Baxter B Timothy, Mahoney Craig, Johnson Perry J, Selmer Kerby M, Pipinos Iraklis I, Rose Justin, Neff James R
Department of General and Orthopedic Surgery, the University of Nebraska Medical Center, Omaha, NE, USA.
Ann Vasc Surg. 2007 May;21(3):272-9. doi: 10.1016/j.avsg.2007.03.005.
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.
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.
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.
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.
在许多下肢肉瘤病例中现在都可以实现保肢。获得无瘤切缘可能需要切除相邻的血管结构。我们介绍了一系列连续的患者的经验，这些患者接受了下肢肉瘤与动静脉整块切除手术，重点关注其血管重建的中长期结果。
回顾性查阅患者年龄、肿瘤位置和类型、手术过程以及早期和晚期结果的记录。1991年至2004年间，10名儿童（平均年龄12岁，范围6 - 18岁）和9名成人（平均年龄48岁，范围24 - 73岁）接受了下肢肉瘤的广泛切除，包括受累的动脉和静脉段。所有儿童均患有骨肉瘤，由于其骨骼未成熟，他们接受了旋转成形术——一种间置截肢术，切除大腿远端、膝关节和胫骨近端，同时保留小腿远端和足部。在旋转成形术中，保留远端残肢，旋转180度，并连接到大腿，使踝关节位于原膝关节水平。在这些病例中，通过一期吻合重建残余血管。除1名成人外，所有成人均患有软组织肉瘤；切除的血管用对侧大隐静脉重建。在所有病例中，手术方法包括在肿瘤切除和骨科重建期间进行动静脉分流。
平均随访时间为5.7年。3例患者死于转移性疾病，1例死于术后肺栓塞。无患者局部复发。2例患者最终需要进行膝上截肢：1名儿童因再灌注损伤导致组织丢失，1名成人因外周动脉疾病进展导致移植物血栓形成。2例患者因围手术期移植物血栓形成需要早期再次手术探查。两者均需要用聚四氟乙烯（PTFE）人工血管替换大隐静脉导管；其中1个PTFE移植物发生感染。
即使整块切除包括动脉和静脉，大多数下肢肉瘤患者仍可实现保肢。术中分流可限制缺血，在骨科重建延迟即时血管修复时尤其有用。重建血管的长期通畅率很高。当大隐静脉口径足够时，是首选的血管导管。
