although rare , tumor involvement of the inferior vena cava ( ivc ) by hepatobiliary , pancreatic or duodenal malignancies can be difficult to assess preoperatively , and can compromise an adequate oncological resection , especially when found incidentally at laparotomy . however , radical resection with negative histological margins remains the only chance of cure , especially for duodenal tumors which have better prognosis .
lessons learned from liver transplantation have improved technical considerations and popularized partial or complete resection of the ivc , with acceptable morbidity .
various techniques are used for venous reconstruction , using a prosthetic graft interposition in most of the cases . however , in case of associated digestive resections , postoperative complications can be responsible for prosthesis infection and related vascular complications . in this setting
we present an original technique of a venous autoplasty in a woman who underwent pancreaticoduodenectomy for a duodenal adenocarcinoma involving the anterior part of the infrarenal ivc .
a 74-year - old woman was referred in our tertiary center for the exploration of an anemia . she had no previous remarkable medical history .
gastroduodenal endoscopy with biopsies identified an adenocarcinoma of the second part of the duodenum . abdominal computed tomography ( ct )
scan showed a huge duodenal mass of 7 cm in size developed from the second part of the duodenum , close to the anterior wall of the  ivc , without extension to other major vessels ( e.g. coeliac , hepatic or superior mesenteric artery ) or metastases ( fig .
figure 1:preoperative ct - scan showing a huge duodenal mass ( * ) of 7 cm in size developed from the second part of the duodenum , close to the anterior wall of the infrarenal ivc ( * * ) .
preoperative ct - scan showing a huge duodenal mass ( * ) of 7 cm in size developed from the second part of the duodenum , close to the anterior wall of the infrarenal ivc ( * * ) .
a kocher maneuver was not possible because of strong adhesions between the tumor and the anterior wall of the ivc . in order to ensure adequate resection margins
, we performed a pancreaticoduodenectomy with en - bloc resection of a 3 cm area of the anterior wall of the ivc ( fig .
2a ) , after total clamping of the right and the left renal veins , and of the ivc from either side of the involved area . direct suture of the ivc was not possible .
we decided not to use a prosthetic graft for the venous reconstruction because of the risk of infection regarding the high rate of infectious complications after pancreaticoduodenectomy , particularly in case of soft pancreas texture .
thus , since the posterior wall of the ivc is usually more floppy than the anterior one because of its higher distance from the renal veins , we harvested a transversal patch of 20  30 mm in size from the posterior wall of the ivc , below the confluence with the renal veins ( fig .
reconstruction of the posterior wall of the ivc was achieved by a direct hand - sewn hemi - circumferential anastomosis using a single - layer non - absorbable 4/0 polypropylene ( fig .
thereafter , the venous patch was disposed longitudinally in place of the resected area at the anterior wall of the ivc , and was sutured using a single - layer non - absorbable 4/0 polypropylene ( figs . 2c , d and f ) .
the digestive reconstruction was then performed according to the child procedure with a pancreaticogastrostomy . 

figure 2:(a ) we performed a pancreaticoduodenectomy with en - bloc resection of a 3 cm area of the anterior wall of the ivc ( * ) .
direct suture of the  ivc was not possible and venous reconstruction required the interposition of a graft .
( b ) since the posterior wall of the ivc is usually more floppy than the anterior one because of its longer distance from the renal veins , we harvested a transversal patch of 20  30 mm in size from the posterior wall of the ivc , below the confluence with the renal veins .
( c ) reconstruction of the posterior wall of the ivc was achieved by a direct hand - sewn hemi - circumferential anastomosis using a single - layer non - absorbable 4/0 polypropylene .
( d and e ) the transversal venous patch was placed longitudinally on the resected area at the anterior wall of the ivc ( * * ) , and was sutured using a single - layer non - absorbable 4/0 polypropylene .
( f ) intraoperative view showing the venous autoplasty of the ivc . srivc , suprarenal inferior vena cava ; irivc , infrarenal inferior vena cava ; rrv , right renal vein ; lrv , left renal vein .
( a ) we performed a pancreaticoduodenectomy with en - bloc resection of a 3 cm area of the anterior wall of the ivc ( * ) . direct suture of the  ivc was not possible and venous reconstruction required the interposition of a graft .
( b ) since the posterior wall of the ivc is usually more floppy than the anterior one because of its longer distance from the renal veins , we harvested a transversal patch of 20  30 mm in size from the posterior wall of the ivc , below the confluence with the renal veins .
( c ) reconstruction of the posterior wall of the ivc was achieved by a direct hand - sewn hemi - circumferential anastomosis using a single - layer non - absorbable 4/0 polypropylene .
( d and e ) the transversal venous patch was placed longitudinally on the resected area at the anterior wall of the ivc ( * * ) , and was sutured using a single - layer non - absorbable 4/0 polypropylene .
srivc , suprarenal inferior vena cava ; irivc , infrarenal inferior vena cava ; rrv , right renal vein ; lrv , left renal vein .
postoperative course was marked by a bile leakage on postoperative day 2 which required surgery to repair the hepaticojejunal anastomosis .
postoperative ct - scan showed good permeability of the ivc with no symptoms related to the reconstruction .
pathological examination confirmed the r0 resection of a t4 n1 m0 duodenal adenocarcinoma involving the ivc .
she received a 6 months adjuvant folfox chemotherapy regimen and was followed up every 3 months with no recurrence at time .
resection of the ivc is widely performed during surgery for various abdominal and retroperitoneal malignancies , since a radical resection is the only chance of cure .
suprarenal ivc resection without venous replacement has been proposed because the venous collateral pathways can supply the caval flow through the lumbar and epigastric pathways , the renal veins , and the vertebral venous system , which are often well developed in case of a ivc chronic occlusion .
however , large dissection of a retroperitoneal tumor and/or thoracoabdominal incisions can both interrupt the ascending collateral venous pathways , resulting in a high risk of major venous insufficiency . in these cases ,
reconstruction of the ivc is mandatory and can be performed through a direct end - to - end anastomosis , or after the interposition of a venous / prosthetic patch .
reported that resection 2 cm of the ivc could be reconstructed by a direct suture while resection > 2 cm required the interposition of a graft . in the same way , tsuji et al .   performed a direct suture when the wall defect was less than one - third of the circumference of the ivc . in our case ,
the venous resection was too large to perform a direct suture of the ivc , either longitudinal or transversal .
therefore , the technique of choice regarding this large venous defect appeared to be a prosthetic reconstruction .
however , considering the high risk of infectious complications after duodenopancreatectomy , especially when performed in the settings of a duodenal tumor with a soft pancreatic gland texture and without dilatation of both the pancreatic and the main bile duct , we chose a reconstruction technique that required a large venous patch .
thus , we decided to harvest the posterior wall of the ivc because it was very floppy , that allowed its direct suture . indeed , these elastic properties of the ivc have already been investigated .
reported the possibility to easily harvest a venous patch from the anterior wall of the ivc , above the confluence of the renal veins , with a low risk to narrow the ivc because its diameter is larger at this point .
our original technique of venous autoplasty could be thus extrapolated to these veins , in order to prevent the use of prosthetic patches and to facilitate reconstruction .
 abstracttumor involvement of the inferior vena cava ( ivc ) by hepatobiliary , pancreatic or duodenal malignancies can compromise adequate resection . 
 however , radical resection with negative histological margins remains the only chance of cure . 
 various techniques are used for venous reconstruction , using a prosthetic graft interposition in most of the cases . however , in case of associated digestive resections , such as pancreaticoduodenectomy , postoperative complications can be responsible for prosthesis infection and related vascular complications . in this setting 
 , the use of biological material for venous reconstruction appears to be preferable . 
 we present an original , easy and useful technique of a venous autoplasty after pancreaticoduodenectomy for tumors involving the anterior wall of the infrarenal ivc , using a patch from the posterior wall of the ivc . 