The first reported case of vascular reconstruction associated with lower limb sarcoma resection is described by Fortner in 1977, (3) the concept of limbs preserving surgery has been progressively adopted, when possible, for the improvement of the quality of life. (4,5)
This objective should be achieved in all invasive neoplasm with vascular involvement with a close collaboration between all the specialists. The decision-making process in lower limbs soft tissue sarcoma is crucial and include oncologist, orthopedic and vascular specialists for a preoperative planning and cooperation also in the postoperative period. (6)
Lower limb soft tissue sarcoma can be rarely removed preserving the arterial and venous vessels, because major vascular resection and reconstruction is required for adequate oncologic margins. The excision with artery and/or vein reconstruction has been already reported. (7) For example, in our series, in a male patient 41 years old, affected by symptomatic neoplasm after local radiotherapy and vascular compression, it discussed which type of resection should be more appropriate. It was performed a “partial resection” with bone transplantation and vessel replacement with GSV, following discussion with oncologist and orthopedic surgeon.
(Fig 1) The histological specimen analysis reveal an intact margin preservation with absence of neoplastic cells.
Preoperative diagnostic imaging
Preoperative vascular imaging is crucial for operative planning.
In our series all patients underwent CT angiography. This examination give, using multiplanar reconstruction, the best imaging requirements for preoperative evaluation in tumor resection surgery, accurately revealing the vascularization of the neoplasm and the relationships of contiguity or continuity between the neoplasm and the vessels. (Fig 2A)
CT gives best depiction of osseous structures and has better spatial resolution compared to MRI, despite the disadvantages of using ionizing radiation and iodine contrast medium, potentially nephrotoxic.
In all cases patients had the contralateral leg vein mapped just before the operation
to obtain precise donor site of the great saphenous vein, in case of need.
Results and complication
The surgical techniques in previous series reports mortality rates of 0-4.8%, tumor control in 86-100% of patients and limb salvage in 92-94.1%. (3) In the postoperative period the presence of edema was clinically evident in about 40% of treated cases, with no obvious difference between veins treated with grafting or with ligation as Schwarzbach , Tsukushi and Spark demonstrated(4,8,9). In our experience 5/32 pts presented edema postoperative with the same characteristics. Morbidity came from wound complications, with dehiscence reported in the literature 33-57%. (10)
In our cases, this kind of complication were experience successfully treated with Vacuum Assisted Closure Therapy (VAC). The literature report a graft infection rates of 6-29%. (2,7,11) (Tab 1)
No infection were observed in our experience. In this condition, when the vessel involvement and removal is crucial for a radical surgery, vascular surgeon role is essential in a multidisciplinary setting, also to choice the better technique of revascularization or to decide no indication for an eventual venous vessel replacement (12,13) (Fig 3-4)
In particular cases the removal of the neoplasm may require a large dissection to preserve the vascular axis and also in the absence of a revascularization, the presence of the vascular surgeon makes the bleeding minimal and the removal more accurate and, at the same time, radical. (Fig 2B). While immediate results are influenced by intraoperative conduct, the follow-up results are conditioned by the appearance of metastases and consequent mortality is not negligible. The 5-year survival rate is 68.4% in the more prolonged follow up. (12,14)
As in reconstructions for atherosclerotic obstructive pathology, the vein is used as an ideal substitute.
In our experience, in the case of unavailability of suitable venous autogenic substitutes, good results have also been obtained with synthetic prostheses with comparable rates of patency. It is necessary to consider that these are normal arteries, therefore with greater possibility of patency even at a distance. For venous reconstructions also in our experience the patency was lower, but with no relevant symptoms. The majority of patients must perform chemo and radiotherapy cycles and despite the good results, the mortality at distance is unpredictable, depending on the neoplasm prognosis.