Inferior Vena Cava Reconstruction with Tubularized Bovine Pericardium.

A 32-year-old male presented with a large locally advanced sarcomatoid right renal cell carcinoma invading the duodenum and IVC. Due to persistent symptomatic gastrointestinal bleeding requiring repeat blood transfusion and the inability to utilize appropriate systemic chemotherapy, the patient was taken for palliative resection. En bloc pancreaticoduodenectomy, right nephrectomy and IVC resection were performed with reconstruction of the IVC with tubularized bovine pericardium. Widespread availability, ease and speed of tubularized graft creation, lack of morbidity to the patient and its inherent resistance to infection in contaminated fields make bovine pericardium an expedient reconstructive option in these challenging cases.

Major oncologic operations necessitating resection of the inferior vena cava (IVC) pose a serious reconstructive challenge. Interposition graft options include composite saphenous vein, femoral vein, and synthetic and cryopreserved vein or artery grafts for these reconstructions.1, 2 In the case of autologous grafts, graft harvest incurs additional morbidity to the patient and adds time to an often already protracted operation.

Bovine pericardium (BP) is used ubiquitously in vascular surgery, typically as a patch for arterial angioplasty, with excellent long-term results. BP can be used in contaminated fields with excellent results and is frequently used for patch repair of major venous defects. Here, the use of tubularized BP as venous conduit is described for an interposition graft of the IVC after en bloc tumor resection. Whereas tubularized pericardium was first described and patented in 1985 by Woodroof and Yang, it has seen limited clinical use in the literature. There are only a few reports of its use as a tubularized graft for major venous reconstructions.5, 6, 7

The purpose of this case report is to describe the use of tubularized BP as a conduit for reconstruction of the IVC. Particularly, this case highlights the safety and practicality of this method. Tubularized BP should be considered an expedient and low-morbidity option for major venous reconstruction requiring an interposition graft. With the consent of the patient's guardian, we present a case report describing the use of tubularized BP for interposition graft of the IVC after oncologic resection.

Case report

A 32-year-old man presented with scrotal swelling and right flank pain beginning approximately 3 months before presentation. Axial imaging demonstrated a large retroperitoneal mass circumferentially invading the IVC (Fig 1) with multiple pulmonary metastases. Fine-needle aspiration of the mass revealed a sarcomatoid renal cell carcinoma. Medical management for possible downstaging was attempted, but the patient developed significant gastrointestinal bleeding requiring multiple blood transfusions. After extensive discussions with the patient, family, and multiple surgical services, the patient was scheduled for right nephrectomy, pancreaticoduodenectomy, partial hepatectomy, and IVC resection with reconstruction.

Fig 1

Sagittal and coronal computed tomography images of the patient's tumor preoperatively. As illustrated here, there is circumferential involvement of the inferior vena cava (IVC) and abutment to the aorta.

He was taken to the operating room by the surgical oncology team for midline laparotomy and abdominal exploration, which revealed a massive tumor occupying the right hemiabdomen. The tumor was mobilized, a Whipple resection was performed, and the tumor was fully resected en bloc with all associated structures with the exception of the midportion of the IVC. At this point, the vascular surgery team completed the resection and reconstructed the IVC. The option of using longitudinally composited cryopreserved saphenous vein was entertained, but there was a significant size mismatch between the graft and the patient's IVC. Ultimately, a large graft of BP was tubularized over a 20-mL syringe with an endovascular tri-stapler. An end-to-end IVC to tubularized pericardium anastomosis was then performed with triangulated running 4-0 Prolene suture, leaving a small gap in the anastomosis for deairing later. The graft was then cut to length and an end-to-end graft to terminal IVC anastomosis was completed, again with triangulated 4-0 Prolene suture. Because of slight size mismatch between the graft and the terminal IVC, the right iliac vein was opened to accommodate the size mismatch and incorporated into the distal anastomosis. Once the distal anastomosis was completed, the patient was placed in Trendelenburg position, and flow was allowed to resume from the lower extremities to flush any air out of the newly reconstructed IVC. The proximal anastomosis was then completed with good hemostasis (Fig 2). At this point, the hepaticojejunostomy, pancreaticojejunostomy, and gastrojejunostomy were performed by the surgical oncology team.

Fig 2

An intraoperative photograph taken after reconstruction of the inferior vena cava (IVC) with tubularized bovine pericardium (BP).

Final pathologic evaluation revealed a 19-cm sarcomatoid renal cell carcinoma with extensive pericaval involvement. The patient's postoperative course was complicated by a culture-negative intra-abdominal fluid collection requiring percutaneous drainage. He was discharged home on postoperative day 12 on 325 mg of aspirin. He was doing well with a patent graft at 1 month (Fig 3) and with no leg swelling at 2 months postoperatively.

Fig 3

A coronal computed tomography scan of the reconstruction 30 days after the operation. As demonstrated here, the inferior vena cava (IVC) is patent, and the patient is doing well.

Ultimately, the patient suffered progression of his disease and expired 8 months later. Therefore, consent for this report was obtained from his wife.

Discussion

This case report describes the use of tubularized BP in the reconstruction of a large IVC defect in a young patient after oncologic resection. Tubularized BP has several potential advantages over other graft materials: it is readily available, is expeditiously fashioned to fit the patient's anatomy, has excellent long-term results in other vascular applications, is durable for arterial reconstructions even in the setting of gross infection, is relatively cheap, and presents no morbidity risk to the patient.3, 4 The cost of BP is a fraction of cryopreserved vessel, even with the additional cost of a vascular tri-stapler; an interposition graft can be fashioned quickly and more cost-effectively than any comparable options.

A small case series of 15 patients presented by Ciccone et al demonstrated excellent outcomes of superior vena cava reconstruction with tubularized BP in the chest with mean follow-up of 46 months. The same institution reported the use of tubularized BP for left femoral vein in the trauma setting with no stenosis, calcification, or degradation at 2-year follow-up. We found one other case report in the literature detailing the use of tubularized BP as an IVC interposition graft. All three of these reports describe a similar technique of BP tubularization over a syringe with either a vascular stapler or running Prolene suture.

In our case, a 32-year-old man with a large, locally advanced sarcomatoid right renal cell carcinoma underwent resection of the tumor, IVC, and infrarenal aorta with tubularized BP IVC reconstruction. In addition to use in oncologic reconstructions, tubularized BP potentially could be used to repair major vascular traumatic injuries where abdominal soilage demands a conduit resistant to infection and the patient's condition precludes a protracted operation. This may find particular application in military or other austere medical environments where tubularized BP's ease of storage and customizability make it an attractive option to more traditional graft materials.

Conclusions

Tubularized BP represents an excellent alternative for venous reconstruction with interposition graft in most situations encountered in vascular, oncologic, and trauma surgery. Clearly, further study of these applications is warranted.