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Retrohepatic vena cava reconstruction with polytetrafluoroethylene graft
Retrohepatic vena cava reconstruction with polytetrafluoroethylene graft William H . Risher, M D , R o b e r t M. Arensman, M D , J o h n L. Ochsner, M D , and L a r r y H . Hollier, MD, New Orleans, La. The case of an 18-month-old male who underwent a right hepatic lobectomy for hepatoblastoma with extensive involvement of the retrohepatic vena cava is presented. The retrohepatic vena cava was replaced with an expanded polytetrafluoroethylene graft. This graft was proved patent by ultrasonography 2 years after operation. The child has no evidence o f recurrent hepatoblastoma. The results of grafting the retrohepatic vena cava have been notoriously poor. It is widely believed that a prosthetic vena cava graft cannot be expected to remain patent. Our experience with polytetrafluoroethylene and previous reports using Dacron and polytetrafluoroethylene have shown that long-term patency of retrohepatic vena cava replacement with synthetic graft can be successful. (J VASC SURG 1990;12:36%70.)
In the course o f right hepatic lobectomy o f the liver for hepatoblastoma the retrohepatic vena cava was replaced with an expanded polytetrafluoroethylene (PTFE) graft (Gore-Tex, registered trademark o f W . L. Gore & Assoc., Elkton, Md.). The patency o f the graft was proved by ultrasonography 2 years later. There have been three previously reported successful replacements o f the retrohepatic vena cava in the literature. Starzl et al. 1 used reversed cadaver vena cava-iliac vein homograft. Iwatsuki et al. 2 used woven Dacron. Kumada et al. a used PTFE. This represents the fourth reported case o f successful retrohepatic vena caval replacement in the Englishlanguage literature. Furthermore, this is the first reported case o f successful replacement in a pediatric ~atient and the second with a P T F E graft in the English-language literature. CASE REPORT An asymptomatic 18-month-old white male during routine well-baby examination by his pediatrician was noted to have a right-sided abdominal mass. Roentgenography showed extensive calcifications in the right upper quadrant of the abdomen; the chest radiograph was norreal. An abdominal ultrasound scan showed an 8 x 9 x 5 cm right upper quadrant abdominal mass. Results of serum chemistry determinations showed carcinoembryonic antigen 1.5 ng/ml (normal < 2.5 ng/ml), beta-human From the Department of Surgery, Ochsner Clinic, and Alton Ochsner Medical Foundation. Presented at the Fourteenth Annual Meeting of the Southern Association for Vascular Surgery, Acapulco, Mexico, Jan. 2427, 1990. Reprint requests: John L. Ochsner, MD, Ochsner Clinic, 1514 Jefferson Highway, New Orelans, LA 70121. 24/6/22151
chorionic gonadotrophin <5.0 mIU/ml (normal < 5.0 mIU/ml), alpha-fetoprotein 68,000 ng/ml (normal 0.8 to 8.5 ng/ml), calcium 10.6 mg/dl (normal 8.6 to 10.4 mg/dl), serum glutanic oxaloacctic transferase 84 units/1 (normal 5 to 41 units/l), lactate dehydrogenase 322 units/1 (normal 80 to 260 units/l), and alkaline phosphatase i73 units/1 (normal 25 to 150 units/l). Complete blood count showed a hemoglobin of 9.7 gm/dl (normal I4 to 18 gm/dl) and hematocrit of 29.9% (normal 40% to 54%). In addition, prothrombin time was 16.3 seconds (normal 10 to i3 seconds). The remaining laboratory examination results were normal. Further workup included CT scanning of the abdomen (Fig. 1) and the chest, which showed a large mass in the liver, bilateral lower lobe pulmonary parenchymal nodules, and a right upper lobe pulmonary nodule. An aortogram with selective hepatic angiography showed a large vascular tumor replacing the right lobe of the liver with blood supply from the right hepatic and right inferior phrenic arteries. A bone marrow examination was normal. A preoperative diagnosis of hepatoblastoma was established. During surgical exploration the patient was noted to have a large, firm, fleshy tumor involving the entire right lobe of the liver with extensive involvement of the retrohepatic vena cava. The vena cava was damped just below the diaphragm and above the renal veins. NinetT percent of the circttmference of the retrohepatic cava was resected along with the right lobe of the liver. An 8 m m x 7 cm PTFE graft was opened longitudinally and used to reconstruct the retrohepatic cava. The posterior 10% of wall circumference of the cava was left intact to allow for future growth. The graft was sewn to this portion of the cava by use of a continuous suture of 7-0 Prolene (Ethicon, Inc., Somerville, N.J.). A formal right hepatic lobectomy was then performed (Fig. 2). The abdomen was not drained. The pathology report showed mixed mesenchymal and epithelial hepatoblastoma. 367
368
Journal of VASCULAR SURGERY
Risher et al.
Fig. 1. Preoperative CT scan of liver shows large hepatoblastoma (L, liver, H, hepatoblastoma, K, kidney, S, stomach).
Left Lobe of Liver
f
Gore-Tex II ~;~i *,~'~p Graft ~
Hepatobla~
Right I~aney
Left Kidney
Fig. 2. Replacement of the retrohepatic vena cava with PTFE graft (right lobectomy has been performed) (Left, Before resection. Right, After right hepatic lobectomy). The patient was extubated on postoperative day 1 and transferred from the pediatric intensive care unit on postoperative day 3. He developed a right middle lobe infiltration on postoperative day 6 and was treated with a 5day course of intravenous antibiotics. H e was discharged on postoperative day 13. The patient received outpatient chemotherapy consisting ofvincristine, cisplatin, and adriamycin. Repeat CT scanning of the thorax 1 year after operation showed resolution of bilateral lower lobe nodules but persistence of tight upper lobe nodule. He underwent a tight lateral tho-
ractomy with wedge resection of right middle and right upper lobe nodules. Pathologic examination showed oval foci of benign-appearing ossification, with no residual hepatoblastoma identified. Two years after surgery CT scanning of the abdomen (Fig. 3) and chest are normal. Alpha-fetoprotein level is less than 4.0 ng/ml (normal 0.8 to 8.5 ng/ml). Liver function tests are normal. Ultrasonography of the retrohepatic vena cava showed a patent PTFE graft with normal flow of venous blood (Fig. 4). There is no evidence of recurrence of hepatoblastoma.
Volume 12 Number 3 September 1990
Retrohepatic vena cava reconstruction
369
Fig. 3. CT scan of the abdomen obtained 2 years after surgery shows absence of any ~maor recurrence (L, liver, K, kidney, S, stomach).
Fig. 4. Postoperative ultrasound scan 2 years after resection of hepatoblastoma shows good flow through retrohepatic vena cava and patency of PTFE graft (L, liver, VC, vena cava). DISCUSSION Replacement of the retrohepatic vena cava is a rare occurrence, with only three cases of successful replacement reported in the English-language literattire. The first report was by Starzl et al. 1 in 1980 who described the use of a reversed cadaver vena cava-iliac vein homograft for replacement of the retrohepatic vena cava during right trisegmentectomy. The second report in 1988 by Iwatsuki et al.2
described the use of a woven Dacron graft for replacement of the retrohepatic vcna cava during right trisegmentectomy for a leiomyosarcoma that had extensively invaded the retrohepatic vena cava. They documentcd patency of the Dacron graft 12 months after operation by inferior venocavograms. The third report in 1988 by Kumada et alJ described the use of PTFE for replacement of the retrohepatic vena cava during extended right hepatic lobectomy
370
Journal ot VASCULAR SURGERY
Risher et al.
for a hepatocellular carcinoma. This turnor involved the right adrenal gland and right diaphragm. Patency of the PTFE graft was documented at 9 months after surgery by magnetic resonance imaging. Our case is the fourth report of successful replacement of the retrohepatic vena cava and was accomplished with a PTFE graft. Herring et al.4 studied the patency of canine inferior vena cava grafting with Dacron and PTFE. They found a 28% patency with PTFE and a zero patency with Dacron. Smith et al.s found PTFE grafts to be superior to homologous veins as well as to autogenous collagenous tubes for the suprarenal inferior vena cava replacement in canines. An 83% patency rate was achieved with PTFE. This suggests that PTFE may be a better material for replacement of the vena cava. Plate et al.6 suggested that prosthetic replacement of the vena cava with concomitant arteriovenous fistula had patency rates approaching those of spinal vein grafts. Although no arteriovenous fistula was used on this patient, it is an adjunctive procedure that we feel will increase patency and will be used in future cases. CONCLUSION The results of grafting the retrohepatic vena cava have been notoriously poor, and it is widely believed
that a prosthetic or vena caval graft can not be expected to remain patent. The experience of Iwatsuki et al. with Dacron, Kumada et al. with PTFE, as well as our experience with PTFE have shown that longterm patency of retrohepatic vena caval replacement with synthetic material can be successful.
REFERENCES
1. Starzl TE, Koep LJ, Weil RIII, et al. Right trisegmentectomy for hepatic neoplasma. Surg Gynecol Obstet 1980;150:208i4. 2. Iwatsuki S, Todo S, Starzl TE. Right trisegmentectomy with a synthetic vena cava graft. Arch Sttrg 1988;123:1021-2. 3. Kumada K, Shimahara Y, Fukui K, et al. Extended right hepatic lobectomy: combined resection of inferior vena cava and its reconstruction by ePTFE graft (GORE-TEX). Acta Chit Scand 1988;154:481-3. 4. Herring M, Gardner A, Peigh P, et al. Patency on canin~ inferior vena Cava grafting: effects of graft material, site, and endothelial seeding. J VASC SURG 1984;1:877-87. 5. Smith D, Hammon J, Anane-Sefah R, Richardson R, Trimble C. Segmental venous replacement: a comparison of biological and synthetic substitutes. J Thorac Cardiovasc Surg 1975; 69:589-98. 6. Plate G, Hollier LH, Gloviezki P, et al. Overcoming failure of venous vascular prosthesis. Sttrgery 1984;96:503-10.
In the course o f right hepatic lobectomy o f the liver for hepatoblastoma the retrohepatic vena cava was replaced with an expanded polytetrafluoroethylene (PTFE) graft (Gore-Tex, registered trademark o f W . L. Gore & Assoc., Elkton, Md.). The patency o f the graft was proved by ultrasonography 2 years later. There have been three previously reported successful replacements o f the retrohepatic vena cava in the literature. Starzl et al. 1 used reversed cadaver vena cava-iliac vein homograft. Iwatsuki et al. 2 used woven Dacron. Kumada et al. a used PTFE. This represents the fourth reported case o f successful retrohepatic vena caval replacement in the Englishlanguage literature. Furthermore, this is the first reported case o f successful replacement in a pediatric ~atient and the second with a P T F E graft in the English-language literature. CASE REPORT An asymptomatic 18-month-old white male during routine well-baby examination by his pediatrician was noted to have a right-sided abdominal mass. Roentgenography showed extensive calcifications in the right upper quadrant of the abdomen; the chest radiograph was norreal. An abdominal ultrasound scan showed an 8 x 9 x 5 cm right upper quadrant abdominal mass. Results of serum chemistry determinations showed carcinoembryonic antigen 1.5 ng/ml (normal < 2.5 ng/ml), beta-human From the Department of Surgery, Ochsner Clinic, and Alton Ochsner Medical Foundation. Presented at the Fourteenth Annual Meeting of the Southern Association for Vascular Surgery, Acapulco, Mexico, Jan. 2427, 1990. Reprint requests: John L. Ochsner, MD, Ochsner Clinic, 1514 Jefferson Highway, New Orelans, LA 70121. 24/6/22151
chorionic gonadotrophin <5.0 mIU/ml (normal < 5.0 mIU/ml), alpha-fetoprotein 68,000 ng/ml (normal 0.8 to 8.5 ng/ml), calcium 10.6 mg/dl (normal 8.6 to 10.4 mg/dl), serum glutanic oxaloacctic transferase 84 units/1 (normal 5 to 41 units/l), lactate dehydrogenase 322 units/1 (normal 80 to 260 units/l), and alkaline phosphatase i73 units/1 (normal 25 to 150 units/l). Complete blood count showed a hemoglobin of 9.7 gm/dl (normal I4 to 18 gm/dl) and hematocrit of 29.9% (normal 40% to 54%). In addition, prothrombin time was 16.3 seconds (normal 10 to i3 seconds). The remaining laboratory examination results were normal. Further workup included CT scanning of the abdomen (Fig. 1) and the chest, which showed a large mass in the liver, bilateral lower lobe pulmonary parenchymal nodules, and a right upper lobe pulmonary nodule. An aortogram with selective hepatic angiography showed a large vascular tumor replacing the right lobe of the liver with blood supply from the right hepatic and right inferior phrenic arteries. A bone marrow examination was normal. A preoperative diagnosis of hepatoblastoma was established. During surgical exploration the patient was noted to have a large, firm, fleshy tumor involving the entire right lobe of the liver with extensive involvement of the retrohepatic vena cava. The vena cava was damped just below the diaphragm and above the renal veins. NinetT percent of the circttmference of the retrohepatic cava was resected along with the right lobe of the liver. An 8 m m x 7 cm PTFE graft was opened longitudinally and used to reconstruct the retrohepatic cava. The posterior 10% of wall circumference of the cava was left intact to allow for future growth. The graft was sewn to this portion of the cava by use of a continuous suture of 7-0 Prolene (Ethicon, Inc., Somerville, N.J.). A formal right hepatic lobectomy was then performed (Fig. 2). The abdomen was not drained. The pathology report showed mixed mesenchymal and epithelial hepatoblastoma. 367
368
Journal of VASCULAR SURGERY
Risher et al.
Fig. 1. Preoperative CT scan of liver shows large hepatoblastoma (L, liver, H, hepatoblastoma, K, kidney, S, stomach).
Left Lobe of Liver
f
Gore-Tex II ~;~i *,~'~p Graft ~
Hepatobla~
Right I~aney
Left Kidney
Fig. 2. Replacement of the retrohepatic vena cava with PTFE graft (right lobectomy has been performed) (Left, Before resection. Right, After right hepatic lobectomy). The patient was extubated on postoperative day 1 and transferred from the pediatric intensive care unit on postoperative day 3. He developed a right middle lobe infiltration on postoperative day 6 and was treated with a 5day course of intravenous antibiotics. H e was discharged on postoperative day 13. The patient received outpatient chemotherapy consisting ofvincristine, cisplatin, and adriamycin. Repeat CT scanning of the thorax 1 year after operation showed resolution of bilateral lower lobe nodules but persistence of tight upper lobe nodule. He underwent a tight lateral tho-
ractomy with wedge resection of right middle and right upper lobe nodules. Pathologic examination showed oval foci of benign-appearing ossification, with no residual hepatoblastoma identified. Two years after surgery CT scanning of the abdomen (Fig. 3) and chest are normal. Alpha-fetoprotein level is less than 4.0 ng/ml (normal 0.8 to 8.5 ng/ml). Liver function tests are normal. Ultrasonography of the retrohepatic vena cava showed a patent PTFE graft with normal flow of venous blood (Fig. 4). There is no evidence of recurrence of hepatoblastoma.
Volume 12 Number 3 September 1990
Retrohepatic vena cava reconstruction
369
Fig. 3. CT scan of the abdomen obtained 2 years after surgery shows absence of any ~maor recurrence (L, liver, K, kidney, S, stomach).
Fig. 4. Postoperative ultrasound scan 2 years after resection of hepatoblastoma shows good flow through retrohepatic vena cava and patency of PTFE graft (L, liver, VC, vena cava). DISCUSSION Replacement of the retrohepatic vena cava is a rare occurrence, with only three cases of successful replacement reported in the English-language literattire. The first report was by Starzl et al. 1 in 1980 who described the use of a reversed cadaver vena cava-iliac vein homograft for replacement of the retrohepatic vena cava during right trisegmentectomy. The second report in 1988 by Iwatsuki et al.2
described the use of a woven Dacron graft for replacement of the retrohepatic vcna cava during right trisegmentectomy for a leiomyosarcoma that had extensively invaded the retrohepatic vena cava. They documentcd patency of the Dacron graft 12 months after operation by inferior venocavograms. The third report in 1988 by Kumada et alJ described the use of PTFE for replacement of the retrohepatic vena cava during extended right hepatic lobectomy
370
Journal ot VASCULAR SURGERY
Risher et al.
for a hepatocellular carcinoma. This turnor involved the right adrenal gland and right diaphragm. Patency of the PTFE graft was documented at 9 months after surgery by magnetic resonance imaging. Our case is the fourth report of successful replacement of the retrohepatic vena cava and was accomplished with a PTFE graft. Herring et al.4 studied the patency of canine inferior vena cava grafting with Dacron and PTFE. They found a 28% patency with PTFE and a zero patency with Dacron. Smith et al.s found PTFE grafts to be superior to homologous veins as well as to autogenous collagenous tubes for the suprarenal inferior vena cava replacement in canines. An 83% patency rate was achieved with PTFE. This suggests that PTFE may be a better material for replacement of the vena cava. Plate et al.6 suggested that prosthetic replacement of the vena cava with concomitant arteriovenous fistula had patency rates approaching those of spinal vein grafts. Although no arteriovenous fistula was used on this patient, it is an adjunctive procedure that we feel will increase patency and will be used in future cases. CONCLUSION The results of grafting the retrohepatic vena cava have been notoriously poor, and it is widely believed
that a prosthetic or vena caval graft can not be expected to remain patent. The experience of Iwatsuki et al. with Dacron, Kumada et al. with PTFE, as well as our experience with PTFE have shown that longterm patency of retrohepatic vena caval replacement with synthetic material can be successful.
REFERENCES
1. Starzl TE, Koep LJ, Weil RIII, et al. Right trisegmentectomy for hepatic neoplasma. Surg Gynecol Obstet 1980;150:208i4. 2. Iwatsuki S, Todo S, Starzl TE. Right trisegmentectomy with a synthetic vena cava graft. Arch Sttrg 1988;123:1021-2. 3. Kumada K, Shimahara Y, Fukui K, et al. Extended right hepatic lobectomy: combined resection of inferior vena cava and its reconstruction by ePTFE graft (GORE-TEX). Acta Chit Scand 1988;154:481-3. 4. Herring M, Gardner A, Peigh P, et al. Patency on canin~ inferior vena Cava grafting: effects of graft material, site, and endothelial seeding. J VASC SURG 1984;1:877-87. 5. Smith D, Hammon J, Anane-Sefah R, Richardson R, Trimble C. Segmental venous replacement: a comparison of biological and synthetic substitutes. J Thorac Cardiovasc Surg 1975; 69:589-98. 6. Plate G, Hollier LH, Gloviezki P, et al. Overcoming failure of venous vascular prosthesis. Sttrgery 1984;96:503-10.