EJVES Extra
Volume 18, Issue 1 , Pages 9-11, July 2009

Reconstruction of the Common Femoral Vein and Artery after Resection of a Leiomyosarcoma of the CFV

  • M.M. Veerman

      Affiliations

    • Department of Surgery, St. Elisabeth Hospital, Tilburg, The Netherlands
    • Corresponding Author InformationCorresponding author. M.M. Veerman. Department of Surgery, St. Elisabeth Hospital, P.O. Box 90151, 5000 LC Tilburg, The Netherlands. Tel.: +31 13 5393559.
    • ,
  • J.M.M. Heyligers

      Affiliations

    • Department of Surgery, St. Elisabeth Hospital, Tilburg, The Netherlands
    • ,
  • J.T. Heikens

      Affiliations

    • Department of Surgery, St. Elisabeth Hospital, Tilburg, The Netherlands
    • ,
  • A. Smeets

      Affiliations

    • Department of Radiology, St. Elisabeth Hospital, Tilburg, The Netherlands
    • ,
  • J.A. Roukema

      Affiliations

    • Department of Surgery, St. Elisabeth Hospital, Tilburg, The Netherlands
    • ,
  • D.P. van Berge Henegouwen

      Affiliations

    • Department of Surgery, St. Elisabeth Hospital, Tilburg, The Netherlands

Received 15 February 2009; accepted 17 February 2009. published online 01 June 2009.

Article Outline

Abstract 

An innovative reconstruction of the common femoral vein (CFV) concomitant to reconstruction of the femoral arteries in case of a vascular leiomyosarcoma of the CFV is presented here. Preserving venous outflow in the CFV could prevent a post-thrombotic syndrome. A venous reconstruction with a venous spiral graft in combination with a stent prevents postoperative occlusion. Both the venous and arterial grafts remain patent at 1 year of follow-up.

Keywords: Leiomyosarcoma, Common femoral vein, Femoral arteries, Venous reconstruction

 

Primary leiomyosarcomas originating from the femoral veins or arteries are rare.1 A case of a vascular leiomyosarcoma of the common femoral vein (CFV) with a simultaneous reconstruction is reported.

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Case Report 

A 68-year-old man was referred for a painful mass in the left groin and leg oedema. Ultrasonography and CT angiography showed a tumour of 52×50×67mm with encasement of the common femoral vein and artery. Colour duplex showed a patent great saphenous vein (GSV). Further CT scans were negative for metastasis. A Tru-cut biopsy revealed a primary leiomyosarcoma.

Surgical treatment consisted of en bloc resection of the tumour followed by a CFV reconstruction, using a spiral graft with a dilatating stent and an arterial reconstruction. An ipsilateral upper leg GSV (30cm in length) was harvested and cut open longitudinally, creating the venous conduit: a spiral venous graft (Fig. 1a). A self-expanding stent was placed within the graft (Fig. 1b). A bifurcated interposition for the femoral artery bifurcation was constructed using a heparinised polytetrafluoroethylene (PFTE) prosthesis (Propaten®). Harvesting and construction of the venous conduit and the arterial interposition simultaneously with the en bloc resection of the tumour, sparing the femoral nerve, was completed in 45min. Subsequently, the venous spiral graft and the PTFE conduit were implanted. An arteriovenous fistula was added to the venous conduit (Fig. 2a and b). Doppler showed normal flow in both the reconstructions. Total clamp time was 75min.

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  • Figure 1 

    Construction of the venous conduit. (a) Construction of the saphenous vein spiral graft using continuous 6/0 vascufil sutures mounted on a 12mm Hegar dilator. (b) Placement of a dilating 12mm stent within the venous spiral graft, 9.5cm long and 11mm in width.

  • View full-size image.
  • Figure 2 

    Venous and arterial reconstruction. (a) Reconstruction of the common femoral vein (CFV) with a venous spiral graft: proximal end-to-end anastomosis between the graft and the CFV and a distal anastomosis between the graft and the superficial femoral vein (SFV), using continuous 6/0 vascufil sutures. (b) Arterial reconstruction with a 8mm, heparinised PFTE interposition graft with end-to-end anastomoses between the common femoral artery (CFA) and the superficial femoral artery (SFA) and the profunda femoral artery (PFA). Arrow shows the arterial–venous fistula between the venous spiral graft and the PFA.

Postoperative treatment consisted of Fragmin® (therapeutic dose of 15,000IU daily) followed by oral anticoagulants and support stockings. Pathological examination revealed a high-grade leiomyosarcoma of the CFV with irradical resection margins. No adjuvant radiation therapy was administered because of the lack of evidence to reduce the recurrence rate and to prevent lymphoedema.

After 12 months, both reconstructions were patent. The arteriovenous fistula was still open 2 weeks after surgery, but occluded spontaneously at 3 months. One year after surgery, no signs of local recurrence, distal oedema or venous hypertension occurred.

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Discussion 

Vascular reconstructions facilitate limb-sparing treatment of soft-tissue sarcomas with involvement of the major vessels of the lower extremities. En bloc resection of the tumour with reconstruction of the affected femoral arteries is required to preserve the affected limb. A PFTE interposition graft reconstruction was chosen in case of adjuvant radiation therapy. Controversy remains with respect to an additional venous reconstruction in case of both arterial and venous involvement.2 An important argument that favours venous reconstruction is the prevention of postoperative venous hypertension.3 Because of the tendency to shrink, the patency rates are not satisfactory.3 If sufficient venous collaterals developed preoperatively, a venous reconstruction would be unnecessary.4 However, this option is not feasible for patients with involvement of the complete femoral vein bifurcation.3, 5

In this case report, a simultaneous arterial and venous reconstruction with an innovative solution for the disadvantages of venous grafts is shown. We used a spiral graft constructed from autologous venous material4 with stenting. The stent had a twofold purpose: improving the patency rate and reducing the vulnerability of the graft for adjuvant radiation. With an arteriovenous fistula, the venous blood is increased to prevent thrombosis. Finally, anticoagulant treatment was given for 6 months.

By working with two teams the length of the operation time was reduced.

We illustrated that a concomitant arterial and venous reconstruction is feasible when using adjuvant measures to prevent postoperative clotting of the venous conduit. Simultaneous vascular conduit construction and resection of the tumour saves essential operating time.

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Conflict of Interest/Funding 

None.

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References 

  1. Streukens SAF, Scheltinga MRM, Ebels J, van Lijnschoten G, Roumen RMH, Pasmans HLM. A patient with vague inguinal complaints due to a leiomyosarcoma of the inferior caval vein. Ned Tijdschr Geneeskd. 2007;151:2574–2579
  2. Tsukushi S, Nishida Y, Sugiura H, Nakashima H, Ishiguro N. Results of limb-salvage surgery with vascular reconstruction for soft tissue sarcoma in the lower extremity: comparison between only arterial and arteriovenous reconstruction. J Surg Oncol. 2008;97(3):216–220
  3. Matsushita M, Kuzuya A, Mano N, Nishikimi N, Sakurai T, Nimura Y, et al. Sequelae after limb-sparing surgery with major vascular resection for tumor of the lower extremity. J Vasc Surg. 2001;33:694–699
  4. Schwarzbach MH, Hormann Y, Hinz U, Bernd L, Willeke F, Mechtersheimer G, et al. Results of limb-sparing surgery with vascular replacement for soft tissue sarcoma in the lower extremity. J Vasc Surg. 2005;42:88–97
  5. McKay A, Motamedi M, Temple W, Mack L, Moore R. Vascular reconstruction with the superficial femoral vein following major oncologic resection. J Surg Oncol. 2007;96(2):151–159

PII: S1533-3167(09)00012-0

doi:10.1016/j.ejvsextra.2009.02.004

Refers to article:

  • Reconstruction of the Common Femoral Vein and Artery after Resection of a Leiomyosarcoma of the CFV , 01 June 2009

    European Journal of Vascular & Endovascular Surgery August 2009 (Vol. 38, Issue 2, Page 251)

EJVES Extra
Volume 18, Issue 1 , Pages 9-11, July 2009

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