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 1990-2024 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 (MAE), 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%). Pre-operative performance status (ECOG) 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 PTFE in 163 patients (98%). Two patients died from intraoperative hemorrhage. Six others died within four months, three were procedure-related. One or more MAEs occurred in 28 patients (17%). Intraabdominal hemorrhage requiring transfusion was the most common complication, occuring in ten patients (5.9%). Only one patient each 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 one month of graft placement, two were within one year, and 6 were over one year, with one at 23 years post-op. 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. Median overall survival was 52% and 36% at five and ten years, respectively (range 0-27 years). Freedom from local recurrence was 85%, 71%, and 54% at 1-, 5- and 10-years. Kaplan-Meier estimates of IVC graft primary patency were 96%, 95%, and 88% at 1-, 5-, and 10-years.

Conclusion: IVC resection and graft replacement for malignant disease is safe, durable, and provides excellent local control of the tumor, offering a chance for long-term survival in select patients.