Primary leiomyosarcoma of inferior vena cava adjacent to hepatic veins: complete off-pump resection and inferior vena cava graft reconstruction with application of external skin surface cooling.

OBJECTIVES

Resection of a leiomyosarcoma of the inferior vena cava (IVC) requires venovenous bypass, especially if IVC clamping above the hepatic veins is planned. This report describes the application of external skin surface cooling for off-pump resection of a primary IVC leiomyosarcoma adjacent to the hepatic veins with graft IVC reconstruction in conditions of suprahepatic caval clamping and uninterrupted Pringle's manoeuvre.

METHODS

A 62-year-old woman presented with IVC leiomyosarcoma adjacent to the hepatic veins. After anaesthesia induction, the patient's head, neck, abdomen, chest, thighs and shanks were covered by polyethylene bags containing granulated ice. The ice bag was also placed between the internal surfaces of the thighs. After 108 min, the target oesophageal temperature (29°C) was achieved, all bags were removed, except the bags that were used for temperature control during the operation located on head, neck and between internal surfaces of the thighs. Off-pump resection of the tumour was performed in conditions of suprahepatic IVC and portal triad clamping via median laparotomy.

RESULTS

IVC clamping was accompanied by arterial hypotension of 55-65 mmHg well-tolerating in the hypothermic background for 69 min. The simultaneous application of an uninterrupted Pringle's manoeuvre was accompanied by low levels of transaminases and bilirubin. There was no local relapse of the tumour or metastases over a 6-month follow-up.

CONCLUSIONS

External skin surface cooling in cases demanding IVC clamping above the hepatic veins and Pringle's manoeuvre allows avoiding venovenous bypass. This method is safe, cost effective, easily performed and may be used in clinical cases involving systemic arterial hypotension.