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Technique of Aortic Replacement Through Endovascular Stenting Before Aortic Wall Resection for Primary Leiomyosarcoma of the Abdominal Aorta
Selected Technique Technique of Aortic Replacement Through Endovascular Stenting Before Aortic Wall Resection for Primary Leiomyosarcoma of the Abdominal Aorta Calogero Presti, and Ivan Benaduce Casella, S~ao Paulo, Brazil
Tumors involving the aorta represent a challenging situation because the surgical approach can lead to blood loss and/or clamping-related complications such as ischemia, thrombosis, or reperfusion syndromes. We describe the technique of aortic endograft placement to cover part of the abdominal aorta and provide conditions for extensive aortic wall resection, without clamping or blood loss, followed immediately by aortic reconstruction with bovine pericardium. This technique also allows the surgeon to wait for the results of freeze biopsy without additional clamping time, thus avoiding the risk of leaving residual tumor cells in the aortic wall.
INTRODUCTION Tumors presenting with arterial and/or venous invasion require a proper technical approach for vessel preservation and reconstruction, generally using synthetic grafts.1e3 The recent development of endovascular aortic stent-grafts offered new possibilities in the therapy of such disease. We report the use of an aortic stent-graft to provide proper aortic wall resection and reconstruction in a case of extensive aortic leiomyosarcoma with left kidney invasion that was treated surgically.
CLINICAL SUMMARY A 41-year-old man presented with a 2-month history of back pain without weight loss or other symptoms, and with a normal physical examination. An initial contrast-enhanced computed Hospital Sı´rio Liban^es, S~ao Paulo, Brazil. Correspondence to: Ivan Benaduce Casella, Rua Peixoto Gomide, 515, cj 64, CEP 01409-001, S~ao Paulo, Brazil; E-mail: ivancasel@ uol.com.br Ann Vasc Surg 2012; 26: 1052–1055 DOI: 10.1016/j.avsg.2012.03.008 Ó Annals of Vascular Surgery Inc. Published online: July 26, 2012
1052
tomography revealed a left retroperitoneal mass invading the aortic wall and the ipsilateral kidney (Fig. 1). The initial therapeutic option was surgical resection of the mass, along with the involved aortic wall, and left nephrectomy.
TECHNIQUE DESCRIPTION With the patient under general anesthesia, a 6F pigtail catheter was inserted through the left common femoral artery and placed in the upper abdominal aorta. The right common femoral artery was exposed, and a 16 100-mm Excluder stentgraft (Gore, Newark, DE) was inserted into the abdominal aorta and positioned with its proximal portion just below the renal arteries and the distal segment close to the iliac bifurcation. After confirmation of proper positioning of the endoprosthesis on postdeployment angiographies, the femoral artery was repaired, and the groin incision was closed. We then performed a longitudinal transperitoneal laparotomy with complete removal of the retroperitoneal mass and the left kidney in a single block (Fig. 2A). The tumor was sized approximately 12 20 cm and was adherent to the left infrarenal aortic wall (Fig. 2B), which demanded its segmental
Vol. 26, No. 7, October 2012
Stent grafts for aortic leiomyossarcomas 1053
defect on the aortic wall was covered with bovine pericardium (Fig. 2D). There were no postoperative complications, and the patient was discharged after 7 days. The definitive anatomopathologic diagnosis was primary leiomyosarcoma of the abdominal aorta, with low-grade cellular differentiation. After 6 months, the patient presented with metastatic lesions in the lumbar spine, and died after 19 months after complications related to chemotherapy procedures. No complications related to the endovascular therapy were observed during this follow-up period.
DISCUSSION
Fig. 1. Axial and longitudinal computed tomography scan views showing the retroperitoneal mass originating from the aorta and involving the left kidney. White arrows delimitate the tumor in the axial view (bottom).
resection with safety margins of approximately 4 3 cm. During the aortic wall resection, no clamping was needed and no blood loss was observed, after the stent-graft was covering the resected area completely. The stent-graft became temporarily exposed and could be directly observed (Fig. 2C). Freeze biopsy confirmed the absence of tumor cells in the margins of the aortic wall. The resulting
Leiomyosarcomas of vascular origin are extremely rare events, especially when located in the aorta.4e6 According to Tilkorn et al.,7 these tumors represent <1% of all malignant soft-tissue tumors. In retroperitoneal tumors, the presence of aortic invasion is generally investigated before surgery to enable optimal planning of the surgical approach. In the present case, the early diagnosis of aortic wall involvement offered the possibility for endovascular covering of the inner vessel wall. Two elementary techniques can be used to remove neoplasms involving the walls of great vessels: subadventitial resection of the vessel wall, or complete resection of the involved parts and subsequent vessel reconstruction with a prosthetic or an autogenous substitute. Using the first option, it is possible to remove theneoplasm and involved vessel layers without clamping and consequent flow interruption, thereby minimizing blood loss and avoiding limb ischemia. However, this method carries a high risk of aortic rupture and late aortoenteric fistulae.8,9 In addition, local recurrence may occur because of microscopic invasion of the remaining layers of the artery.10,11 Using the second option, complete removal of the invaded aortic wall demands arterial reconstruction, involving aortic clamping, relatively high blood loss, and other complications related to this type of surgery.12e14 The use of the described endovascular technique to aid abdominal tumor resection has many advantages over related conventional methods. Direct application of an aortic stent-graft eliminates the necessity for vascular anastomoses and reduces direct blood loss. Aortic flow interruption is unnecessary, and clamping is restricted to a single femoral artery. Furthermore, the complete covering of the abdominal aorta provides conditions for a wide resection of its wall, and the surgeon can wait for
1054 Presti and Casella
Annals of Vascular Surgery
Fig. 2. Surgical procedure: (A) tumor and kidney resected; (B) surgical resection of the tumor showing the aortic wall partially involved (arrowhead ); (C) partial exposition of the endoprosthesis, without bleeding
points, after aortic wall resection; (D) the aortic wall after reconstruction with bovine pericardium, covering the endoprosthesis (vertical arrowhead ).
freeze biopsy results without harm to the patient, after aortic blood flow is preserved. In the present case, we chose a 16-mm endograft based on measurements taken directly from computed tomography images. We selected an endograft with a diameter similar to that of the aorta, intentionally avoiding oversizing. We made this decision because there was virtually no risk of leaks in a normal-diameter vessel, and also to avoid late degenerative changes in the aortic wall due to continuous excessive tension, as later described by Sincos et al.15 Previous authors16e18 report the use of aortic endografts in the thoracic aorta, also for management of neoplastic invasion, with good shortand midterm results. Nimmo et al.19 also reported thoracic aorta endografting as a prophylactic measure to avoid vessel rupture caused by radiotherapy-related wall damage. After the absence of tumor cells in the resected margins of the aorta is confirmed, the exposed endoprosthesis should be covered with a bovine pericardium sheath, by suturing it to the aortic margins. Such cover provides additional reinforcement for the aorta and prevents contact between the prosthetic material and bowel segments, especially
when retroperitoneum reconstruction is not feasible. This technique could also be advantageous in other situations, such as neck tumors with carotid artery involvement.
CONCLUSION In the presented technique, using an endovascular stent-graft provided technical advantages in the resection of a retroperitoneal neoplasm involving the aortic wall. REFERENCES 1. Nishinari K, Wolosker N, Yazbek G, et al. Arterial reconstructions associated with the resection of malignant tumors. Clinics (Sao Paulo) 2006;61:339e44. 2. Jerius JT, Elmajian DA, Rimmer DM, et al. Floppy aortic graft reconstruction for germ cell tumor invasion of the infrarenal aorta. J Vasc Surg 2003;37:889e91. 3. Nishinari K, Wolosker N, Yazbek G, et al. Vascular reconstruction in limbs associated with resection of tumors. Ann Vasc Surg 2003;17:411e6. 4. Mann GN, Mann LV, Levine EA, et al. Primary leiomyosarcoma of the inferior vena cava: a 2-institution analysis of outcomes. Surgery 2012;151:261e7. 5. Mayer F, Aebert H, Rudert M, et al. Primary malignant sarcomas of the heart and great vessels in adult patientsda single-center experience. Oncologist 2007;12:1134e42.
Vol. 26, No. 7, October 2012
6. Chiche L, Mongredien B, Brocheriou I, et al. Primary tumors of the thoracoabdominal aorta: surgical treatment of 5 patients and review of the literature. Ann Vasc Surg 2003;17:354e64. 7. Tilkorn DJ, Hauser J, Ring A, et al. Leiomyosarcoma of intravascular originda rare tumor entity: clinical pathological study of twelve cases. World J Surg Oncol 2010;8:103. 8. Jaeger N, Weissbach L, Hartlapp JH, et al. Risk/benefit of treating retroperitoneal teratoid bulky tumors. Urology 1989;34:14e7. 9. Donohue JP, Thornhill JA, Foster RS, et al. Vascular considerations in postchemotherapy. Retroperitoneal lymph-node dissection: part II. World J Urol 1994;12:187e9. 10. Huvos AG, Leaming RH, Moore OS. Clinicopathologic study of the resected carotid artery. Analysis of sixty-four cases. Am J Surg 1973;126:570e4. 11. Kennedy JT, Krause CJ, Loevy S. The importance of tumor attachment to the carotid artery. Arch Otolaringol 1977;103: 70e3. 12. Kelly R, Skinner D, Yellin AE, et al. En bloc aortic resection for bulky metastatic germ cell tumors. J Urol 1995;153: 1849e51.
Stent grafts for aortic leiomyossarcomas 1055
13. Beck SD, Foster RS, Bihrle R, et al. Aortic replacement during post-chemotherapy retroperitoneal lymph node dissection. J Urol 2001;165:1517e20. 14. Bianchi C, Ballard JL, Bergan JH, et al. Vascular reconstruction and major resection for malignancy. Arch Surg 1999;134:851e5. 15. Sincos IR, Aun R, da Silva ES, et al. Impact of stent-graft oversizing on the thoracic aorta: experimental study in a porcine model. J Endovasc Ther 2011;18:576e84. 16. Berna P, Bagan P, De Dominicis F, et al. Aortic endostent followed by extended pneumonectomy for T4 lung cancer. Ann Thorac Surg 2011;91:591e3. 17. Roche-Nagle G, de Perrot M, Waddell TK, et al. Neoadjuvant aortic endografting. Ann Vasc Surg 2009;23:787.e1e5. 18. Marulli G, Lepidi S, Frigatti P, et al. Thoracic aorta endograft as an adjunct to resection of a locally invasive tumor: a new indication to endograft. J Vasc Surg 2008;47: 868e70. 19. Nimmo C, Lyons O, Clough R, et al. Novel use of endoluminal repair as prophylaxis of aortic rupture secondary to radiotherapy for lung cancer. J Vasc Surg 2011;54: 1795e7.
Tumors involving the aorta represent a challenging situation because the surgical approach can lead to blood loss and/or clamping-related complications such as ischemia, thrombosis, or reperfusion syndromes. We describe the technique of aortic endograft placement to cover part of the abdominal aorta and provide conditions for extensive aortic wall resection, without clamping or blood loss, followed immediately by aortic reconstruction with bovine pericardium. This technique also allows the surgeon to wait for the results of freeze biopsy without additional clamping time, thus avoiding the risk of leaving residual tumor cells in the aortic wall.
INTRODUCTION Tumors presenting with arterial and/or venous invasion require a proper technical approach for vessel preservation and reconstruction, generally using synthetic grafts.1e3 The recent development of endovascular aortic stent-grafts offered new possibilities in the therapy of such disease. We report the use of an aortic stent-graft to provide proper aortic wall resection and reconstruction in a case of extensive aortic leiomyosarcoma with left kidney invasion that was treated surgically.
CLINICAL SUMMARY A 41-year-old man presented with a 2-month history of back pain without weight loss or other symptoms, and with a normal physical examination. An initial contrast-enhanced computed Hospital Sı´rio Liban^es, S~ao Paulo, Brazil. Correspondence to: Ivan Benaduce Casella, Rua Peixoto Gomide, 515, cj 64, CEP 01409-001, S~ao Paulo, Brazil; E-mail: ivancasel@ uol.com.br Ann Vasc Surg 2012; 26: 1052–1055 DOI: 10.1016/j.avsg.2012.03.008 Ó Annals of Vascular Surgery Inc. Published online: July 26, 2012
1052
tomography revealed a left retroperitoneal mass invading the aortic wall and the ipsilateral kidney (Fig. 1). The initial therapeutic option was surgical resection of the mass, along with the involved aortic wall, and left nephrectomy.
TECHNIQUE DESCRIPTION With the patient under general anesthesia, a 6F pigtail catheter was inserted through the left common femoral artery and placed in the upper abdominal aorta. The right common femoral artery was exposed, and a 16 100-mm Excluder stentgraft (Gore, Newark, DE) was inserted into the abdominal aorta and positioned with its proximal portion just below the renal arteries and the distal segment close to the iliac bifurcation. After confirmation of proper positioning of the endoprosthesis on postdeployment angiographies, the femoral artery was repaired, and the groin incision was closed. We then performed a longitudinal transperitoneal laparotomy with complete removal of the retroperitoneal mass and the left kidney in a single block (Fig. 2A). The tumor was sized approximately 12 20 cm and was adherent to the left infrarenal aortic wall (Fig. 2B), which demanded its segmental
Vol. 26, No. 7, October 2012
Stent grafts for aortic leiomyossarcomas 1053
defect on the aortic wall was covered with bovine pericardium (Fig. 2D). There were no postoperative complications, and the patient was discharged after 7 days. The definitive anatomopathologic diagnosis was primary leiomyosarcoma of the abdominal aorta, with low-grade cellular differentiation. After 6 months, the patient presented with metastatic lesions in the lumbar spine, and died after 19 months after complications related to chemotherapy procedures. No complications related to the endovascular therapy were observed during this follow-up period.
DISCUSSION
Fig. 1. Axial and longitudinal computed tomography scan views showing the retroperitoneal mass originating from the aorta and involving the left kidney. White arrows delimitate the tumor in the axial view (bottom).
resection with safety margins of approximately 4 3 cm. During the aortic wall resection, no clamping was needed and no blood loss was observed, after the stent-graft was covering the resected area completely. The stent-graft became temporarily exposed and could be directly observed (Fig. 2C). Freeze biopsy confirmed the absence of tumor cells in the margins of the aortic wall. The resulting
Leiomyosarcomas of vascular origin are extremely rare events, especially when located in the aorta.4e6 According to Tilkorn et al.,7 these tumors represent <1% of all malignant soft-tissue tumors. In retroperitoneal tumors, the presence of aortic invasion is generally investigated before surgery to enable optimal planning of the surgical approach. In the present case, the early diagnosis of aortic wall involvement offered the possibility for endovascular covering of the inner vessel wall. Two elementary techniques can be used to remove neoplasms involving the walls of great vessels: subadventitial resection of the vessel wall, or complete resection of the involved parts and subsequent vessel reconstruction with a prosthetic or an autogenous substitute. Using the first option, it is possible to remove theneoplasm and involved vessel layers without clamping and consequent flow interruption, thereby minimizing blood loss and avoiding limb ischemia. However, this method carries a high risk of aortic rupture and late aortoenteric fistulae.8,9 In addition, local recurrence may occur because of microscopic invasion of the remaining layers of the artery.10,11 Using the second option, complete removal of the invaded aortic wall demands arterial reconstruction, involving aortic clamping, relatively high blood loss, and other complications related to this type of surgery.12e14 The use of the described endovascular technique to aid abdominal tumor resection has many advantages over related conventional methods. Direct application of an aortic stent-graft eliminates the necessity for vascular anastomoses and reduces direct blood loss. Aortic flow interruption is unnecessary, and clamping is restricted to a single femoral artery. Furthermore, the complete covering of the abdominal aorta provides conditions for a wide resection of its wall, and the surgeon can wait for
1054 Presti and Casella
Annals of Vascular Surgery
Fig. 2. Surgical procedure: (A) tumor and kidney resected; (B) surgical resection of the tumor showing the aortic wall partially involved (arrowhead ); (C) partial exposition of the endoprosthesis, without bleeding
points, after aortic wall resection; (D) the aortic wall after reconstruction with bovine pericardium, covering the endoprosthesis (vertical arrowhead ).
freeze biopsy results without harm to the patient, after aortic blood flow is preserved. In the present case, we chose a 16-mm endograft based on measurements taken directly from computed tomography images. We selected an endograft with a diameter similar to that of the aorta, intentionally avoiding oversizing. We made this decision because there was virtually no risk of leaks in a normal-diameter vessel, and also to avoid late degenerative changes in the aortic wall due to continuous excessive tension, as later described by Sincos et al.15 Previous authors16e18 report the use of aortic endografts in the thoracic aorta, also for management of neoplastic invasion, with good shortand midterm results. Nimmo et al.19 also reported thoracic aorta endografting as a prophylactic measure to avoid vessel rupture caused by radiotherapy-related wall damage. After the absence of tumor cells in the resected margins of the aorta is confirmed, the exposed endoprosthesis should be covered with a bovine pericardium sheath, by suturing it to the aortic margins. Such cover provides additional reinforcement for the aorta and prevents contact between the prosthetic material and bowel segments, especially
when retroperitoneum reconstruction is not feasible. This technique could also be advantageous in other situations, such as neck tumors with carotid artery involvement.
CONCLUSION In the presented technique, using an endovascular stent-graft provided technical advantages in the resection of a retroperitoneal neoplasm involving the aortic wall. REFERENCES 1. Nishinari K, Wolosker N, Yazbek G, et al. Arterial reconstructions associated with the resection of malignant tumors. Clinics (Sao Paulo) 2006;61:339e44. 2. Jerius JT, Elmajian DA, Rimmer DM, et al. Floppy aortic graft reconstruction for germ cell tumor invasion of the infrarenal aorta. J Vasc Surg 2003;37:889e91. 3. Nishinari K, Wolosker N, Yazbek G, et al. Vascular reconstruction in limbs associated with resection of tumors. Ann Vasc Surg 2003;17:411e6. 4. Mann GN, Mann LV, Levine EA, et al. Primary leiomyosarcoma of the inferior vena cava: a 2-institution analysis of outcomes. Surgery 2012;151:261e7. 5. Mayer F, Aebert H, Rudert M, et al. Primary malignant sarcomas of the heart and great vessels in adult patientsda single-center experience. Oncologist 2007;12:1134e42.
Vol. 26, No. 7, October 2012
6. Chiche L, Mongredien B, Brocheriou I, et al. Primary tumors of the thoracoabdominal aorta: surgical treatment of 5 patients and review of the literature. Ann Vasc Surg 2003;17:354e64. 7. Tilkorn DJ, Hauser J, Ring A, et al. Leiomyosarcoma of intravascular originda rare tumor entity: clinical pathological study of twelve cases. World J Surg Oncol 2010;8:103. 8. Jaeger N, Weissbach L, Hartlapp JH, et al. Risk/benefit of treating retroperitoneal teratoid bulky tumors. Urology 1989;34:14e7. 9. Donohue JP, Thornhill JA, Foster RS, et al. Vascular considerations in postchemotherapy. Retroperitoneal lymph-node dissection: part II. World J Urol 1994;12:187e9. 10. Huvos AG, Leaming RH, Moore OS. Clinicopathologic study of the resected carotid artery. Analysis of sixty-four cases. Am J Surg 1973;126:570e4. 11. Kennedy JT, Krause CJ, Loevy S. The importance of tumor attachment to the carotid artery. Arch Otolaringol 1977;103: 70e3. 12. Kelly R, Skinner D, Yellin AE, et al. En bloc aortic resection for bulky metastatic germ cell tumors. J Urol 1995;153: 1849e51.
Stent grafts for aortic leiomyossarcomas 1055
13. Beck SD, Foster RS, Bihrle R, et al. Aortic replacement during post-chemotherapy retroperitoneal lymph node dissection. J Urol 2001;165:1517e20. 14. Bianchi C, Ballard JL, Bergan JH, et al. Vascular reconstruction and major resection for malignancy. Arch Surg 1999;134:851e5. 15. Sincos IR, Aun R, da Silva ES, et al. Impact of stent-graft oversizing on the thoracic aorta: experimental study in a porcine model. J Endovasc Ther 2011;18:576e84. 16. Berna P, Bagan P, De Dominicis F, et al. Aortic endostent followed by extended pneumonectomy for T4 lung cancer. Ann Thorac Surg 2011;91:591e3. 17. Roche-Nagle G, de Perrot M, Waddell TK, et al. Neoadjuvant aortic endografting. Ann Vasc Surg 2009;23:787.e1e5. 18. Marulli G, Lepidi S, Frigatti P, et al. Thoracic aorta endograft as an adjunct to resection of a locally invasive tumor: a new indication to endograft. J Vasc Surg 2008;47: 868e70. 19. Nimmo C, Lyons O, Clough R, et al. Novel use of endoluminal repair as prophylaxis of aortic rupture secondary to radiotherapy for lung cancer. J Vasc Surg 2011;54: 1795e7.