Endoluminal occlusion of the inferior vena cava in renal cell carcinoma with retro- or suprahepatic caval thrombus

OBJECTIVE: To evaluate endoluminal occlusion of the inferior vena cava (IVC) during surgical treatment of renal cell carcinoma (RCC) with either retrohepatic (level II) or suprahepatic (level III) caval tumour thrombus. PATIENTS AND METHODS: From January 2000 to February 2005, 31 patients with renal vein/IVC involvement (T3b/c) of 278 who had a radical nephrectomy, were selected for review. Of these 31, 13 consecutive patients with RCC presenting a thrombus level II or III were prospectively treated with endoluminal occlusion of the free IVC cranial to the thrombus, to avoid dissection of the suprahepatic IVC or the subdiaphragmatic IVC. The occlusion balloon was positioned using transoesophageal echocardiography (TEE) control through a cavotomy at the ostium of the renal vein. Thrombectomy and radical nephrectomy were then performed. The operative duration, peri-operative bleeding, and complications during and after surgery were assessed. Overall patient survival time, disease-free survival and development of metastasis were calculated. RESULTS: Caval thrombectomy was successful in all patients. The IVC needed to be replaced with an expanded polytetrafluoroethylene graft in three patients and a patch closure after lateral cavectomy was used in four. There was no case of air embolism. One case of asymptomatic tumour migration was detected during the procedure by TEE. The mean (sd) and median (range) operative duration was 170 (29) and 170 (120-210) min, and the mean number of units of packed red cells transfused during hospitalization was 5 (5) and 3 (0-16). There was no peri-operative mortality. The complications were one splenectomy and one early thrombosis of the IVC. The mean (range) follow-up was 22.1 (2-50) months. Distant metastases occurred in seven patients; there was no local or IVC tumour recurrence. Four patients died from metastatic progression and six are alive with no progression. CONCLUSION: Endoluminal occlusion of the IVC with TEE monitoring for level II and III thrombus avoided a suprahepatic or subdiaphragmatic approach to the IVC. This technique caused no major complications and was very reliable, due to TEE monitoring. Segmental resection and reconstruction of the IVC could also be used for adherent thrombi.     

Intraoperative transesophageal echocardiography for inferior vena caval tumor thrombus in renal cell carcinoma

BACKGROUND: We investigated the advantages of intraoperative transesophageal echocardiography (TEE) during inferior vena caval tumor thrombectomy in renal cell carcinoma (RCC). METHODS: Five patients with RCC that extended into the inferior vena cava (IVC) underwent radical nephrectomy. To remove the tumor thrombus in the IVC, an inflated Fogarty balloon catheter was used to pull the thrombus below the level of the hepatic veins with real-time TEE monitoring. RESULTS: In all cases, TEE monitoring during surgery provided an accurate and excellent view of the IVC thrombus. TEE was particularly helpful for the thrombectomy to minimize hepatic mobilization by using occlusion balloon catheter in two patients whose thrombus extended to the intrahepatic IVC. CONCLUSIONS: Intraoperative real-time TEE monitoring is a safe, minimally invasive technique that can provide accurate information regarding the presence and extent of IVC involvement, guidance for placement of a vena caval clamp, confirmation of complete removal of the IVC thrombus and intervention using catheters to assist in thrombectomy.     

Results of endoluminal occlusion of the inferior vena cava during radical nephrectomy and thrombectomy

BACKGROUND: The surgical management of renal tumours with thrombi in the inferior vena cava (IVC) has become the gold standard treatment. OBJECTIVE: To evaluate endoluminal occlusion of the IVC during radical nephrectomy with either retrohepatic (level II) or suprahepatic (level III) caval tumour thrombus. DESIGN, SETTING, AND PARTICIPANTS: From January 2000 to October 2007, 28 consecutive patients with renal cell carcinoma presenting a thrombus level II or III were treated with endoluminal occlusion of the free IVC cranial. SURGICAL PROCEDURE: The occlusion balloon was positioned under transesophageal echography (TEE) control through a cavotomy performed at the level of the renal vein ostium. Thrombectomy and radical nephrectomy were then performed. MEASUREMENTS: Operative time, perioperative bleeding, and pre- and postoperative complications were assessed. Overall patient survival time, disease-free survival, and development of metastasis were assessed. RESULTS AND LIMITATIONS: Caval thrombectomy was performed successfully in all patients. IVC replacement with an expanded polytetrafluoroethylene graft or patch closure after lateral cavectomy was performed in 10 and 4 patients, respectively. Average operative time was 160min (range: 120-210). There was no perioperative mortality. The complications were one splenectomy and one early thrombosis of the IVC. Mean length of follow-up was 22.1 mo (range: 3-90). There was no local or IVC tumour recurrence. Cause-specific death and metastasis occurred in six (21.4%) and nine patients (32.1%), respectively. Thirteen patients (46.4%) are disease-free. CONCLUSIONS: Endoluminal occlusion of the IVC with TEE monitoring for level II and III thrombus avoided a suprahepatic or subdiaphragmatic approach of the IVC. Segmental resection and reconstruction of the IVC could also be performed in case of adherent thrombi.     

Surgical strategy for treating renal cell carcinoma with thrombus extending into the inferior vena cava

OBJECTIVE: A surgical strategy for treating malignant renal tumors with thrombus extending into the inferior vena cava (IVC) was assessed. METHODS: We retrospectively reviewed the records for all patients with renal cell carcinoma (RCC; n=30) or Wilms tumor (n=1) with tumor thrombus extending into the IVC who underwent surgical intervention at our institution between January 1980 and December 2001. Tumors were classified preoperatively according to the cephalad extension of thrombus, and intraoperative procedures were selected on the basis of degree of extension. Patients with RCC underwent radical nephrectomy and removal of thrombus with (n=11) or without (n=19) IVC resection. Partial normothermic cardiopulmonary bypass without cardiac arrest was used in 4 patients. The Pringle maneuver was performed in 8 patients. Infrarenal abdominal aortic cross-clamping was used in 8 patients to maintain systemic blood pressure. IVC cross-clamping and the Pringle maneuver were performed in 5 patients with suprahepatic thrombus extension. Temporary placement of a filter in the IVC or plication of the IVC above the hepatic vein was performed before hepatic mobilization, to decrease the risk for pulmonary embolism. RESULTS: One patient died intraoperatively of pulmonary embolism. Postoperative complications occurred in 11 patients; all resolved with conservative therapy. The postoperative duration of survival in patients with RCC was 37 +/- 44 months (range, 4-180 months); the 5-year survival rate was 42%. CONCLUSION: Aortic cross-clamping during IVC occlusion prevented hypotension and maintained hemodynamic stability that has required bypass in other series. This surgical treatment with the less extensive approach could result in long-term survival of patients with RCC in whom tumor thrombus extends into the IVC. We recommend that radical nephrectomy and tumor thrombectomy, with or without caval resection, be performed in these patients, with less invasive additional maneuvers.     

Balloon control of the suprahepatic inferior vena cava: a novel technique for renal cell carcinoma tumor thrombus

Renal cell carcinoma has a tendency to extend via the renal vein into the inferior vena cava (IVC), and we describe a novel approach to this situation. A 64-year-old male presented with metastatic right renal cell carcinoma and tumor thrombus extending into the retrohepatic IVC. Preoperative imaging revealed a large hemangioma adjacent to the IVC, potentially complicating hepatic mobilization. Instead, we used a compliant balloon to occlude the suprahepatic IVC, securing the wire in the right hepatic vein. With the infrarenal IVC and left renal vein occluded, the thrombus was extracted via a right renal venotomy/partial cavotomy with minimal bleeding. Balloon occlusion of the suprahepatic IVC offers a safe alternative to surgical control of this vessel in difficult situations. In addition, it allows for nephrectomy through a conventional, small retroperitoneal incision rather than the extended exposure needed for the IVC. Hepatic vein positioning of the wire prevents thrombus manipulation during balloon placement.     

肝癌合并下腔静脉癌栓的外科治疗

目的总结7例肝癌合并下腔静脉（inferior vena cava,IVC）癌栓患者的手术方法及治疗经验。方法自2003年7月至2005年5月,我们为7例肝癌合并IVC癌栓的患者实施了肝癌切除及右心房和（或）IVC切开取栓手术。所有患者均采用全肝血流阻断来控制IVC血流。根据癌栓上极位置的不同,分别采用5种不同术式：（1）静脉转流,心脏停搏,右心房及下腔静脉切开取栓1例;（2）静脉转流,心脏不停搏,心包内高位阻断下腔静脉,右心房和（或）下腔静脉切开取栓2例;（3）经腹部切口切开膈肌,心包内高位阻断下腔静脉,下腔静脉切开取栓1例;（4）经腹部切口,经膈肌腔静脉裂孔小切口,心包外高位阻断肝上下腔静脉,下腔静脉切开取栓1例;（5）经腹部切口,肝上阻断下腔静脉,下腔静脉切开取栓2例。结果所有手术均获成功,术后并发症包括胸腔积液2例,右膈下积液1例,切口感染1例。7例患者的生存时间为2周～26个月,平均9．8个月。已死亡的6例患者术后生存时间分别为13、9、11、2、17个月和2周,尚生存的1例患者已无瘤生存26个月。结论对合适病例实施肝癌切除和IVC切开取栓手术是安全可行的。手术治疗可以避免右心流人道阻塞和肺动脉栓塞造成的猝死,并有可能获得相对提高的生存时间和生活质量。     

经皮球囊导管阻断技术在下腔静脉瘤栓切除术中的应用

目的 探讨经皮球囊导管阻断技术在下腔静脉瘤栓切除术中的应用价值. 方法 经CT、MRI及彩色多普勒超声等检查确诊为肾或肾上腺肿瘤合并肝后型或肝下型下腔静脉瘤栓患者12例.男7例,女5例.年龄20～76岁,平均51岁.右侧肿瘤11例,左侧1例.肾肿瘤11例,肾上腺肿瘤1例.12例均于术前经皮穿刺右侧颈内静脉,于瘤栓近心端下腔静脉内预置一球囊导管,术中经导管充盈球囊阻断下腔静脉后,再行下腔静脉瘤栓切除术. 结果 12例肿瘤合并下腔静脉瘤栓的根治性切除术全部完成.手术时间210～670 min,平均324 min.术中出血量600～7960 ml,平均2563 ml.无手术或围手术期死亡.术后患者恢复良好,肝肾功能正常,无并发症发生.术后平均12(9～15)d出院.术后病理报告:肾细胞癌9例,转移性肝细胞癌1例,良性血管平滑肌脂肪瘤1例,肾上腺平滑肌肉瘤1例.肾癌术后TNM分期:T3b N0M08例,T3bNxM11例.术后平均随访(21±10)个月,中位随访时间24个月.4例分别于术后6、9、15、22个月死于肺转移、肝转移及肝癌复发,其余8例术后已存活6～35个月,平均26个月.9例肾癌患者术后1、3年肿瘤特异生存率分别为78%和67%. 结论 经皮球囊导管阻断技术在低位肝后型或肝下型下腔静脉瘤栓的根治性切除术中是一种安全、简便、有效的方法,具有重要的临床应用价值.     

Tumor Thrombectomy Without Bypass for Low-Grade Malignant Tumors Extending into the Inferior Vena Cava: Report of Two Cases

Endometrial stromal sarcoma (ESS) rarely extends into the inferior vena cava (IVC). Two cases of ESS extending into the IVC were encountered. In the first case a low-grade sarcoma and cavography revealed the tumor thrombus to extend to just below the left renal vein from the right internal iliac vein, and the IVC was patent. A tumor thrombectomy was accomplished to prevent pulmonary embolism (PE) and to achieve a good prognosis. The second case was also a low-grade sarcoma. Abdominal computed tomography scanning revealed a large thrombus extending into the IVC just below the hepatic vein. A tumor thrombectomy with an IVC resection was performed. The postoperative course was uneventful for both cases. Aggressive surgical treatment is thus recommended to excise a tumor thrombus with or without an IVC resection in patients with ESS of low-grade malignancy extending into the IVC to prevent sudden death due to PE.     

Renal cell carcinoma with inferior vena cava thrombus: The Hacettepe experience

ObjectivesWe evaluated the clinical outcome and factors affecting survival in patients with renal cell carcinoma (RCC) and tumor thrombus involving inferior vena cava (IVC).MethodsBetween 1990 and 2007, 28 patients with RCC and tumor thrombus extending into IVC underwent radical nephrectomy and thrombectomy. Patient data were reviewed retrospectively to evaluate the demographics, clinical presentation, surgical approach, pathological features, clinical outcomes, and survival.ResultsTwenty-eight patients with a mean age of 52.7 years were operated. Thrombus level was infrahepatic in 15 patients (54%), intrahepatic in 3 patients (10%), suprahepatic in 3 patients (10%), supradiaphragmatic in 2 patients (8%), and intracardiac in 5 patients (18%). All patients with intracardiac thrombi underwent cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA). The mean tumor size was 98.21 mm. Four patients had distant metastases and 3 patients had lymph node involvement. Pathological examination revealed RCC of clear cell type in 26 patients, papillary in 1 and chromophobe in 1 patient. At a mean follow-up of 36.4 months, 16 patients were still alive while 8 patients died due to disease progression and 2 patients died of other causes. Two patients died of pulmonary emboli in the early postoperative period. Lymph node involvement, distant metastases, hypercalcemia, and sarcomatoid component were found to be factors affecting overall survival significantly. Level of tumor thrombus and Fuhrman grade did not affect survival.ConclusionsRadical nephrectomy and tumor thrombectomy is currently known to be the most effective method in patients with RCC and tumor thrombus extending into IVC. Factors affecting survival are the ones related to tumor biology. Tumor thrombus level does not affect the prognosis.     

合并下腔静脉癌栓原发性肝癌的手术治疗及其价值

目的探讨合并下腔静脉癌栓原发性肝癌的手术治疗方法及其价值。方法自2000年11月～2004年12月我科采用全肝血流阻断技术,实施10例肝癌及下腔静脉、肝静脉内癌栓切除手术。其中肝血流阻断手术方法包括有：1、Pringle’s手法＋肝上下腔静脉侧壁肝静脉阻断（2例）;2．Pringle’s手法＋肝上肝下下腔静脉联合阻断（7例）;3．Pringle’s手法＋经膈下胸纵隔内下腔静脉阻断＋肝下IVC阻断（1例）。并对其疗效进行观察。结果10例手术均获成功。9例患者术后半年内复发,1例至今术后3月未见复发。全组病人中位生存期6个月。结论采用全肝血流阻断技术下,实施肝癌及下腔静脉、肝静脉内癌栓切除手术,技术安全可行,然而如何加强防止手术后复发是将来研究重点。     

Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus

BACKGROUND: The successful excision of a renal cell carcinoma (RCC) invading the inferior vena cava (IVC) remains a technical intraoperative challenge and requires a careful preoperative surgical management planning. Although a radical operation remains the mainstay of the therapy for RCC, the optimal management of the patients with RCC causing IVC tumor thrombus remains unresolved. In this study, we reviewed our experience in this group of patients and herein report the results. METHODS: Between July 1990 and August 1998, 11 patients with RCC with IVC tumor thrombus underwent surgical treatment. The mean patient age was 54.2 years and the male to female ratio was 1.75. The cephalad extension of the tumor was suprarenal in all cases, being infrahepatic in 6 patients, intrahepatic in 2, and suprahepatic with right atrial extension in 3 patients. All tumors were resected via inferior vena cava isolation and, when necessary, extended hepatic mobilization and Pringle maneuver, with primary or patch closure of vena cavotomy. Cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) were used in 3 patients. RESULTS: The mortality rate was 9.1% (1 patient was lost on the 11th postoperative day). Complications occurred in 3 patients. The remaining 10 patients (90.9%) could be successfully discharged from hospital. Two of them were lost during follow-up because of tumor progression at the 43rd and 54th postoperative months. The 10-year Kaplan-Meier survival estimate was 71.4%, with a mean follow-up of 4.6 years. The presence of lymph node metastases and perinephric spread seemed to possess an adverse effect on the survival. Although the groups included small numbers of patients, there was no significant difference in survival in regard to the different levels of tumor thrombus extension into the vena cava. CONCLUSIONS: Surgical treatment is the preferred approach to patients with RCC and IVC tumor thrombi as it provides markedly better results when compared with the other therapeutical modalities. We believe that complete surgical excision of the tumor and the resulting thrombus with appropriate preoperative staging and a well-planned surgical approach, using CPB and DHCA when necessary, provide an acceptable long-term survival with a good quality of life expectation.     

后腹腔镜肾癌根治性切除并下腔静脉癌栓取出术的麻醉管理

目的探讨后腹腔镜肾癌根治性切除并下腔静脉癌栓取出术的麻醉管理要点。方法回顾性分析2010年12月一2014年6月3例后腹腔镜肾癌并下腔静脉癌栓根治术患者的围术期临床资料。I型癌栓2例,Ⅱ型癌栓1例。气管插管全身麻醉,Ⅱ型癌栓术中行短暂下腔静脉阻断。结果3例均顺利完成取栓,无中转开腹,手术时间244、333、289rain,1例下腔静脉完全阻断时间10rain,术中均未发生肺栓塞及其他严重麻醉并发症。l例术后拔管返回普通病房,2例转入ICU后24h内拔气管导管并转回普通病房。结论后腹腔镜肾癌根治性切除并下腔静脉癌栓取出术是新型、高危但可行的手术方式,麻醉医师应当熟知具体手术操作步骤,以制定相关麻醉计划并密切配合,密切关注下腔静脉阻断期间循环波动,严防大出血、肺栓塞等严重并发症的发生。     

Modified pump-driven venous bypass in surgery for renal cell carcinoma (RCC) involving the inferior vena cava (IVC)

Surgical management of renal cell carcinoma (RCC) with a tumour thrombus that infiltrates the caval wall or extends above the hepatic veins can be problematic. Total control of the suprahepatic inferior vena cava (IVC) is mandatory in order to prevent thrombus mobilization and minimize blood loss. Pump-driven veno-venous bypass (VVB), modified by adding portal decompression, is a safe and useful procedure and avoids the important risks connected with deep hypothermic circulatory arrest while allowing the normal perfusion of vital organs.     

Single-center experience of caval thrombectomy in patients with renal cell carcinoma with tumor thrombus extension into the inferior vena cava

The objective of this study is to describe a single-center experience of caval thrombectomy in patients with renal cell carcinoma (RCC) and tumor thrombus extension into the inferior vena cava (IVC). We retrospectively reviewed 23 patients undergoing radical nephrectomy with caval thrombectomy. Follow-up included an office visit and computed tomography scan. Statistical comparisons were made using 2-sample t tests. Patients' ages ranged from 32 to 83 years (mean, 62 years; 18 male, 5 female). Tumor size ranged from 3 to 21 cm (mean, 8.6 cm). Tumor thrombus staging was based on the Nevus classification: level I (2/23), II (6/23), III (13/26), IV (2/23). Tumor thrombi were removed by means of digital extraction (20), Fogarty embolectomy (2), or endarterectomy (1-caval wall invasion). Lateral venorrhaphy was used for IVC repair in all cases. Hepatic mobilization and suprahepatic clamping were necessary in 14 patients. Clamp times were significantly different between the suprahepatic (SH) and infrahepatic (IH) groups (15 vs 9.4 minutes, P < .012). Mean blood loss was also significantly different (3.2 L vs 2 L, P < .045). In the SH group, 2 patients developed postoperative atrial fibrillation and 2 patients died (respiratory failure; missed enterotomy). The IH group had no perioperative morbidity or mortality. Median followup was 15 months (range, 1-54 months). Follow-up imaging was available for 19/23 patients. Ninety-five percent of patients had a patent IVC (18). One SH patient developed an IVC stenosis/thrombosis 12 months postoperatively with successful thrombolysis and stenting. There was a 16% (3/19) recurrence rate in follow-up, with all patients demonstrating renal vascular invasion and high Fuhrman grade upon final pathologic evaluation. Caval thrombectomy can be performed safely during radical nephrectomy for RCC with tumor thrombus extension. The need for suprahepatic clamping is associated with longer clamp times, increased blood loss, and increased morbidity and mortality. Lateral venorrhaphy with primary repair avoids complicated caval reconstructions and results in high patency rates, despite a not insignificant recurrence rate.     

肝细胞癌合并下腔静脉癌栓的手术治疗

目的 探讨肝细胞癌(简称肝癌)合并下腔静脉癌栓的手术治疗方法。方法 采用肝切除 腔静脉取栓治疗4例肝癌合并下腔静脉癌栓患者,取栓方法包括经荷栓肝静脉取栓(1例)和下腔静脉切开取栓(3例),后者又分在全肝血流阻断下取栓(2例)和在萨氏钳局部血管阻断下取栓(1例)。结果 4例肝癌及下腔静脉癌栓均得到成功切除,术中无明显并发症发生;术后除l例发生中等量胸水外,无其他并发症发生;随访中3例已死亡,分别生存30、10和14个月;1例尚存活,已生存7个月。结论 肝癌合并下腔静脉癌栓的手术治疗安全可行,其基本术式为肝切除 下腔静脉切开取栓。     

单一体位机器人腹腔镜肝后下腔静脉癌栓取出术的初步体会

目的:探讨单一体位机器人辅助腹腔镜肝后下腔静脉癌栓取出术的可行性和安全性。方法:回顾性分析2015年12月至2020年8月郑州大学第一附属医院收治的6例行单一体位机器人辅助腹腔镜肝后下腔静脉癌栓取出术患者的临床资料。男5例,女1例;平均年龄58(46~74)岁。平均体质指数24.6 (20.6~28.2) kg/m ...     

Renal cell carcinoma with inferior vena caval extention: impact of tumour extent on surgical outcome

OBJECTIVE

To evaluate our experience with surgical resection of renal cell carcinoma (RCC) with inferior vena cava (IVC) involvement and examine the relationship between prognosis and tumour extent.

PATIENTS AND METHODS

A retrospective review of nephrectomy performed between 1985 and 2005 identified 50 patients presenting with tumour thrombus extension into the IVC. Clinical characteristics and outcome were evaluated.

RESULTS

Of the 50 patients evaluated, 7, 26, 10 and 7 presented with level I, II, III and IV thrombus, respectively. Major postoperative complications occurred in 16% of patients. Local or distant failure occurred in 25 (64%) patients. The mean time to recurrence was 10 months. Only supra‐diaphragmatic extension of the tumour thrombus was predictive of disease recurrence.

CONCLUSION

Locally advanced RCC with IVC thrombus remains associated with significant local and distant failure rate. The level of thrombus extension is significantly associated with disease recurrence. Effective adjuvant therapy is needed to improve outcome in this patient population.     

Recidive of renal cell carcinoma tumor thrombus in inferior vena cava via lumbar vein

Renal cell carcinoma (RCC) develops tumor thrombus in the renal vein and inferior vena cava (IVC) in 10% of cases. Surgical treatment is radical nephrectomy and thrombectomy of the IVC. Local recidive can develop in the lumbar fossa, lymph nodes, and the IVC. We report a 58-year-old patient admitted to the Clinic for Urology at the Military Medical Academy, Belgrade, Serbia, in February 2009 with RCC of the left kidney and tumor thrombus in the IVC. After ultrasonography exam and multislice computed tomography scan, we performed radical nephrectomy and thrombectomy of the IVC (level II). Four months after the operation, ultrasound exam and cavography showed intracaval and paracaval recidive tumor masses in the renal part of the IVC. On operation we removed intraluminal IVC thrombus, which arises from the lumbar vein on the IVC posterior wall, with paracaval thrombus in the lumbar vein. We conclude that RCC tumor thrombus can spread from the kidney to the IVC through the lumbar vein.     

Combined resection of a tumor and the inferior vena cava: report of two cases

Tumor resection and caval tumor thrombectomy, with or without cavotomy and inferior vena cava (IVC) replacement are sometimes performed in patients with renal cell carcinoma (RCC) extending into the IVC or liver tumors invading the IVC. Two such cases were treated. Case 1: a 68-year-old female was transferred with a diagnosis of right RCC with tumor thrombus extending into the IVC. A plication was performed to prevent extension into the right atrium before the nephrectomy and cavotomy with removal of the tumor thrombus was accomplished, because the IVC was almost completely obstructed and the hemodynamics were stable during cross-clamping of the IVC. Case 2: a 37-year-old female was transferred with a diagnosis of a giant metastatic liver tumor. A trisegmentectomy with resection of the invaded IVC and IVC replacement was performed while the abdominal aorta was cross-clamped to maintain the hemodynamics. Therefore, abdominal aortic cross-clamping was convenient to maintain the hemodynamics when the IVC replacement was performed during IVC cross-clamping.