Aortocaval Resection and Reconstruction
Daniel H. Newton, MD, Anand Parikh, MD, MBA, Thomas J. Guzzo, MD, MPH, Jon Quatromoni, MD, MTR, Paul J. Foley, MD, Benjamin M. Jackson, MD, MS.
University of Pennsylvania, Philadelphia, PA, USA.
OBJECTIVES: In this video, we present a 36-year-old man with a history of testicular cancer who had chemotherapy-resistant metastases in the retroperitoneal lymph nodes involving both the aortic and inferior vena cava (IVC) bifurcations. En bloc aorta and IVC resection and reconstruction were offered.
METHODS: Upon exploration, the right ureter was found to be encased by tumor. Given the extent of surgery he otherwise required, the right kidney was not salvageable and was removed. After the patient was systemically heparinized, the aorta, IVC, and iliac vessels were all clamped. The tumor was resected en bloc with the right ureter, the aortic bifurcation, and the caval bifurcation. Prosthetic graft material was avoided because of the necessary division of the chronically obstructed ureter and its indwelling stent, which was colonized with bacteria. Instead, bifurcated abdominal aortic homografts were chosen and thawed. End-to-end reconstruction of the IVC and iliac veins was performed first to restore venous return and decrease resuscitation requirements. The aortic reconstruction was performed similarly. Finally, his liver lesions were ablated and his abdomen closed.
RESULTS: His postoperative course was complicated by the development of simple ascites requiring paracentesis, acute kidney injury, as well as C. difficile infection. However, he was recovered quickly and was discharged on postoperative day 16. Pathology identified no areas of viable cancer remaining in the tumor. At nine-month follow-up, he had neither leg swelling nor claudication, and his creatinine had stabilized. Cross sectional imaging showed his reconstructed vasculature to be patent with no evidence of recurrent disease. In addition, all tumor markers had returned to normal levels.
CONCLUSIONS: This well-selected patient with favorable tumor biology and fitness for extensive surgery achieved a good outcome after resection and reconstruction of his aorta and IVC.
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