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Surgical Reconstruction of the Inferior Vena Cava and Iliofemoral Venous System


Historical Background

The first direct venous reconstruction using a saphenous vein graft for “postphlebitic stasis” was reported in 1954 by Warren and Thayer. In the late 1950s and 1960s venous reconstructions for benign occlusions using a cross-pubic venous bypass were introduced by Palma and Esperon in Uruguay and later popularized in the United States by Dale. Although Perl first described the entity of venous leiomyosarcoma in 1971, descriptions of surgical resection for primary and secondary malignancies of the iliocaval venous system have been largely limited to series reported since 1993.

Indications

Benign Ileofemoral Venous Occlusion

Surgical reconstruction of the inferior vena cava (IVC) and iliac veins for benign disease has been relegated to symptomatic patients with long-segment iliac vein or vena cava occlusions who either are not candidates for stenting or have failed attempts at percutaneous recanalization. The most common cause of benign occlusions is deep venous thrombosis because of May-Thurner syndrome, iatrogenic or blunt trauma, radiation, or external compression from retroperitoneal fibrosis, tumors, or large iliac or abdominal aortic inflammatory aneurysms. Congenital causes of venous obstruction include membranous obstruction of the suprahepatic IVC in either the absence or the presence of hepatic vein occlusion, as in Budd-Chiari syndrome, or hypoplasia of the iliofemoral veins, as observed in Klippel-Trenaunay syndrome.

Malignant IlIofemoral Venous Occlusion

Select patients with primary or secondary malignancies of the iliac veins or IVC may be offered operation ( Box 56-1 ). Candidates include patients without metastatic disease and good cardiopulmonary function who are able to perform daily activities with minimal limitation. Patients with renal cell cancer tumor thrombus extending to the right heart who have limited pulmonary metastases may also benefit from tumor thrombectomy and postoperative chemotherapy.

Box 56-1
TUMORS OF THE INFERIOR VENA CAVA

Primary

  • Leiomyosarcoma

Secondary

  • Retroperitoneal soft-tissue tumors

    • Liposarcoma

    • Leiomyosarcoma

    • Malignant fibrous histiocytoma

  • Hepatic tumors

    • Cholangiocarcinoma

    • Hepatocellular carcinoma

    • Metastatic (e.g., colorectal)

  • Pancreaticoduodenal cancers

  • Osteosarcoma, osteochondroma, or chordomas involving the lumbar spine or sacrum

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