End-to-End Renal Vein Anastomosis to Preserve Renal Venous Drainage Following Inferior Vena Cava...
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![Page 1: End-to-End Renal Vein Anastomosis to Preserve Renal Venous Drainage Following Inferior Vena Cava Radical Resection due to Leiomyosarcoma](https://reader031.fdocuments.net/reader031/viewer/2022020619/575097f01a28abbf6bd7d5f9/html5/thumbnails/1.jpg)
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: [email protected]
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
![Page 2: End-to-End Renal Vein Anastomosis to Preserve Renal Venous Drainage Following Inferior Vena Cava Radical Resection due to Leiomyosarcoma](https://reader031.fdocuments.net/reader031/viewer/2022020619/575097f01a28abbf6bd7d5f9/html5/thumbnails/2.jpg)
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.
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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
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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.
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