Elsevier

Annals of Vascular Surgery

Volume 21, Issue 3, May–June 2007, Pages 272-279
Annals of Vascular Surgery

Festschrift for James S.T. Yao, MD, PhD
Concomitant Arterial and Venous Reconstruction with Resection of Lower Extremity Sarcomas

https://doi.org/10.1016/j.avsg.2007.03.005Get rights and content

Introduction

Limb salvage can now be achieved in many cases of lower extremity sarcoma. Obtaining disease-free margins may require resection of adjacent vascular structures. We present our experience with a consecutive series of patients undergoing resection of lower extremity sarcomas en block with the artery and vein, focusing on the mid- and long-term outcomes of their vascular reconstruction.

Methods

Records were reviewed retrospectively for patient age, tumor location and type, procedure, and early and late outcomes. Between 1991 and 2004, 10 children (mean age 12 years, range 6-18 years) and 9 adults (mean age 48 years, range 24-73 years) underwent wide resection of lower extremity sarcomas to include the involved arterial and venous segments. All children had bone sarcomas, and because of their skeletal immaturity, they were treated with rotationplasty—a type of intercalary amputation that removes the distal thigh, knee, and proximal tibia while preserving the distal leg and foot. In rotationplasty, the distal residual limb is preserved, rotated 180 degrees, and attached to the thigh, positioning the ankle at the level of the former knee joint. In these cases, the residual vessels were reconstructed by primary anastomosis. All of the adults except one had soft tissue sarcomas; the resected vessels were reconstructed with contralateral saphenous vein. In all cases, the operative approach included shunting of artery and vein during tumor removal and orthopedic reconstruction.

Results

The mean follow-up was 5.7 years. Three patients died of metastatic disease, and one died from a postoperative pulmonary embolism. No patient had local recurrence. Two patients ultimately required above-knee amputation: one child for tissue loss secondary to reperfusion injury, and one adult because of graft thrombosis secondary to progression of peripheral arterial disease. Two patients required early re-exploration for perioperative graft thrombosis. Both required replacement of saphenous vein conduits with polytetrafluoroethylene (PTFE) prosthetic graft; one of the PTFE grafts became infected.

Conclusions

Limb salvage can be achieved in the majority of patients who have lower extremity sarcomas even when en bloc resection includes the artery and vein. Intraoperative shunting can limit ischemia and is especially useful when immediate vascular repair is delayed by orthopedic reconstruction. The long-term patency rate of the reconstructed vessels is high. Saphenous vein is the preferred conduit when it is of adequate caliber.

Section snippets

Methods

During the period of 1991 to 2004, a total of 19 patients with primary bone and soft tissue sarcomas of the lower extremity underwent en block resection of tumor and involved artery and vein. The patient age, gender, tumor location, histologic tumor type, resected vessels, and graft material used are outlined in Table I. Nine of the patients 19 years of age or older were classified as adults; the remaining patients were considered children. At the time of initial evaluation, two patients had

Results

During the follow-up period (mean 5.7 years), three patients died of metastatic disease, and one died from a postoperative pulmonary embolism. Two of the patients with metastatic disease had known metastatic foci at the time of the initial operation done to control local disease; the other patient developed metastatic disease 1 year after the primary operation. Two of the patients had subsequent lung metastasectomies. None of the patients had local recurrence of their sarcoma. The average

Discussion

The results of this study are consistent with recent reports showing that treatment of lower extremity sarcoma with extended resection and vascular reconstruction can achieve both local disease control and limb salvage with good function. Perioperative multimodal therapy, including radiation treatment and chemotherapy, plays an important role in this process, reducing the incidence of local recurrence and metastasis.15 In our series, all patients received preoperative chemotherapy with seven

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