Femoral-Axis Oncovascular Reconstruction in Thigh Sarcomas: A Structured Narrative Review of Decision-Making, Techniques, and Outcomes

Thigh sarcomas (soft-tissue and bone) may encase or invade the femoral vascular axis, historically prompting primary amputation. Contemporary limb-sparing surgery increasingly incorporates planned en bloc vascular resection and reconstruction to secure oncologic margins while preserving limb function. This structured narrative review addresses 3 femoral-axis-specific decision domains in thigh and groin sarcoma surgery: (1) arterial planning, with particular attention to the common femoral bifurcation and profunda femoris artery; (2) selective venous reconstruction versus ligation; and (3) adjunctive factors influencing graft durability, including conduit choice, soft-tissue/lymphatic management, and surveillance. Across contemporary cohorts and meta-analyses, limb salvage is achievable in most patients, but perioperative morbidity remains substantial and is driven primarily by wound/lymphatic complications and graft thrombosis. Current evidence supports mandatory arterial reconstruction after circumferential resection of the femoral axis, while the need for venous reconstruction remains unresolved and should be individualized according to deep venous trunk loss, preoperative patency/collateralization, field hostility, and anticoagulation feasibility. We propose a pragmatic femoral-axis decision framework emphasizing profunda preservation, selective venous reconstruction, proactive wound/coverage planning, and standardized reporting to improve reproducibility and future comparative inference.