July 1, 2007
Tumors at the Aortoiliac/Inferior Vena Cava Bifurcation: Preoperative, Anesthetic, and Intraoperative Considerations
By Ouellette, James R Cossman, David V; Sibert, Karen S; McAndrew, Nicholas P; Silberman, Allan W
Primary and recurrent retroperitoneal tumors can involve the aortoiliac vasculature. They are often considered inoperable or incurable because of the locally advanced nature of the disease or the technical aspects involved in safely resecting the lesion. Safe resection of these lesions requires experience and extensive preoperative planning for success. A retrospective database review of 76 patients with retroperitoneal tumors identified tumors involving major vascular structures in the abdomen and pelvis undergoing resection of tumor en bloc with the aortoiliac vasculature. Preoperative planning and intraoperative technical maneuvers are reviewed. Patients were followed until time of this report. Four patients with retroperitoneal tumors involving the aortoiliac vessels underwent surgery: two patients with sarcoma (one primary and one recurrent), one with metastatic renal cell carcinoma, and one with a paraganglioma. All patients had resection of the aorta and vena cava or the iliac artery and vein. Arterial reconstruction (anatomic or extra-anatomic) was performed in all cases. The patient with renal cell carcinoma also required venous reconstruction to support a renal autotransplant. Veno-venous bypass was required in one patient. Local control was achieved in 3 of 4 cases. Surgery for retroperitoneal tumors involving major vascular structures is technically feasible with appropriate planning and technique. Multiple disciplines are required, including general surgical oncology, vascular surgery, and possibly, cardiothoracic surgery. TUMORS AT THE aortoiliac bifurcation (AIB) with or without involvement of the inferior vena cava (IVC) and iliac veins are often considered inoperable or incurable because of the locally advanced nature of the disease or the technical aspects involved in safely resecting the lesion. The usefulness of other treatment modalities, like chemotherapy or radiation, to effectively treat these patients is variable, depending on the tumor histology; however, it is usually limited without concomitant surgical resection.1-2 Because of improved operative techniques, anesthetic care, and intensive care unit support over the last several years, the morbidity and mortality from major oncologic re sections has significantly decreased.3 Successful tumor resections involving major vascular structures have also been reported with acceptable morbidity.1, 4-6
The approach to tumors with vascular invasion or encasement must be well planned and multidisciplinary.7 The possibility of major blood loss must be anticipated and prepared for. In addition to a general surgical oncologist, a vascular surgeon is often required because of the need for vascular resection and reconstruction. Veno- venous bypass techniques and even cardiopulmonary bypass with profound hypothermia with total circulatory arrest are occasionally needed to safely resect these tumors.8 Thus, a cardiac surgeon and a perfusionist may be necessary in certain situations. Failure to plan for these contingencies may lead to poor outcomes.
From a database of patients undergoing surgery for retroperitoneal tumors from 1981 to 2005, we identified four patients with lesions at the AIB and IVC bifurcation (IVCB) that demonstrate the importance of a well-coordinated, multidisciplinary approach to these difficult problems. Two of our patients had primary tumors and two had recurrent/metastatic tumors.
A 49-year-old white man complained of vague abdominal pain. A magnetic resonance imaging (MRI) scan revealed a 3-cm, partially exophytic, right upper pole renal mass extending through at least 50 per cent of the cortex, and a 14 x 11-cm pelvic mass (Fig. 1) located at the AIB/IVCB. There were multiple collateral vessels surrounding the pelvic lesion; the right common iliac artery was partially enveloped and the left common iliac artery was completely enveloped by the lesion. A CT-directed needle biopsy of the pelvic mass was consistent with a paraganglioma. Biochemical testing was performed and found to be normal. The patient underwent a right radical nephrectomy through a right flank incision. The pathology revealed a chromophobe-type renal cell carcinoma. Additionally, the pelvic lesion was evaluated for possible resection through a lower midline incision. The tumor started just above the AIB, completely surrounded the iliac vasculature bilaterally, and extended deep into the pelvis with the rectosigmoid mesentery draped over the mass. Multiple vascular lakes were noted within the tumor and large collateral vessels surrounded the tumor. In addition, the residual distal right ureter went through the mass, and, of concern, the left ureter was adherent to the lateral aspect of the mass. For several reasons, we elected to abort resection of the tumor at this time: first, it was clear that a colon resection and an aortic resection with grafting would be required with its attendant risk of infection; second, the remaining left kidney might be in jeopardy with a radical resection that included the left ureter; third, temporary cross clamping of the infra-renal aorta caused a considerable decrease in the size of the tumor. Thus, pretreatment of the tumor with angiographic embolization might shrink the tumor and make a subsequent attempt at resection safer. Moreover, paragangliomas in other anatomic positions have been treated with radiation and/or embolization with subsequent shrinkage.9, 10 Thus, our plan was to treat this patient with radiation followed by angiographie embolization in an attempt to shrink the tumor and deprive it of its blood supply before an attempt at resection.
FIG. 1. MRI showing pelvic paraganglioma involving aortoiliac vasculature.
After a course of pelvic radiation (4500 rads), a follow-up MRI scan showed a slight decrease (10 x 9 cm) in the size of the mass. Five weeks after completion of radiation, the patient underwent angiographie embolization of multiple feeding vessels (Figs. 2A and 2B). The next day, the patient was taken electively to the operating room and was found to have ischemia of his sigmoid colon necessitating colectomy. Despite the radiation and embolization, there was little change in the size of the tumor and its vascular involvement, although we were able to dissect the left ureter off the tumor. The multiple vascular lakes noted within the substance of the tumor and the large collateral vessels were still present. Our thinking at this time was that venovenous bypass or cardiac bypass with hypothermie arrest would be necessary to control the potential bleeding. These contingencies were not prepared for; thus, we again aborted the procedure with plans to return to the operating room later in the week. Because of the presence of the tumor, an anastomosis between the proximal sigmoid colon and mid rectum could not be accomplished, necessitating a colostomy and Hartmann pouch.
FIG. 2. (A) Late arterial phase showing extensive arterial communication of aortoiliac vessels with tumor. (B) Postembolization film showing tumor vessels without blood supply.
At the third operation, the pelvic paraganglioma was resected with in-continuity removal of the distal aorta, all iliac arteries (common, external, and internal), the IVCB, and all iliac veins (common, external, and internal). A right axillofemoral-femoral bypass graft was constructed so that blood flow to the lower extremities would continue during the procedure when it became clear that the aortic cross clamp time would be prolonged. The femoral arteries proximal to the femoral anastomoses were ligated and a venovenous bypass circuit was inserted from both femoral veins to the right axillary vein. Despite these techniques, including the use of two Cell-Savers (Belmont Instrument Corporation, Billerica, MA), massive bleeding was encountered from the surrounding collateral vessels even after the tumor was removed. Hemostasis was finally obtained by packing the pelvis with multiple laparotomy pads. The patient was returned to the operating room several days later for pack removal and closure.
The patient developed complications of acute renal failure, massive scrotal and lower extremity edema, and an enterocutaneous fistula (several weeks later). The renal failure required short- term dialysis; however, he was discharged with a creatinine of 1.1 mg/dL. The massive scrotal and lower extremity edema completely resolved 3 months after surgery. The fistula required operative repair 18 months after the initial operation. The patient remains disease-free, alive and well, 3 years later.
A 51-year-old white man presented to the emergency room with severe abdominal pain and a low-grade fever. A CT scan revealed a large (11 x 9.5-cm) retroperitoneal mass surrounding the distal aorta and the AIB, and severe effacement of the IVC. A CT-guided core needle biopsy was performed consistent with a high-grade sarcoma. The patient subsequently underwent neoadjuvant chemotherapy with cisplatin, adriamycin, and ifosfamide in an effort to reduce the size and induce necrosis of the tumor before surgical removal. The patient's symptoms resolved after two courses of chemotherapy. A follow-up CT scan showed a large amount of necrosis, although there was little change in the size of the tumor (Fig. 3). Before the operation, an aortogram and inferior vena cavagram were performed that showed an avascular mass displacing the aorta and causing partial obstruction and effacement of the caudal IVC. The patient then underwent resection of the tumor, which necessitated a right hemicolectomy, right ureteronephrectomy, resection of the distal aorta, both common iliac arteries, the IVC, and both common iliac veins. Aortoiliac reconstruction was performed with a bifurcated Dacron graft. The IVC was ligated primarily. In preparation for the procedure, venovenous bypass and cardiac bypass were available, but were not necessary. FIG. 3. MRI after neoadjuvant chemotherapy. Mass shows >60 per cent necrosis without a significant decrease in size and persistent compression on vena cava and iliac vessels.
This patient also developed massive scrotal and lower extremity edema that resolved in 6 weeks. Although the pathologic margins were clear, several small lung metastases have developed subsequently. He is currently undergoing chemotherapy and is alive with no local recurrence 2 years postoperatively.
A 44-year-old Hispanic woman initially presented 5 years ago to another institution with a left renal mass. At that time, she underwent a left nephrectomy. The pathology revealed a renal cell carcinoma with positive lymph nodes. Shortly thereafter, she developed a brain metastasis and underwent stereotactic brain radiation. Later that year, she developed pulmonary metastases and received interleukin 2, with a complete response. The patient remained disease-free for 4 years and then presented with a right pelvic mass. She underwent resection of the mass, which was adherent to the right iliac vasculature. No surrounding organs or vascular structures were removed. The pathology revealed recurrent renal cell carcinoma with all margins involved. The lesion recurred within 4 months. At that time, she presented to our institution and was noted to have a creatinine of 2.8 mg/dL with right hydronephrosis. A right ureteral stent was inserted with a drop in her creatinine to 1.5 mg/ dL. A metastatic evaluation was negative except for the right-sided retroperitoneal/pelvic mass. If resection of the recurrent lesion were possible, we felt that radiation therapy to the right pelvis/ retroperitoneum would be useful in the postoperative period. However, we were concerned that radiation might jeopardize any type of ureteral reconstruction (psoas hitch/Boari flap) and also injure the lower half of the remaining kidney. Consequently, preparations were made for possible renal autotransplantation to the left iliac fossa. An MR-angiogram demonstrated a single renal artery and vein and confirmed the mass in the right lower retroperitoneum. It compressed the right ureter, the distal right external iliac vein, and the IVC near the bifurcation (Fig. 4).
At operation, removal of the right pelvic/retroperitoneal recurrence required appendectomy, right ureterectomy, and right salpingo-oophorectomy. In addition, the IVCB and the right and left common iliac veins were resected. A venous reconstruction was performed using a 12-mm polytetrafluoroethylene (PTFE) graft between the IVC and the left common iliac vein and an 8-mm PTFE graft between the right common iliac vein and the previously placed 12-mm graft. An autotransplant of the right kidney to the left lower quadrant was performed by anastomosing the right ureter to the stump of the left ureter, the right renal artery to the right external iliac artery, and the right renal vein to the native left common iliac vein. All gross disease was removed, although margins were involved along the paravertebral musculature.
She recovered from surgery without incident and subsequently had her ureteral stent removed. The kidney autotransplant is functioning well; she has a creatinine of 1.2 mg/dL. She underwent radiation therapy to the resection bed and is currently disease free, 18 months postresection.
A 53-year-old Middle-Eastern woman initially presented 5 years ago to another institution with a mass in her right thigh. An incisional biopsy revealed a high-grade sarcoma. The patient underwent neoadjuvant chemotherapy with ifosfamide and adriamycin followed by a wide excision. Postoperatively, she received radiation and additional chemotherapy. Three years later, the patient developed a local recurrence and underwent another wide excision followed by a second course of radiation and additional chemotherapy. An MRI scan 18 months later revealed an 8.5 x 8 x 7.5-cm right pelvic mass surrounding the right iliac vasculature, consistent with a recurrence. A metastatic work-up was otherwise negative. A preoperative arteriogram demonstrated encasement of the right external iliac artery, although no definite invasion was noted. At operation, the recurrent right-sided pelvic/ retroperitoneal sarcoma was resected with an in-continuity right ureteronephrectomy and resection of the right external iliac artery and vein. Both internal iliac arteries were ligated along with the right common iliac vein. Vascular reconstruction was performed with a 6-mm Dacron graft between the right common iliac artery and the right external iliac artery just proximal to the inguinal ligament. The vein was thrombosed at operation and ligated. All gross disease was removed.
FIG. 4. MRI coronal view of right pelvic mass recurrent after recent resection.
She recovered from surgery without complication; however, the right lower extremity woody edema, which was present before our operation, worsened. She developed a local recurrence within 6 months of surgery (her third recurrence), resulting in significant pain and debilitating symptoms. She died 8 months after surgery.
Preparations for Surgery
A thorough understanding of the involved anatomy is mandatory using CT and/or MRI scans. Although cross-sectional and sagittal imaging of the tumor and the involved vasculature is sufficient to determine what vessels are invaded or encased and will require sacrifice, conventional arteriography is important in planning reconstruction. This is especially true when the aortoiliac tree is extensively involved, the patient has preexisting arteriosclerotic occlusive disease, potential for contamination exists, or extra- anatomic reconstruction is anticipated. Extra-anatomic reconstruction, such as axillo-femoral and/or femoral-femoral bypass are useful ways of keeping prosthetic grafts and anastomoses out of the main surgical field when there has been bowel spillage, leakage of potentially contaminated urine from the ureter or bladder, or when the tumor itself is necrotic and bacterial contamination cannot be immediately ruled out. Basic vascular surgical principles require preoperative assessment of inflow vessels and distal target vessels. Contrast imaging confirms that the target vessel is suitable for bypass and is in continuity with the distal vascular bed. This is especially important in patients who have had prior procedures in the groin, have extensive arteriosclerotic occlusive disease, or have had prior radiation therapy in the operative field. Absence of femoral pulses is an indication for conventional dye arteriography. Because venous reconstruction is optional, preoperative venous assessment is adequately performed with contrast-enhanced cross- sectional and sagittal imaging to evaluate venous invasion by tumor.
A tissue diagnosis is mandatory before any attempt at resection to rule out a lymphoma or any other type of tumor that could be treated nonoperatively. In addition, we recommend that any primary malignant tumor at the AIB/IVCB be considered for preoperative chemotherapy and/or radiation therapy in an effort to shrink the tumor. This also allows for a period of observation to see if distant metastatic disease develops that would preclude surgery of this magnitude. In addition, this in vivo clonogenic assay may be helpful in the postoperative period in deciding on adjuvant therapy. For recurrent tumors, the decision on neoadjuvant therapy would be dictated by the patient's previous chemotherapy/radiation history.11, 12
Preoperative embolization or radiation, in an effort to shrink the size of the tumor (benign or malignant) and control its blood supply, can be considered when feasible.13, 14 This may allow involution of tumor and potentially decrease angiogenesis.15 On occasion, preoperative placement of an infrarenal or suprarenal IVC filter will be required to prevent tumor emboli. If the tumor extends above the renal veins into the retrohepatic IVC or above, cardiopulmonary bypass with or without profound hypothermia and total circulatory arrest may be required.
The anesthetic management of patients with tumors involving the great vessels of the lower abdomen and pelvis must take into account that these cases may last 8 hours or longer and involve substantial blood loss. Blood products and rapid infusion devices should be readily available. Judicious volume support is given along with blood products as needed. Adjunctive pressor administration guided by invasive monitoring can be better than large-volume administration and easier on the patient in the postoperative period. In the preanesthetic work-up, it is important to question the use of any cardiotoxic chemotherapeutic drugs (i.e., adriamycin) that may result in underlying cardiac dysfunction.
We recommend performing the arterial reconstruction earlier, rather than later, in the course of the operation. As noted above, operations involving resection of massive tumors encompassing aortoiliac arteries and/or caval and iliac veins frequently require multiple transfusions of blood and blood products, large infusions of crystalloid and/or colloid, and advanced hemodynamic monitoring. Distal tissue ischemia and subsequent reperfusion acidosis and hyperkalemia are poorly tolerated in patients already being challenged by massive fluid losses and replacement. Coagulopathy, hemodynamic instability, electrolyte imbalance, hypothermia, and marginal distal tissue perfusion will all be worsened by distal tissue ischemia. An unexpected bleeding event after crossclamping that is difficult to control might prolong the period of ischemia and push the patient over the precipice into hemodynamic and clotting instability. If the tumor proves unresectable at surgery or the major vascular structures remain intact, the previously placed bypasses can be easily removed. Venous reconstruction of the vena cava and iliac veins can be performed if conditions permit.16, 17 Large caliber tube or bifurcated PTFE grafts or femoral vein homografts make excellent conduits and are very rapidly grafted when the proximal vena cava and distal iliac veins have already been dissected out. Unlike the arterial reconstruction, venous reconstruction may be done when resection of the tumor is complete and the patient is stable. Highly vascular tumors that extend deep into the pelvis may require additional blood loss control measures. The surgeon and the perfusionist should be prepared for venovenous bypass. Previous groin surgery or radiation may increase the risk of long-term complications.18
The initial question that needs to be addressed is whether or not patients with tumors encompassing the AIB/IVCB should be considered for surgical resection. Is the potential curative, survival, or palliative benefit worth the considerable risk involved? Chemotherapy and/or radiation therapy may be helpful in the neoadjuvant or adjuvant setting, but would not be expected to be effective as primary therapy for most solid tumors in this location.11, 12 We believe, depending on the pathology, that patients with primary tumors at the AIB/IVCB or patients with an isolated recurrence at the AIB/IVCB with a reasonable diseasefree interval can be better palliated with surgical intervention and have a better opportunity to respond to adjunctive therapy if all gross disease is removed. In all of our cases, the patient was left with one kidney, and in cases 1 and 3, the remaining kidney was in jeopardy. Clearly, poor cardiopulmonary and renal function would be a contraindication to this type of surgery.19
In highly vascular tumors, such as the paraganglioma in case 1, preoperative angiographie embolization can be considered. We were very pleased with the radiographie appearance of the completed embolization procedure (Fig. 2B), but were disappointed at surgery that it had little effect on the vascular nature of the tumor. In addition, the embolization complicated the situation by causing ischemia of the sigmoid colon. The combination of radiation and embolization has been used for paragangliomas in other locations, for example head and neck and mediastinum, with better results.10, 14, 20, 21 Our experience suggests caution with these techniques for tumors at the AIB.
Blood product transfusion is guided by intraoperative assessment. The use of cell-saver technology is not usually desirable during the resection of malignant tumors. In the case of Patient 1, the paraganglioma was considered histologically benign, thus, cell- saver blood was used and was certainly life-saving. Hansen et al.22 studied the use of intraoperative blood collection and autotransfusion in patients with cancer. Malignant cells were identified regularly in the blood shed during tumor surgery, justifying the standard teaching against cell-saver methods in cancer surgery. The concern, of course, is that salvaged blood may lead to hematogenous metastases after retransfusion.22
Other investigators have sought better methods to allow for autotransfusion. For instance, Papadimitriou and colleagues23 have shown autotransfusion to be safe in hepatic resection for malignancy. In more recent studies, tumor cells have been able to be filtered. Although a standard red cell filter will not adequately remove circulating tumor cells, a leukocyte depletion filter will remove tumor cells completely.24 Of course, with massive blood loss, saving the patient becomes paramount to the small risk of perpetuating hematogenous metastases.
In reviewing case 1, despite arterial inflow occlusion, axillobifemoral bypass grafts with ligation of the femoral arteries proximal to the anastomoses, bilateral femoral venous occlusion with venovenous bypass, massive bleeding was still encountered. This has caused us to consider cardiopulmonary bypass with profound hypothermia and circulatory arrest as a potentially better way to address the problem of a highly vascular tumor located deep within the pelvis. The advantages include a bloodless field for faster resection in a highly vascular area. In addition, cross-clamp time is decreased and neurologic protection is afforded by the associated hypothermia.25 This technique has been used for high aortic arch procedures and cardiac procedures, although it has been reported with resection of highly vascular pelvic tumors such as arteriovenous malformations.26
Radical resection of tumors involving the AIB/ IVCB can be performed safely and can provide effective palliation, improve quality of life, and afford a potential cure. Based on the tumor location and organs and vascular structures involved, various techniques, including anatomic and extra-anatomic arterial grafting, venous grafting, venovenous bypass, and total circulatory arrest with profound hypothermia, may be necessary to safely resect these difficult tumors. An experienced team is required to achieve optimal results and to justify the potential morbidity associated with resection.
This work was supported in part by the Robert J. and Suzanne Gottlieb Endowment in Surgical Oncology and by the Surgical Oncology Education and Research Fund at Cedars-Sinai Medical Center.
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JAMES R. OUELLETTE, D.O.,*1 DAVID V. COSSMAN, M.D., F.A.C.S.,[dagger] KAREN S. SIBERT, M.D.,[double dagger]
NICHOLAS P. MCANDREW,* ALLAN W. SILBERMAN, M.D., PH.D., F.A.C.S.*
From the * Divisions of Surgical Oncology, [dagger] Vascular Surgery, and [double dagger] Anesthesiology, Cedars Sinai Medical
Center, Los Angeles, California
1 Present address: Division of Surgical Oncology, Wright State University School of Medicine, Dayton, OH.
Address correspondence and reprint requests to Allan W. Silberman, M.D., Ph.D., Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048.
Copyright Southeastern Surgical Congress May 2007
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