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Reconstruction of the vena cava with the peritoneum
SCIENTIFIC PAPERS
Reconstruction of the Vena Cava with the Peritoneum Koho Akimaru, MD, Masahiko Onda, MD, Takashi Tajiri, MD, Hiroshi Yoshida, MD, Yasuhiro Mamada, MD, Nobuhiko Taniai, MD, Masato Yoshioka, MD, Sho Mineta, MD, Tokyo, Japan
BACKGROUND: Reconstruction of the vena cava with an autologous vein requires extra incisions. Prosthetic material is associated with an increased risk of infection. We therefore created an animal model of vena cava reconstruction using the peritoneum. METHODS: A 2.5 ⴛ 2.5 cm piece of peritoneum was resected from 7 pigs weighing 30 to 40 kg. An oval window (long axis: 1.5 cm) was made in the infrarenal vena cava. This was repaired with the peritoneal patch fixed in alcohol. RESULTS: In 2 animals sacrificed at 5 hours, there was no evidence of thrombosis, but there was fibrin clot on the patches. Two animals sacrificed on day 8 exhibited excellent patency of the vena cava. Complete endothelialization of the patch was noted at day 15. At 6 weeks, the vena cava was healed. No infections or other problems were noted. CONCLUSIONS: The peritoneum is an accessible and safe substitute for reconstruction of the vena cava. Am J Surg. 2000;179:289 –293. © 2000 by Excerpta Medica, Inc.
R
econstruction of the inferior vena cava after resection of an invasive liver1,2 or adrenal1,3,4 tumor is usually performed with an autologous vein graft, a textile patch or a tube graft. These methods require additional incisions or may result in infection of the prosthesis due to intraoperative contamination. Peritoneum is readily available and may be used5–7 for repair of the inferior vena cava. We developed an animal model of vena cava reconstruction with a peritoneal patch to demonstrate its clinical applicability.
MATERIALS AND METHODS This experimental study conformed to the Guidelines for Regulation of Animal Experimentation of the Nippon Medical School (Nippon Medical School publication, 1989). After endotracheal intubation, 7 Landrace pigs weighing 30 to 40 kg were anesthetized with isoflurane after the intramuscular injection of ketamine hydrochlo-
From the First Department of Surgery, Nippon Medical School, Tokyo, Japan. Requests for reprints should be addressed to Koho Akimaru, MD, First Department of Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan 113-8603. Manuscript submitted September 2, 1999, and accepted in revised form February 24, 2000.
© 2000 by Excerpta Medica, Inc. All rights reserved.
ride. The auricular vein was cannulated for pentobarbital sodium administration and intraoperative fluid delivery. With the pig in the supine position, the abdomen was incised transversely. After the vena cava was fully exposed below the right renal vein, a 2.5 ⫻ 2.5 cm patch of peritoneum was excised from the right upper quadrant. In animals 2 through 7, it was dipped in 100% alcohol for 10 minutes. It was then trimmed into an oval patch with a long axis measuring 1.7 to 2.0 cm (Figure 1). After the intravenous injection of heparin, the vena cava was partially or completely cross-clamped at two sites 3 cm apart. An oval window (1.5 cm diameter) was made in the vena cava. The window was repaired with the peritoneal patch using 6-0 monofilament suture and a vascular clip applier (VCS; United States Surgical Corp., Norwalk, Connecticut). The abdomen was closed without drainage. The surgical wound was dressed with gauze, which was allowed to fall off. Each pig was kept in a separate cage, and was given unlimited access to food and water, but without administration of any antibiotics, anticoagulants, or antiplatelet agents. At specified intervals, the animals were placed under general anesthesia, the vena cava was clamped, and the segment was removed. The animals were then killed with an intravenous injection of potassium chloride. The inner surface of the vena cava was examined macroscopically, histologically, and by scanning electron microscopy (SEM).
RESULTS All of the pigs survived the surgery. There were no postoperative fatalities. The animals were sacrificed at 5 hours, 8 days, 15 days, and 6 weeks (Table 1). At 5 hours (animal 1), there was no evidence of thrombosis or obstruction of the vena cava. There was a rough surface of obvious fibrin clot on the patch surface (Figure 2). The subsequent peritoneal patches were fixed in 100% alcohol for 10 minutes (SEM shown in Figure 3) to prevent biological reactions of the mesothelial cells to blood on the peritoneal patch. At 5 hours after the reconstruction in animal 2, there was no evidence of thrombosis or obstruction of the vena cava and minimal fibrin on the patch graft (SEM in Figure 4). On the 8th postoperative day (animals 3 and 4), no thrombosis, obstruction, or narrowing of the cava was noted. The patch grafts and suture sites were partially coated with endothelium. On the 15th postoperative day (animal 5), there was complete endothelialization of the patch (SEM in Figure 5). At 6 weeks (animals 6 and 7), there was no evidence of obstruction or stenosis of the vena cava, although mild adhesions of the omentum to the abdominal wall were noted. Complete endothelial0002-9610/00/$–see front matter PII S0002-9610(00)00332-9
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Figure 1. Schema of vena cava reconstruction with the peritoneum. A window in the anterior wall of the vena cava was made, and then it was repaired with an alcohol-fixed and trimmed peritoneal patch by handsewn suture and VCS clip applier. Intraoperative photo is inserted.
ization of the peritoneal patch was revealed also by positive staining of von Willebrand factor in the cytoplasm of the cells over the anastomosis and the patch (Figure 6).
COMMENTS Vena cava reconstruction is required after resection of invasive hepatic malignancies,1,8 leiomyosarcomas,1,4,9 renal cell carcinomas,1,3,10,11 and adrenal carcinomas.1,4,12–14 Inferior vena cava reconstruction can improve survival, particularly of patients with slow-growing tumors.1–3,8,12,14 Reconstruction of the portal vein,3,15–17 hepatic vein,3,18 and iliac vein19 has also been reported. The materials commonly used for the reconstruction of the large veins include autologous vein and prosthetic grafts. The superficial femoral vein13 has been used for inferior vena cava reconstruction. The greater saphenous vein,17,20 left renal vein,15 and internal jugular vein16 have been used for portal vein reconstruction. The iliac vein18 has been used for hepatic vein reconstruction. Inferior vena cava reconstruction with a pericardial patch has been described.11 The pericardium is larger and more accessible than the saphenous vein for this application. And as in our study, the peritoneum has also been used for venous reconstructions5–7,21,22 in expectation of the similarity of mesothelial cell to venous endothelial cell. Polytetrafluoroethylene (PTFE) grafts1,19,23 have been used as a synthetic alternative to autologous vein grafts for the reconstruction of the inferior vena cava,1– 4,10,14 the portal vein,3,23,24 and the iliac vein.19 Synthetic grafts are used when vein grafts 290
are unavailable because of prior use or disease, or are of inadequate size. In experimental studies, PTFE grafts have been shown to be suitable23,25 for use in the low-flow, low-pressure venous system. The patency of the inferior vena cava reconstructed with autologous material11,13 is obtainable clinically. Autologous material should exhibit a low thrombosis rate in the low-flow and low-pressure venous system.11 Experimentally, the peritoneum has thrombogenicity,7,26 which could be overcome with use of anticoagulants27 or antithrombotic drugs21 to maintain patency of the repaired vena cava. But, in our study, the peritoneal patches did not cause obstruction of the vena cava even without postoperative administration of any those drugs. Fibrin clotting was observed only on the patch that was not fixed in alcohol, although the peritoneal cells also have fibrinolytic activity.22,27 The fixation suppressed the mesothelial cell reactions to flowing blood in the cava. This seemingly prevented the merely matrix6,7 from thrombosis, but we need more extended experiments using longer peritoneal tube grafts, which could be easily thrombosed.6 The patency of PTFE patch4 and tube1–3,8,10 grafts for inferior vena cava replacement is satisfactory, especially when reinforced grafts1,2,8 and anticoagulant therapy2,4 are used. Reinforced or ringed PTFE grafts resist external compression from adjacent organs and positive intraabdominal pressure.1,2 Their long-term results,1,3 with the longest observations of 42 and 60 months, have been fairly good.
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TABLE I Reconstruction of the Vena Cava with Peritoneal Patch Animals (Landrace pigs; 3 males, 4 females) Body weight: 32.9 ⫾ 3.7 kg Peritoneum Alcohol fixation: Yes 6 No 1* Patch size (long diameter): 16.9 ⫾ 0.9 mm Reconstruction of the vena cava Heparin dose (1 mL ⫽ 1000 U): 6.0 ⫾ 1.6 mL Circumference of the vena cava: 3.4 ⫾ 0.4 cm Vena cava clamping: Side 2 Cross 5 Sewing: Hand 2 VCS 2 Combined 3 Outcome of the vena cava Patency of the vena cava: Thrombus 0 Narrowing 0 Endothelialization of the peritoneal patch: None* 2 Half coating† 2 Complete coating‡ 3 * The peritoneal patch of one animal was not fixed in alcohol, and showed obvious fibrin clots only on itself in 5 hours after the reconstruction. † Two animals sacrificed in 8 days showed incomplete endothelialization. ‡ Three animals sacrificed later than 2 weeks revealed complete coating of the patch.
Figure 3. Scanning electron microscopy of an unused peritoneal patch just after fixation with 100% alcohol for 10 minutes. The surface was wavy and rough (⫻220).
Figure 2. Peritoneal patch graft of animal 1. The graft segment removed 5 hours after the vena cava reconstruction showed obvious fibrin clotting only on the graft surface. Because of this finding, the subsequent patches were fixed in alcohol (see text).
Small-vein reconstruction with PTFE grafts is associated with thrombosis, occlusion, and stenosis.3,19 Portal vein reconstruction with PTFE grafts has been shown to result in unstable neointima formation on the graft surface.23 The unstable neointima may be susceptible to thickening, thrombus formation, and embolic complications. Complete endothelialization is important for prolonged patency,5,7 as we showed good patency with the endothelial cells over the peritoneal patch where von Willebrand factor stained distinctly, not as mesothelial cells did.28
Figure 4. Scanning electron microscopy of the suture site. The resected vena cava of animal 2 sacrificed 5 hours postoperatively shows the suture site with uncovered threads and rough surfaces. Lower part is the patch (⫻40).
No infections were observed in this study, despite the fact that no postoperative antibiotics were used. Although the clinical reports of inferior vena cava reconstruction using a
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PTFE patch4 or PTFE tube graft1,3 did not mention infections as PTFE-associated complications at all, and a few studies29,30 have shown that PTFE grafts are superior to autologous vein grafts for arterial flow reconstruction in contaminated wounds, autologous material is still less susceptible to infection than prosthetic grafts.11,13,23 And furthermore, portal vein3,23 and vena cava2 reconstructions are often performed with hepatic surgery or intestinal resection. The material used for vena cava reconstruction in these contaminated fields must be carefully selected to ensure patency with a low risk of graft infection. Autologous vein grafts exhibit good patency with a low risk of infection, although additional incisions are required. A peritoneal patch fixed in alcohol can be used for reconstruction of large veins. Patency appears to be good, the risk of infection is low, and additional incisions are not required.
REFERENCES
Figure 5. Scanning electron microscopy of the resected vena cava of the animal sacrificed on the 15th postoperative day. Interior surface of the anastomotic site (above) and that of the patch site (below) look the same (⫻220). See how different the patch surface looks from that in Figure 3.
Figure 6. Immunohistochemical study of the repaired vena cava resected at 6 weeks. Cytoplasm of the lining cells covering the anastomotic site (A, magnification ⫻200) and those covering the peritoneal patch (B, ⫻200) stained of factor VIII (von Willebrand’s factor) strongly and diffusely, as endothelial cells of the underlying vessels did.
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1. Huguet C, Ferri M, Gravelli A. Resection of the suprarenal inferior vena cava. The role of prosthetic replacement. Arch Surg. 1995;130:793–797. 2. Bower TC, Nagorney DM, Toomey BJ, et al. Vena cava replacement for malignant disease: is there a role? Ann Vasc Surg. 1993; 7:51– 62. 3. Sakaguchi S, Nakamura S. Venous surgery in resection for abdominal malignancy. Cardiovasc Surg. 1993;1:122–127. 4. Smith BM, Mulherin JL, Sawyers JL, et al. Suprarenal vena caval occlusion. Principle of operative management. Ann Surg. 1984;199:656 – 668. 5. van den Broek TAA, Rauwerda JA, Kuijiper CF. Construction of peritoneal venous valves: an experimental study in rats and piglets. J Surg Res. 1991;50:279 –283. 6. Ribbe EB, Alm P, Hallberg L, et al. Evaluation of peritoneal tube grafts in the inferior vena cava of the pig. Br J Surg. 1988;75: 357–360. 7. Ribbe EB, Alm P, Hallberg E, et al. Peritoneal tube grafts, PTFE-grafts and vein grafts in the inferior vena cava of the rat—a light microscopical and scanning electron microscopical study. Surg Res Comm. 1987;2:43–57. 8. Miyazaki M, Ito H, Nakagawa K, et al. Aggressive surgical resection for hepatic metastases involving the inferior vena cava. Am J Surg. 1999;177:294 –298. 9. Iwatsuki S, Todo S, Starzl TE. Right trisegmentectomy with a synthetic vena cava graft. Arch Surg. 1988;123:1021–1022. 10. Okada Y, Kumada K, Habuchi T, et al. Total replacement of the suprarenal inferior vena cava with an expanded polytetrafluoroethylene tube graft in 2 patients with tumor thrombi from renal cell carcinoma. J Urol. 1989;141:111–114. 11. Marshall FF, Reitz BA. Supradiaphragmatic renal cell carcinoma tumor thrombus: indication for vena caval reconstruction with pericardium. J Urol. 1985;133:266. 12. Decker RA, Kuhner ME. Adrenocortical carcinoma. Am Surg. 1991;57:502–513. 13. Miller CM, Schwartz ME, Nishizaki T. Combined hepatic and vena caval resection with autogenous caval graft replacement. Arch Surg. 1991;126:106 –108. 14. Bodie B, Novick AC, Pontes JE, et al. The Cleveland clinic experience with adrenal cortical carcinoma. J Urol. 1989;141:257– 260. 15. Miyazaki M, Itoh H, Kaiho T, et al. Portal vein reconstruction at the hepatic hilus using a left renal vein graft. J Am Coll Surg. 1995;180:497– 498. 16. Takayama Y, Kanamaru H, Yokoyama H, et al. Portal vein reconstruction using an internal jugular vein as a graft: report of a case. Surg Today. 1995;25:378 –380.
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17. McKinnon WM, Smith RB, Davis SC, et al. Ruptured hepatic artery aneurysm with hepatic artery-to-portal vein fistula: preservation of portal flow by autologous vein reconstruction. Surgery. 1981;89:626 – 630. 18. Wakabayashi H, Maeba T, Okano K, et al. Treatment of recurrent hepatocellular carcinoma by hepatectomy with right and middle hepatic vein reconstruction using total vascular exclusion with extracorporeal bypass and hypothermic hepatic perfusion: report of a case. Surg. Today. 1998;28:547–550. 19. Plate G, Einarsson E, Eklof B, et al. Iliac vein obstruction associated with acute iliofemoral venous thrombosis. Acta Chir Scand. 1985;151:607– 611. 20. Urayama H, Katada S, Matsumoto I, et al. Reconstruction of the jugular and portal blood flows using remodeled great saphenous vein grafts. Surg Today. 1993;23:936 –938. 21. Thomas JMP, Glynn MFX, Rickwood AMK, et al. Grafting of the major veins: the value of anti-thrombotic drugs to maintain patency. Br J Surg. 1976;63:189 –195. 22. Lougie Y, Legrand-Monsierur A, Remacle C, et al. Morphology and fibrinolytic activity of canine autogenous mesothelium used as venous substitute. Res Exp Med. 1986;186:239 –247. 23. Nishibe T, Manase H, Miyazaki K, et al. Portal vein reconstruction with conventional polytetrafluoroethylene grafts: an experimental study in dogs. Surg Today. 1998;28:391–395.
24. Ohkuma T, Ouchi H, Sasaki H, et al. Experimental study on expanded polytetrafluoroethylene for portal vein reconstruction with combined operation of the digestive tract. J Cardiovasc Surg. 1982;23:328 –333. 25. Okuma T, Ouchi H, Sasaki H, et al. Experimental study on EPTFE for portal vein reconstruction with combined operation of the digestive tract. J Cardiovasc Surg. 1982;23:328 –333. 26. Verhagen HJ, Blankensteijn JD, de Groot PG, et al. In vivo experiments with mesothelial cell seeded ePTFE vascular grafts. Eur J Vasc Endovasc Surg. 1998;15:489 – 496. 27. Pronk A, de Groot PG, van Papendrecht H, et al. Thrombogenicity and procoagulant activity of human mesothelial cells. Arterioscler Thromb. 1992;12:1428 –1436. 28. van Hinsbergh VWM, Kooistra T, Scheffer MA, et al. Characterization and fibrinolytic properties of human omental tissue mesothelial cells. Comparison with endothelial cells. Blood. 1990; 75:1490 –1497. 29. Shah PM, Itoh K, Clauss RH, et al. Expanded microporous polytetrafluoroethylene (PTFE) grafts in contaminated wounds: experimental and clinical study. J Trauma. 1983;23:1030 –1033. 30. Stone KS, Walshaw R, Sugiyama GT, et al. Polytetrafluoroethylene versus autogenous vein grafts for vascular reconstruction in contaminated wounds. Am J Surg. 1984;147:692– 695.
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Reconstruction of the Vena Cava with the Peritoneum Koho Akimaru, MD, Masahiko Onda, MD, Takashi Tajiri, MD, Hiroshi Yoshida, MD, Yasuhiro Mamada, MD, Nobuhiko Taniai, MD, Masato Yoshioka, MD, Sho Mineta, MD, Tokyo, Japan
BACKGROUND: Reconstruction of the vena cava with an autologous vein requires extra incisions. Prosthetic material is associated with an increased risk of infection. We therefore created an animal model of vena cava reconstruction using the peritoneum. METHODS: A 2.5 ⴛ 2.5 cm piece of peritoneum was resected from 7 pigs weighing 30 to 40 kg. An oval window (long axis: 1.5 cm) was made in the infrarenal vena cava. This was repaired with the peritoneal patch fixed in alcohol. RESULTS: In 2 animals sacrificed at 5 hours, there was no evidence of thrombosis, but there was fibrin clot on the patches. Two animals sacrificed on day 8 exhibited excellent patency of the vena cava. Complete endothelialization of the patch was noted at day 15. At 6 weeks, the vena cava was healed. No infections or other problems were noted. CONCLUSIONS: The peritoneum is an accessible and safe substitute for reconstruction of the vena cava. Am J Surg. 2000;179:289 –293. © 2000 by Excerpta Medica, Inc.
R
econstruction of the inferior vena cava after resection of an invasive liver1,2 or adrenal1,3,4 tumor is usually performed with an autologous vein graft, a textile patch or a tube graft. These methods require additional incisions or may result in infection of the prosthesis due to intraoperative contamination. Peritoneum is readily available and may be used5–7 for repair of the inferior vena cava. We developed an animal model of vena cava reconstruction with a peritoneal patch to demonstrate its clinical applicability.
MATERIALS AND METHODS This experimental study conformed to the Guidelines for Regulation of Animal Experimentation of the Nippon Medical School (Nippon Medical School publication, 1989). After endotracheal intubation, 7 Landrace pigs weighing 30 to 40 kg were anesthetized with isoflurane after the intramuscular injection of ketamine hydrochlo-
From the First Department of Surgery, Nippon Medical School, Tokyo, Japan. Requests for reprints should be addressed to Koho Akimaru, MD, First Department of Surgery, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan 113-8603. Manuscript submitted September 2, 1999, and accepted in revised form February 24, 2000.
© 2000 by Excerpta Medica, Inc. All rights reserved.
ride. The auricular vein was cannulated for pentobarbital sodium administration and intraoperative fluid delivery. With the pig in the supine position, the abdomen was incised transversely. After the vena cava was fully exposed below the right renal vein, a 2.5 ⫻ 2.5 cm patch of peritoneum was excised from the right upper quadrant. In animals 2 through 7, it was dipped in 100% alcohol for 10 minutes. It was then trimmed into an oval patch with a long axis measuring 1.7 to 2.0 cm (Figure 1). After the intravenous injection of heparin, the vena cava was partially or completely cross-clamped at two sites 3 cm apart. An oval window (1.5 cm diameter) was made in the vena cava. The window was repaired with the peritoneal patch using 6-0 monofilament suture and a vascular clip applier (VCS; United States Surgical Corp., Norwalk, Connecticut). The abdomen was closed without drainage. The surgical wound was dressed with gauze, which was allowed to fall off. Each pig was kept in a separate cage, and was given unlimited access to food and water, but without administration of any antibiotics, anticoagulants, or antiplatelet agents. At specified intervals, the animals were placed under general anesthesia, the vena cava was clamped, and the segment was removed. The animals were then killed with an intravenous injection of potassium chloride. The inner surface of the vena cava was examined macroscopically, histologically, and by scanning electron microscopy (SEM).
RESULTS All of the pigs survived the surgery. There were no postoperative fatalities. The animals were sacrificed at 5 hours, 8 days, 15 days, and 6 weeks (Table 1). At 5 hours (animal 1), there was no evidence of thrombosis or obstruction of the vena cava. There was a rough surface of obvious fibrin clot on the patch surface (Figure 2). The subsequent peritoneal patches were fixed in 100% alcohol for 10 minutes (SEM shown in Figure 3) to prevent biological reactions of the mesothelial cells to blood on the peritoneal patch. At 5 hours after the reconstruction in animal 2, there was no evidence of thrombosis or obstruction of the vena cava and minimal fibrin on the patch graft (SEM in Figure 4). On the 8th postoperative day (animals 3 and 4), no thrombosis, obstruction, or narrowing of the cava was noted. The patch grafts and suture sites were partially coated with endothelium. On the 15th postoperative day (animal 5), there was complete endothelialization of the patch (SEM in Figure 5). At 6 weeks (animals 6 and 7), there was no evidence of obstruction or stenosis of the vena cava, although mild adhesions of the omentum to the abdominal wall were noted. Complete endothelial0002-9610/00/$–see front matter PII S0002-9610(00)00332-9
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Figure 1. Schema of vena cava reconstruction with the peritoneum. A window in the anterior wall of the vena cava was made, and then it was repaired with an alcohol-fixed and trimmed peritoneal patch by handsewn suture and VCS clip applier. Intraoperative photo is inserted.
ization of the peritoneal patch was revealed also by positive staining of von Willebrand factor in the cytoplasm of the cells over the anastomosis and the patch (Figure 6).
COMMENTS Vena cava reconstruction is required after resection of invasive hepatic malignancies,1,8 leiomyosarcomas,1,4,9 renal cell carcinomas,1,3,10,11 and adrenal carcinomas.1,4,12–14 Inferior vena cava reconstruction can improve survival, particularly of patients with slow-growing tumors.1–3,8,12,14 Reconstruction of the portal vein,3,15–17 hepatic vein,3,18 and iliac vein19 has also been reported. The materials commonly used for the reconstruction of the large veins include autologous vein and prosthetic grafts. The superficial femoral vein13 has been used for inferior vena cava reconstruction. The greater saphenous vein,17,20 left renal vein,15 and internal jugular vein16 have been used for portal vein reconstruction. The iliac vein18 has been used for hepatic vein reconstruction. Inferior vena cava reconstruction with a pericardial patch has been described.11 The pericardium is larger and more accessible than the saphenous vein for this application. And as in our study, the peritoneum has also been used for venous reconstructions5–7,21,22 in expectation of the similarity of mesothelial cell to venous endothelial cell. Polytetrafluoroethylene (PTFE) grafts1,19,23 have been used as a synthetic alternative to autologous vein grafts for the reconstruction of the inferior vena cava,1– 4,10,14 the portal vein,3,23,24 and the iliac vein.19 Synthetic grafts are used when vein grafts 290
are unavailable because of prior use or disease, or are of inadequate size. In experimental studies, PTFE grafts have been shown to be suitable23,25 for use in the low-flow, low-pressure venous system. The patency of the inferior vena cava reconstructed with autologous material11,13 is obtainable clinically. Autologous material should exhibit a low thrombosis rate in the low-flow and low-pressure venous system.11 Experimentally, the peritoneum has thrombogenicity,7,26 which could be overcome with use of anticoagulants27 or antithrombotic drugs21 to maintain patency of the repaired vena cava. But, in our study, the peritoneal patches did not cause obstruction of the vena cava even without postoperative administration of any those drugs. Fibrin clotting was observed only on the patch that was not fixed in alcohol, although the peritoneal cells also have fibrinolytic activity.22,27 The fixation suppressed the mesothelial cell reactions to flowing blood in the cava. This seemingly prevented the merely matrix6,7 from thrombosis, but we need more extended experiments using longer peritoneal tube grafts, which could be easily thrombosed.6 The patency of PTFE patch4 and tube1–3,8,10 grafts for inferior vena cava replacement is satisfactory, especially when reinforced grafts1,2,8 and anticoagulant therapy2,4 are used. Reinforced or ringed PTFE grafts resist external compression from adjacent organs and positive intraabdominal pressure.1,2 Their long-term results,1,3 with the longest observations of 42 and 60 months, have been fairly good.
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TABLE I Reconstruction of the Vena Cava with Peritoneal Patch Animals (Landrace pigs; 3 males, 4 females) Body weight: 32.9 ⫾ 3.7 kg Peritoneum Alcohol fixation: Yes 6 No 1* Patch size (long diameter): 16.9 ⫾ 0.9 mm Reconstruction of the vena cava Heparin dose (1 mL ⫽ 1000 U): 6.0 ⫾ 1.6 mL Circumference of the vena cava: 3.4 ⫾ 0.4 cm Vena cava clamping: Side 2 Cross 5 Sewing: Hand 2 VCS 2 Combined 3 Outcome of the vena cava Patency of the vena cava: Thrombus 0 Narrowing 0 Endothelialization of the peritoneal patch: None* 2 Half coating† 2 Complete coating‡ 3 * The peritoneal patch of one animal was not fixed in alcohol, and showed obvious fibrin clots only on itself in 5 hours after the reconstruction. † Two animals sacrificed in 8 days showed incomplete endothelialization. ‡ Three animals sacrificed later than 2 weeks revealed complete coating of the patch.
Figure 3. Scanning electron microscopy of an unused peritoneal patch just after fixation with 100% alcohol for 10 minutes. The surface was wavy and rough (⫻220).
Figure 2. Peritoneal patch graft of animal 1. The graft segment removed 5 hours after the vena cava reconstruction showed obvious fibrin clotting only on the graft surface. Because of this finding, the subsequent patches were fixed in alcohol (see text).
Small-vein reconstruction with PTFE grafts is associated with thrombosis, occlusion, and stenosis.3,19 Portal vein reconstruction with PTFE grafts has been shown to result in unstable neointima formation on the graft surface.23 The unstable neointima may be susceptible to thickening, thrombus formation, and embolic complications. Complete endothelialization is important for prolonged patency,5,7 as we showed good patency with the endothelial cells over the peritoneal patch where von Willebrand factor stained distinctly, not as mesothelial cells did.28
Figure 4. Scanning electron microscopy of the suture site. The resected vena cava of animal 2 sacrificed 5 hours postoperatively shows the suture site with uncovered threads and rough surfaces. Lower part is the patch (⫻40).
No infections were observed in this study, despite the fact that no postoperative antibiotics were used. Although the clinical reports of inferior vena cava reconstruction using a
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PTFE patch4 or PTFE tube graft1,3 did not mention infections as PTFE-associated complications at all, and a few studies29,30 have shown that PTFE grafts are superior to autologous vein grafts for arterial flow reconstruction in contaminated wounds, autologous material is still less susceptible to infection than prosthetic grafts.11,13,23 And furthermore, portal vein3,23 and vena cava2 reconstructions are often performed with hepatic surgery or intestinal resection. The material used for vena cava reconstruction in these contaminated fields must be carefully selected to ensure patency with a low risk of graft infection. Autologous vein grafts exhibit good patency with a low risk of infection, although additional incisions are required. A peritoneal patch fixed in alcohol can be used for reconstruction of large veins. Patency appears to be good, the risk of infection is low, and additional incisions are not required.
REFERENCES
Figure 5. Scanning electron microscopy of the resected vena cava of the animal sacrificed on the 15th postoperative day. Interior surface of the anastomotic site (above) and that of the patch site (below) look the same (⫻220). See how different the patch surface looks from that in Figure 3.
Figure 6. Immunohistochemical study of the repaired vena cava resected at 6 weeks. Cytoplasm of the lining cells covering the anastomotic site (A, magnification ⫻200) and those covering the peritoneal patch (B, ⫻200) stained of factor VIII (von Willebrand’s factor) strongly and diffusely, as endothelial cells of the underlying vessels did.
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