Quickshot: Novel Funnel Technique for Homograft Replacement of the Inferior Vena Cava in the Setting of Oncovascular Reconstruction

The author’s objective is to describe a novel funnel technique for modifying an aortobiiliac cadaveric homograft so that longer length is achieved and allows for a gradual transition in diameter for inferior vena cava (IVC) reconstruction following oncologic resection. A 32-year-old man with a history of mixed germ cell testicular cancer stage IIc with retroperitoneal metastases, prior right orchiectomy and retroperitoneal lymph node dissection (RPLND) was found to have recurrence after first- and second-line chemotherapy in the left iliac and interaortocaval region. IVC and iliac vessel involvement was seen on positron emission tomography – computed tomography (PET-CT). Subsequent surgical intervention was discussed with the patient and the decision was made to proceed.

Methods:

Redo RPLND with vascular reconstruction was planned with vascular surgery and urology teams. The involvement of the left iliac vessels was approached initially and required resection of the common and external iliac vessels. The iliac arteries were amenable to end-to-end re-anastomosis, and the iliac veins required a cryopreserved femoral vein interposition graft as shown in Figure 1. Due to the unexpected duration of the procedure and intraoperative blood loss, the patient's abdomen was left open with a negative pressure dressing, and completion was planned in a staged fashion. During the second stage, due to the extent of IVC resection necessary and the duration of the open abdomen dressing, replacement of the IVC with a cryopreserved aortobiiliac homograft was planned (Figure 1).

Results:

The iliac limbs of the homograft were slit open and resutured in a longitudinal fashion. This resulted in a funnel-shaped graft that was adequate in both size and length. IVC replacement was performed posterior to the right renal artery in case of local recurrence. The intraoperative aspect is shown in Figure 2. Postoperative course was unremarkable and the patient was discharged on postoperative day 6. 1-year follow-up imaging showed no recurrence, patent vessels and negative tumor markers.

Conclusions:

This case demonstrates a possible technique for elongating homograft when greater length is necessary, while also allowing for a gradual transition in diameter. This can be useful in potentially contaminated fields where the use of prosthetic would be ill advised and, in order to avoid prolonged intraoperative time and additional blood loss as well as morbidity related to harvest of autologous deep vein conduits.