Early and late outcomes of patients treated with graft replacement of the inferior vena cava for malignant disease: A single-center experience over three decades

Objective: To describe early and late outcomes of segmental resection and graft replacement of the inferior vena cava (IVC) for malignant disease over three decades. Methods: All patients who had IVC resection with graft replacement from 1990 to 2024 at a single institution were retrospectively reviewed. Patients with tangential excision and primary or patch venorrhaphy were excluded. End points were early (<30 days) mortality, major adverse events, graft-related complications, primary patency, overall survival, and freedom from local recurrence. Results: One hundred sixty-seven patients (54% female; mean age at operation 55 ±14 years) had IVC resection and graft replacement. Primary IVC leiomyosarcoma occurred in 69 patients (41%) and other secondary malignancies in 97 (58%). Preoperative performance status (Eastern Cooperative Oncology Group) was good or excellent in 153 patients (92%). Resection of multiple IVC segments was required in 94 patients (56%), 41 who needed renal vein reconstruction or implantation (25%) and 6 (3.6%) who had hepatic vein implantation. Graft replacement was with ringed polytetrafluoroethylene in 163 patients (98%). Two patients died of intraoperative hemorrhage. Six others died within 4 months; three were procedure-related. One or more major adverse events occurred in 28 patients (17%). Intra-abdominal hemorrhage requiring transfusion was the most common complication, occurring in 10 patients (5.9%). Only one patient developed permanent renal or liver failure. Two patients (1.2%) had asymptomatic subsegmental pulmonary emboli. Over a mean follow-up of 5.5 ± 5.8 years (median 3.2 [1.2, 7.5] years), 10 patients experienced graft occlusion (5.9%). Two occlusions were within 1 month of graft placement, two were within 1 year, and 6 were over 1 year, with one at 23 years postoperatively. Four patients had stents placed to treat asymptomatic high-grade stenoses, one early and three late. There were four graft infections, all related to small bowel leaks. The median overall survival was 52% and 36% at 5 and 10 years, respectively (range, 0-27 years). Freedom from local recurrence was 85%, 71%, and 54% at 1, 5, and 10 years, respectively. Kaplan-Meier estimates of IVC graft primary patency were 96%, 95%, and 88% at 1, 5, and 10 years, respectively. Conclusions: IVC resection and graft replacement for malignant disease are safe and durable, and provide excellent local control of the tumor, offering a chance for long-term survival in select patients.