Extra-anatomical arterial bypass with leiomyosarcoma of the thigh
(Portuguese PDF version)

Rodrigo Machado Landim,1 André Del Negro,2 Lucas Marcelo Dias Freire,1 Alfio José Tincani,3 Antônio Santos Martins,3 George Carchedi Luccas4

1.Resident physician, Vascular Surgery, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil.
2.Attending surgeon, Head and Neck Surgery, UNICAMP, Campinas, SP, Brazil.
3.Ph.D. Professor, Head and Neck Surgery, UNICAMP, Campinas, SP, Brazil.
4.Ph.D. Professor, Vascular Surgery, UNICAMP, Campinas, SP, Brazil.

Correspondence:
André Del Negro
Governador Pedro de Toledo 2157/141
CEP 13400-075 - Piracicaba, SP, Brazil
Phone: +55 19 3422-6014
Fax: +55 19 3422-5323
E-mail: docdnegro@yahoo.com.br

ABSTRACT

Extra-anatomical bypass is a technical option feasible when anatomical pathways are contraindicated or considered of high risk. In this paper we report a case of soft tissue sarcoma in the proximal third of the left lower extremity involving the femoral vessels. The patient was submitted to an extra-anatomical bypass from the external iliac artery to the popliteal artery with PTFE. She was then submitted to en bloc resection of the tumor, quadriceps muscle and femoral vessels. After a 24-month follow-up period the patient has patent PTFE graft and no evidence of local recurrence.

Key-words: revascularization, grafts, soft tissues sarcoma.

J Vasc Br 2005;4(2):205-8

The primary treatment of soft tissue sarcoma is the surgical resection with adequate margins, in order to achieve the local control of the disease. A wide margin is not always easy to obtain, due to the local anatomical limitations. Historically, the involvement of great vascular-nervous bundles almost always resulted in amputations. The current tendency is the en bloc resection of the tumor with muscle groups involved, as well as the main vessels affected by the tumor, frequently associating chemoradiation therapy. Limb salvage has been obtained through vascular derivations when there is the need of a resection of the trunk vessels in up to 90%.¹

The extra-anatomical bypass is al alternative procedure for lower limb revascularization when the usual anatomical pathways are affected, whether by reoperation, local infection or neoplastic lesion. In this case report, we describe a case of vascular reconstruction to preserve the lower limb of a patient with leiomyosarcoma of the thigh with involvement of the common femoral artery and vein, deep and superficial, submitted to an extra-anatomical graft previously to the ablative surgery.

CASE REPORT

A female patient, 48 years old, hypertensive, and smoker was evaluated at the Service of Head and Neck Surgery/Surgical Oncology of the Department of Surgery at the Universidade Estadual de Campinas (UNICAMP) in August 2002, reporting a tumor at the anterior aspect of the left thigh for approximately 2 years, with a slow and progressive growth, with no other symptoms. She reported previous history (9 years) of deep venous thrombosis, which was treated at another service, with oral anticoagulation for 6 months.

At physical examination, she presented with a lesion in the proximal third of the left thigh at its anteromedial aspect, measuring 8 cm x 6 cm, with a hard consistency and attached to deep fascial planes. Femoral, popliteal, posterior tibial, and pedal pulses were palpable. She presented a pitting edema (++/4+) of the leg and distal third of the thigh.

A duplex scanning of the left lower limb was performed, showing obstruction of the superficial femoral vein by tumor. The great saphenous, deep and common femoral, and popliteal veins were patent.

For a histopathologic diagnosis, a fine-needle aspiration puncture was attempted, which proved to be inconclusive.

Due to the need of obtaining a significant sample of neoplastic tissue for histological study, an incisional biopsy (1 cm x 1 cm x 1 cm) was performed under epidural anesthesia on August 28, 2002. During the procedure, there was an accidental lesion in the superficial femoral artery, whose bleeding was controlled by suture-ligation. The flow in the lower limb was exclusively dependent on the deep femoral artery, totally involved by the tumor.

The final report of the pathology confirmed the diagnosis of leiomyosarcoma grade II.

After the biopsy, the patient remained asymptomatic, but with absent popliteal and tibial pulses. She was sent to the Vascular Surgery Service at the Department of Surgery of UNICAMP. A Doppler study was requested, showing an ankle-brachial index of 0.76. A lower limb arteriography was performed, revealing occlusion of the left superficial femoral artery and collateral refilling of the deep femoral artery, the left supragenicular popliteal artery, and patent leg arteries, without alterations. The magnetic nuclear resonance confirmed the femoral vessel invasion by the tumor (Figure 1).

Figure 1 - Magnetic nuclear resonance showing femoral vessel invasion by the sarcoma (arrow).

Before the ablative treatment of the tumor, an arterial bypass was indicated, once the surgical proposal included the resection of common femoral vessels and their deep and superficial branches. After the accidental lesion of the superficial femoral artery, the limb remained compensated, with no signs of critical ischemia, probably due to the circulation through the deep branch, showing the need for preserving the flow through this artery.

An extraperitoneal access to the external iliac artery was performed by a 6-mm PTFE lateral graft for the supragenicular popliteal artery through a subcutaneous tunnel, termino-lateral anastomosis, with continuous suture of polypropylene.

The conduit chosen for arterial bypass was a PTFE graft, not using the homolateral great saphenous vein, preserved due to the deep venous system impairment by the tumor. Moreover, this material was selected, instead of the Dacron, due to the risk of infection. The lateral route was given preference, since the bypass through the obturator foramen would expose the graft to a surgical field, when resecting the tumor, and to the radiation field.

The patient progressed satisfactorily after the surgery, with present popliteal and tibial pulses, and an ankle-brachial index of 0.9. A postoperative duplex scanning was performed, showing triphasic flow with normal velocity and no alterations, being the patient able to be submitted to a resection surgery.

On the sixth postoperative day, she was submitted to resection of the left quadriceps muscle group, from its origin at the pelvis until its insertion in the patella, with a deep margin in the periosteum of the femur, sacrificing the common femoral artery and vein, preserving the great saphenous vein for the venous reflow. The postoperative evolution was satisfactory, only presenting a slight worsening in the limb edema.

The adjuvant treatment was completed after 36 sessions of radiotherapy, with a total dose of 6480 cGy, and systemic chemotherapy with Doxorubicin, six cycles.

After an 18-month follow-up, multiple pulmonary metastases were verified. Since surgical resection could not be performed, a new cycle of chemotherapy was indicated. In the follow-up after 24 months, the patient is wearing elastic stockings, with improvement in the edema, with no local recurrence of the tumor, and with partial response to chemotherapy of pulmonary metastases.

DISCUSSION

The incidence of soft tissue sarcoma has been increasing in the United States, with approximately 8,700 new cases/year.² Of these patients, more than 50% will evolve to death due to the tumor, secondary to the metastatic disease, being the lungs the most affected site.²

The extra-anatomical bypass avoids complex vascular problems when the conventional anatomical procedures are considered as high risk or impossible to be performed.³ The extra-anatomical bypass was first described by Freeman & Leeds, when they used the superficial femoral artery to transport blood to the contralateral femoral artery via subcutaneous transabdominal.³

The treatment management of soft tissue sarcoma of the extremities is primarily surgical, independently from the tumor location and staging. The determiners of the tumor staging are size (larger or smaller than 5 cm), histological grade and location above or below the muscle fascia of the affected muscle. In the past, amputation was the standard treatment for extremities lesions. Over the past 2 decades, there has been a change for the more conservative surgical treatment, associated with radio-chemotherapy, with good locoregional control and comparable survival rates. Restrictive current indications for amputation are the multiple local recurrences, multicompartmental diseases, and massive bone or neurovascular invasion in recurrent tumors.⁴

In the present case, the patient presented a locally advanced soft tissue sarcoma of the thigh, with invasion of the common, superficial and deep femoral vessels, preserving the great saphenous vein, and had to be submitted to en bloc resection of the tumor, quadriceps muscle, and vascular-nervous bundle. In order to avoid the prolonged ischemia time and the extensive surgical act during the resection and reconstruction procedure in a single period of time, limb revascularization was performed previously to the ablative surgery.

We have chosen the extra-anatomical conduit through a lateral access of the popliteal artery, in order to exclude the graft from the oncologic surgical field that would later be exposed to high doses of radiation, avoiding exposition of the prosthesis during groin manipulation of the surgical procedure of resection and reducing the risk of local infection.^5-9 The access through the obturator foramen would also have the inconvenience of exposing the graft to the radiotherapy field, as well as to the surgical field during the resection of the tumor.

Once the great saphenous vein was preserved, we chose not to perform the venous reconstruction, which presents questionable patency rates.¹⁰

Despite the locoregional treatment of the tumor having been effective, with no evidence of local recurrences, the patient presented multiple pulmonary metastases after an 18-month follow-up, confirming the aggressive character of these lesions.^11-12

CONCLUSION

The extra-anatomical restoration associated to the resection of the tumor and femoral vessels is a viable therapeutic alternative for the treatment of soft tissue sarcomas of the extremities, with a substantial improvement in the quality of life compared to amputation, with no alteration of the locoregional control or survival of the disease.⁷

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