.2 In this

Vol. 28, No. 4, May 2014 Renal vein anastomosis and IVC 1051

setting, it has been shown that prosthetic replace-

ment of the infrahepatic IVCwith renal vein anasto-

moses to the graft after en bloc tumor resection can

be safely performed.7,10e12 However, reconstruc-

tion of the infrarenal IVC is not always mandatory

because the lower limb flow could be supported by

retroperitoneal and abdominal wall collateral circu-

lation that develops as a result of chronic IVC

obstruction.1 Additionally, graft replacement carries

a risk for potentially severe complications, such as

graft-enteric fistula, graft infection, and pulmonary

embolism.7

From a technical point of view, end-to-end renal

vein anastomosis is simple and fast to perform,

requiring only minimal clamping. Both the right

renal artery and the vein can be clamped to mini-

mize congestion of the right kidney; this maneuver

it is not necessary for the left kidney because

collateral pathways are already patent. It is impor-

tant to note that right kidney mobilization may be

required because of the short length of the right

renal vein, and a prosthetic graft may be required

if the distance between the 2 veins remains too

long. Left kidney mobilization should be avoided

to preserve its collateral pathways. Nonreplacement

of the IVC is best tolerated in patients with pre-

operative IVC thrombosis associated with the devel-

opment of left renal and inferior limb collaterals.

Our experience shows that these collaterals support

left kidney outflow evenwhen the right kidney flow

is added, as shown using intraoperative and postop-

erative Doppler assessment. After this procedure,

the need for postoperative and long-term anti-

coagulation therapy should be determined on a

case-by-case basis according to the individual’s

hemorrhage/thrombotic risk balance.

Although there is no clear evidence for an

increased risk of thromboembolic complications

after prosthetic replacement, we believe, as others

do, that cavoplasty in potentially low flow venous

segments could dispose to thrombosis.9,13,14 Thus,

in case 2, warfarin therapy was introduced after

resumption of oral food intake.

In conclusion, this operative technique de-

scribing end-to-end renal vein anastomosis without

IVC reconstruction appears to be an interesting

alternative when IVC reconstruction is not feasible

because of the presence of collateral veins, as occurs

in cases of chronic IVC obstruction. This allows pres-

ervation of right renal venous drainage through the

left renal vein and function after IVC resection

including the renal confluence.

SUPPLEMENTARY DATA

Supplementary data related to this article can

be found at http://dx.doi.org/10.1016/j.avsg.2013.

08.027.

REFERENCES

1. Hollenbeck ST, Grobmyer SR, Kent KC, Brennan MF. Surgi-

cal treatment and outcomes of patients with primary inferior

vena cava leiomyosarcoma. J Am Coll Surg 2003;197:

575e9.

2. WangQ, Jiang J,WangC, et al. Leiomyosarcomaof the inferior

vena cava level II involvement: curative resection and recon-

struction of renal veins. World J Surg Oncol 2012;10:120.

3. Carde P, Elias D, Breil P, et al. Leiomyosarcoma of the supra-

renal inferior vena cava. Chemotherapy and renorenal

venous surgical anastomosis for the preservation of the right

kidney [in French]. Presse Med 1983;12:242.

4. Laskin WB, Fanburg-Smith JC, Burke AP, et al. Leiomyosar-

coma of the inferior vena cava: clinicopathologic study of 40

cases. Am J Surg Pathol 2010;34:873e81.

5. Mingoli A, Cavallaro A, Sapienza P, et al. International

registry of inferior vena cava leiomyosarcoma: analysis of a

world series on 218 patients. Anticancer Res 1996;16:

3201e5.

6. Chan AC, Chan SC, Yiu MK, et al. Technical considerations

for radical resection of a primary leiomyosarcoma of the

vena cava. HPB (Oxford) 2012;14:565e8.

7. Illuminati G, Calio FG, D’Urso A, et al. Prosthetic replace-

ment of the infrahepatic inferior vena cava for leiomyosar-

coma. Arch Surg 2006;141:919e24. discussion 924.

8. Sarkar R, Eilber FR, Gelabert HA, Quinones-Baldrich WJ.

Prosthetic replacement of the inferior vena cava for malig-

nancy. J Vasc Surg 1998;28:75e81. discussion 82e83.9. Alexander A, Rehders A, Raffel A, et al. Leiomyosarcoma of

the inferior vena cava: radical surgery and vascular recon-

struction. World J Surg Oncol 2009;7:56.

10. Miller CM, Schwartz ME, Nishizaki T. Combined hepatic

and vena caval resection with autogenous caval graft

replacement. Arch Surg 1991;126:106e8.

11. Huguet C, Ferri M, Gavelli A. Resection of the suprarenal

inferior vena cava. The role of prosthetic replacement.

Arch Surg 1995;130:793e7.

12. Sarmiento JM, Bower TC, Cherry KJ, et al. Is combined

partial hepatectomy with segmental resection of inferior

vena cava justified for malignancy? Arch Surg 2003;138:

624e30. discussion 630e31.

13. Bower TC, Nagorney DM, Cherry KJ Jr, et al. Replacement

of the inferior vena cava for malignancy: an update. J Vasc

Surg 2000;31:270e81.

14. Fueglistaler P, Gurke L, Stierli P, et al. Major vascular resec-

tion and prosthetic replacement for retroperitoneal tumors.

World J Surg 2006;30:1344e9.