Technique and Outcomes of Concomitant Aortic and Caval Resection and Reconstruction for Retroperitoneal Tumors

ObjectivesMajor vascular involvement is often considered a contraindication to resection of malignant tumors, but in highly selected patients it can be performed safely, with results that are highly dependent upon the tumor biology. Resection of both the aorta and inferior vena cava (IVC) is a rare undertaking, requiring both favorable tumor biology and a patient fit for a substantial surgical insult; nevertheless, it provides the possibility of a cure.MethodsPatients requiring resection and reconstruction of both the aorta and IVC from 2009 through 2019 at two university medical centers were included. Patient characteristics, operative technique, and outcomes were retrospectively collected.ResultsWe identified nine patients, all with infrarenal reconstruction or repair of the aorta and IVC. All cases were performed with systemic heparinization and required simultaneous aortic and caval cross-clamping for tumor resection. No temporary venous or arterial bypass was used. Since arterial reperfusion with the IVC clamped was poorly tolerated in one patient, venous reconstruction was typically completed first. Primary repair was performed in one patient, while eight required replacements. In two patients, aortic homograft was used for replacement of both the aortoiliac and iliocaval segments in contaminated surgical fields. In the remaining six, Dacron was used for arterial replacement; either Dacron (n=2) or PTFE (n=4) were used for venous replacement. Patients were discharged after a median stay of 8 days (range: 5-16). At median follow up of 17 months (range 3-79 months), two patients with paraganglioma and one patient with Leydig cell carcinoma had cancer recurrences. Venous reconstructions occluded in three patients (38%), though symptoms were minimal. One patient presented acutely with a thrombosed iliac artery limb and bilateral common iliac artery anastomotic stenoses, treated successfully with thrombolysis and stenting.ConclusionsPatients with tumor involving both the aorta and IVC can be successfully treated with resection and reconstruction. En bloc tumor resection, restoration of venous return before arterial reconstruction, and most importantly, careful patient selection, all contribute to positive outcomes in this otherwise incurable population.