Spinal cord protection during aortic cross-clamping using retrograde venous perfusion

Background. Paraplegia remains a devastating complication following thoracic aortic operation. We hypothesized that retrograde perfusion of the spinal cord with a hypothermic, adenosine-enhanced solution would provide protection during periods of ischemia due to temporary aortic occlusion.

Methods. In a rabbit model, a 45-minute period of spinal cord ischemia was produced by clamping the abdominal aorta and vena cava just below the left renal vessels and at their bifurcations. Four groups (n = 8/group) were studied: control, warm saline, cold saline, and cold saline with adenosine infusion. In the experimental groups, saline or saline plus adenosine was infused into the isolated cavae throughout the ischemic period. Clamps were removed and the animals to recovered for 24 hours before blinded neurological evaluation.

Results. Tarlov scores (0 = paraplegia, 1 = slight movement, 2 = sits with assistance, 3 = sits alone, 4 = weak hop, 5 = normal hop) were (mean ± standard error of the mean): control, 0.50 ± 0.50; warm saline, 1.63 ± 0.56; cold saline, 3.38 ± 0.26; and cold saline plus adenosine, 4.25 ± 0.16 (analysis of variance for all four groups, p < 0.00001). Post-hoc contrast analysis showed that cold saline plus adenosine was superior to the other three groups (p < 0.0001).

Conclusion. Retrograde venous perfusion of the spinal cord with hypothermic saline and adenosine provides functional protection against surgical ischemia and reperfusion.     

肝血流出道阻断后腹腔镜肝切除术

目的:探讨下腔静脉气囊导管阻断肝静脉流出道在腹腔镜肝切除术中的可行性。方法:用特制的带中央分流管的气囊导管阻断肝静脉血流,观察血流动力学和下腔静脉、肝静脉血流改变,行左半肝切除。结果:受试动物均耐受了腹腔镜左半肝切除。实验过程中平均动脉压轻度下降,心输出量下降至基础值的70％,中心静脉压下降明显,气囊内液体排除后,血流动力学指标均立即恢复正常。气囊充盈后,肝静脉血流几乎消失,下腔静脉中有部分血流通过。结论:用带中央分流的气囊导管阻断肝静脉血流行腹腔镜肝切除术安全、可行。     

Partial right atrial inflow occlusion for controlled systemic hypotension during thoracic endovascular aortic repair

Controlled hypotension is sometimes necessary for accurate endograft deployment and adjunctive ballooning and stenting near the arch and proximal descending thoracic aorta. This article describes a technique in which a compliant occlusion balloon inflated in the right atrium is used to occlude the inflow from the inferior vena cava and reduce the cardiac preload. This reliably and effectively induces systemic hypotension to any desired level and is also able to be rapidly reversed. The technique has been used in 11 cases of thoracic endovascular aortic repairs with complete success and no procedure-related complications.     

Systemic and myocardial oxygen transport responses to brain death in pigs

BACKGROUND: Brain death is associated with profound disturbances of systemic and myocardial oxygen transport, but little is known regarding the acute response of systemic oxygen consumption (VO(2)). METHODS: Brain death was induced in 6 pigs (30.6 +/- 3.0 kg) by balloon inflation into the cranial cavity. VO(2) was continuously measured by respiratory mass spectrometry. Blood pressures and gases were measured from the aorta, superior vena cava, and coronary sinus, with arterial epinephrine and norepinephrine, prior to brain death, at 1, 10, and 90 minutes after brain death. Cardiac output (CO), systemic vascular resistance (SVR), oxygen delivery (DO(2)), oxygen extraction (EO(2)), and myocardial oxygen (mEO(2)) and lactate extractions (mE(1ac)) were calculated. Left ventricular contractility was assessed by micromanometer tipped catheters. RESULTS: VO(2) increased from 4.8 +/- 0.9 to 6.3 +/- 0.9 mL/min/kg 1 minute after brain death (P < .001), and subsequently decreased to below baseline at 90 minutes (P < .001). Left ventricular contractility, CO, and DO(2) increased 1 minute after brain death (P < .001), followed by a rapid decrease to baseline within 10 minutes (P < .001). SVR and EO(2) decreased after brain death (P < .01) and remained low. Lactate remained unchanged. mE(1ac) decreased after brain death despite a decrease in mEO(2) (P < .01), and returned to baseline at 90 minutes. CONCLUSIONS: The initial surge in VO(2) after brain death is offset by the greater increase in DO(2), thus tissue perfusion remains adequate. The lower than baseline VO(2) and SVR at the end of the study period may indicate general metabolic and hemodynamic compromise. The information regarding the profound metabolic alterations imposed by brain death may have implications for management of brain death donors.     

Inferior and superior vena caval blood flows during cross-clamping of the thoracic aorta in pigs

Changes in blood flow through the inferior and superior venae cavae during cross-clamping of the thoracic aorta just above the diaphragm were studied in 28 miniature pigs anesthetized with enflurane titrated to maintain systemic arterial blood pressure close to normal values. Surgical preparation included sternotomy with subsequent placement of a noncannulating electromagnetic probe around the ascending aorta and a cannulating electromagnetic probe in the transected inferior vena cava. Superior vena caval flow was calculated as the difference between aortic flow and inferior vena caval flow. Clamping of the thoracic aorta alone (n = 10) was accompanied by severe arterial hypertension, a dramatic decrease in inferior vena caval flow, and an increase in superior vena caval flow, which resulted in a moderate increase in aortic flow. Simultaneous clamping of the thoracic aorta and inferior vena cava (n = 13) was accompanied by no significant change in arterial pressure or superior vena caval flow. The oxygen content in mixed venous blood significantly (p less than 0.05) increased from 9.5 +/- 1.1 to 13.4 +/- 1.8 ml.dl-1 in animals undergoing clamping of the thoracic aorta only, but did not change significantly in animals subjected to simultaneous clamping of the aorta and inferior vena cava. The study demonstrates a substantial increase in superior vena caval flow during cross-clamping of the thoracic aorta. Further studies elucidating the mechanism of the observed changes are required.     

The failure of venovenous bypass to prevent graft liver postreperfusion syndrome.

We studied 58 patients undergoing orthotopic liver transplantation, aged 42 +/- 10 years (mean +/- SD), and weighing 65 +/- 14 kg. Anesthesia was maintained with fentanyl, midazolam, and vecuronium. Serum bicarbonate, serum potassium, serum ionized calcium and pH did not change significantly throughout the study. Usual hemodynamic parameters were recorded. Hemodynamic tolerance was assessed by a trial of clamping of the inferior vena cava, above and below the liver and the portal vein; patients were allocated to two groups: the group without venovenous bypass (NBP, n = 29) consisted of patients whose MAP did not decrease by more than 30% and/or cardiac output did not decrease by more than 50%; the group with venovenous bypass (BP, n = 29) consisted of patients whose MAP decreased by more than 30% and/or cardiac output decreased by more than 50% or required venovenous bypass for easier surgical dissection. After clamping of the vena cava and the portal vein, the cardiac index (CI) and mean pulmonary arterial pressure (MPAP) decreased significantly, whereas systemic vascular resistances (SVR) increased. After unclamping the inferior vena cava suprahepatically and infrahepatically, no hemodynamic change was observed. After unclamping the portal vein, MAP decreased, despite the increase in the CI, because of an significant decrease in SVR; in addition MPAP increased despite the decrease in pulmonary vascular resistances. The decrease in MAP of more than 30% during at least 1 min occurred in 6 patients (20%) in the NBP group and in 6 patients (20%) in the BP group. We concluded that the occurrence of the syndrome of cardiovascular collapse following liver reperfusion was similar whether venovenous bypass was used or not.     

Hemodynamics and oxygen uptake below and above aortic occlusion during crossclamping of the thoracic aorta and sodium nitroprusside infusion

The effects of controlled vasodilation on blood flow and oxygen consumption above and below the aortic occlusion during crossclamping of the thoracic aorta were examined in 16 mongrel dogs anesthetized with halothane. Blood flow in the inferior vena cava was measured with an electromagnetic cannulating flow probe, and cardiac output was measured by thermodilution. The animals were divided into two groups. In the control group the thoracic aorta was crossclamped at the diaphragmatic level for 30 minutes. In the sodium nitroprusside group the aorta was also crossclamped for 30 minutes, but an infusion of sodium nitroprusside was initiated after 10 minutes of occlusion to decrease systemic blood pressure. Measurements were made before and at 10, 20, and 30 minutes after aortic crossclamping, and at 10 minutes after aortic unclamping. Crossclamping of the thoracic aorta was associated with marked decreases in blood flow and oxygen consumption in organs and tissues below the aortic occlusion in both groups. Above the occlusion, blood flow increased but oxygen uptake decreased. Sodium nitroprusside increased cardiac output and blood flow above the aortic occlusion even more than crossclamping alone while it decreased blood flow and oxygen consumption below the crossclamp.     

Aortic occlusion balloon catheter technique is useful for uncontrollable massive intraabdominal bleeding after hepato-pancreato-biliary surgery

Massive intraabdominal hemorrhage sometimes requires urgent hemostatic surgical intervention. In such cases, its rapid stabilization is crucial to reestablish a general hemodynamic status. We used an aortic occlusion balloon catheter in patients with massive intraabdominal hemorrhage occurring after hepatopancreato-biliary surgery. An 8-French balloon catheter was percutaneously inserted into the aorta from the femoral artery, and the balloon was placed just above the celiac artery. Fifteen minutes inflation and 5 minutes deflation were alternated during surgery until the bleeding was surgically controlled. An aortic occlusion balloon catheter was inserted on 13 occasions in 10 patients undergoing laparotomy for hemostasis of massive hemorrhage. The aorta was successfully occluded on 12 occasions in nine patients. Both systolic pressure and heart rate were normalized during aortic occlusion, and the operative field became clearly visible after adequate suction of leaked blood. Bleeding sites were then easily found and controlled. Hemorrhage was successfully controlled in 7 of 10 patients (70%), and they were discharged in good condition. The aortic occlusion balloon catheter technique was effective for easily controlling massive intraabdominal bleeding by hemostatic procedure after hepato-pancreato-biliary surgery.     

The role of intra-aortic balloon occlusion in penetrating abdominal trauma

Intra-aortic balloon occlusion (IABO) of the thoracic aorta was attempted in 21 consecutive hemodynamically unstable patients with missile injuries of the abdomen. Retrospectively, the patients fell into three groups. Group One consisted of five patients with a cardiac rhythm but no recordable blood pressure (BP). Group Two were six patients with refractory hypotension, that is, BP of 80 torr systolic or less. Group Three comprised ten patients who had hemodynamic deterioration to a BP of 80 torr systolic or less during preparation for or in the course of celiotomy. IABO was successful in occluding the thoracic aorta in 20 patients with a resultant rise of BP; one patient required thoracotomy for aortic clamping. Operative control of hemorrhage was accomplished in 11 patients; seven patients survived and were discharged in a functional status. There were no survivors in Group One, three in Group Two, and four in Group Three.     

Improvement in thoracic aortic pressure after proximal aortic cross-clamping by balloon occlusion of the distal aorta

Spinal cord hypoperfusion injury is a devastating complication of cross-clamping the proximal thoracic aorta. The collateral circulation around the cross-clamp is generally poorly developed, and the run-off is immense, resulting in extremely low thoracic aortic and spinal cord perfusion pressures. The authors postulated that balloon occlusion of the abdominal aorta might confine this reduced collateral flow around the cross-clamp to the thoracic aorta. In 8 of 16 dogs subjected to aortic cross-clamping of the aorta just beyond the arch vessels, the abdominal aorta was also occluded by a balloon. Thoracic aortic pressure and spinal cord perfusion pressure were significantly higher in the animals with aortic balloon occlusion than in those without balloon occlusion (77 +/- 8 mm Hg versus 26 +/- 1 mm Hg, p less than 0.01, and 67 +/- 8 mm Hg versus 18 +/- 2 mm Hg, p less than 0.01, at 10 minutes after cross-clamping). Abdominal aortic balloon occlusion increases thoracic aortic pressure after the aorta is cross-clamped proximally. Further studies are necessary in primates to assess the effect of this procedure in spinal cord perfusion and the rate of paraplegia.     

肾癌合并Ⅱ、Ⅲ型下腔静脉瘤栓11例手术疗效分析

目的探讨经皮球囊导管阻断在合并Ⅱ、Ⅲ型下腔静脉瘤栓的肾癌患者的手术疗效。方法回顾性分析河南省肿瘤医院普外科自2006年7月至2011年3月治疗的11例合并Ⅱ、Ⅲ型下腔静脉瘤栓的肾癌患者的临床病理资料、手术方法及疗效。结果 11例患者的平均年龄为48.4岁(36～66岁),所有患者均经术前CT、MRI或彩超明确肿瘤及瘤栓情况。所有患者术前在DSA下经颈内静脉预置球囊导管在瘤栓附近,术中充盈球囊阻断下腔静脉后再切除肾脏及瘤栓。手术时间为(67.3±12.3)min,手术出血量为(762.3±125.5)ml,术后住院时间为(12.6±1.8)d,无手术或围手术期死亡。术后1年生存率为81%,3年生存率为54%。结论经皮球囊导管阻断法在肾癌合并Ⅱ、Ⅲ型下腔静脉瘤栓手术中是安全有效的预防瘤栓脱落方法,具有一定的临床推广价值。     

Cardiovascular effects of simultaneous occlusion of the inferior vena cava and aorta in patients treated with hypoxic abdominal perfusion for chemotherapy

Background. Animal studies suggest less cardiovascular disturbanceif the aorta and vena cava are occluded simultaneously. We setout to establish the effects of simultaneous clamping in humans,because oncologists suggested that perfusion for chemotherapycould be done under local anaesthesia without invasive haemodynamicmonitoring. Methods. We studied the cardiovascular effects of the onsetand removal of simultaneous occlusion of the thoracic aortaand inferior vena cava, in seven ASA II patients. Two stop-flowcatheters positioned in the aorta and in the inferior vena cavawere inflated to allow hypoxic abdominal perfusion to treatpancreatic cancer. We measured the arterial pressure, heartrate (HR), right atrial pressure (RAP), pulmonary artery pressure(PAP), pulmonary artery wedge pressure (PAWP) and cardiac output(CO), and calculated systemic vascular resistance index (SVRi),pulmonary vascular resistance index (PVRi), left ventricularstroke work index (LVSWi) and right ventricular stroke workindex (RVSWi). Three patients were studied with transoesophagealechocardiography. Results. Six patients needed intravenous nitroprusside duringthe occlusion because mean arterial pressure (MAP) increasedto more than 20% of baseline (SVRi increased by 87%). One minuteafter occlusion release, all patients had a 50% decrease inMAP, and mPAP increased by 50%. The procedure had severe cardiovasculareffects, shown by a 100% increase in cardiac index at occlusionrelease with increases in left and right ventricular strokework indices of 75% and 147%. Left ventricular wall motion abnormalitieswere seen on transoesophageal echocardiography. Conclusions. Serious haemodynamic changes occur during simultaneousocclusion of the thoracic aorta and inferior vena cava, whichmay need invasive haemodynamic monitoring. Br J Anaesth 2002; 88: 193–8     

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.     

Repair of the descending thoracic aorta: impact of open distal anastomosis technique on spinal cord perfusion, neurological outcome and spinal cord histopathology.

OBJECTIVES: We investigated the impact of equilibrating distal aortic pressure with atmospheric pressure (open distal anastomosis) on spinal cord perfusion, neurological outcome and spinal cord histopathology in a rat model of descending thoracic aortic surgery. METHODS: Proximal thoracic aortic occlusion was obtained in Sprague-Dawley rats by inflating the balloon of a 2F Fogarty catheter introduced through the left femoral artery. Rats were separated into three groups: sham-operation (n = 5) without balloon inflation, control (n = 15) with inflation of the balloon, and open distal (n = 15) with inflation of the balloon combined with incision of the right femoral artery to allow free drainage of distal aortic blood. Balloon inflation was maintained for 15 min. Rectal temperature, arterial blood gases and pH, distal arterial blood pressure (DABP) and lumbar spinal cord blood flow (SCBFl) were recorded throughout the procedure. Neurobehavioral status was assessed daily using a 0-5 scale and rats were sacrificed after 48 h of reperfusion and their spinal cord harvested for histopathology and immunohistochemistry for microtubule-associated protein-2 (MAP-2). RESULTS: DABP and SCBFl values were lower during thoracic aortic occlusion in the open distal group, compared to the control group (P < 0.001). Paraplegia and mortality rates were dramatically increased in the open distal group (87.7 and 46.6%, respectively) compared to the control group (0 and 6.6%, respectively, (P < 0.001 and 0.02). Severe metabolic acidosis and bowel infarct were also more frequent in the open distal group (P < 0.001). Sham-operated and control rats had virtually normal spinal cords, whereas rats in the open distal group had severe ischemic injury throughout gray matter. CONCLUSIONS: Equilibrating distal arterial pressure with atmospheric pressure during thoracic aortic occlusion decreased spinal cord blood flow, increased mortality and worsened spinal cord injury in rats. These results suggest that the open distal anastomosis technique should be used with caution in patients undergoing repair of the descending thoracic or thoracoabdominal aorta.     

Prophylactic interruption of the inferior vena cava: immediate and long-term hemodynamic effects.

Two hundred patients were evaluated retrospectively to determine the clinical effects of prophylactic inferior vena cava (IVC) interruption in association with aortic reconstruction. No pulmonary embolism occurred in the group with IVC interruption, but embolisms did occur in seven of 68 patients who had aortic reconstruction performed without IVC interruption. In two patients, the pulmonary embolism was fatal. Postoperative incidence of deep vein thrombosis was fatal. Postoperative incidence of deep vein thrombosis was 9% in both groups. Clinical and hemodynamic effects of prophylactic IVC interruption were studied in 20 additional patients. Venous hemodynamics (maximum venous outflow, inferior vena cava pressure, and ambulatory venous pressure) showed no change following interruption in 19/20. Sixteen patients from the original group of patients with prophylactic interruption were studied hemodyamically. No pulmonary embolism was clinically evident. One new case of deep vein thrombosis was seen. Again, venous hemodynamics showed no change as a result of IVC interruption. Prophylactic IVC interruption is a safe means of decreasing the incidence of pulmonary embolism without increasing venous-related morbidity.     

Retrograde cerebral perfusion provides negligible flow through brain capillaries in the pig

OBJECTIVES: Although retrograde cerebral perfusion is being used clinically during aortic arch surgery, whether retrograde flow perfuses the brain effectively is still uncertain. METHODS: Fourteen pigs were cooled to 20 degrees C with cardiopulmonary bypass and perfused retrogradely via the superior vena cava for 30 minutes: 7 underwent standard retrograde cerebral perfusion and 7 underwent retrograde perfusion with occlusion of the inferior vena cava. Antegrade and retrograde cerebral blood flow were calculated by quantitating fluorescent microspheres trapped in brain tissue after the animals were put to death; microspheres returning to the aortic arch, the inferior vena cava, and the descending aorta were also analyzed during retrograde cerebral perfusion. RESULTS: Antegrade cerebral blood flow was 16 +/- 7.7 mL. min(-1). 100 g(-1) before retrograde cerebral perfusion and 22 +/- 6.3 mL. min(-1). 100 g(-1) before perfusion with caval occlusion (P =.14). During retrograde perfusion, calculations based on the number of microspheres trapped in the brain showed negligible flows (0.02 +/- 0.02 mL. min(-1). 100 g(-1) with retrograde cerebral perfusion and 0.04 +/- 0.02 mL. min(-1). 100 g(-1) with perfusion with caval occlusion; P =.09): only 0.01% and 0.02% of superior vena caval inflow, respectively. Less than 13% of retrograde superior vena caval inflow blood returned to the aortic arch with either technique. During retrograde cerebral perfusion, more than 90% of superior vena caval input was shunted to the inferior vena cava and was then recirculated, as indicated by rapid development of an equilibrium in microspheres between the superior and inferior venae cavae. With retrograde perfusion and inferior vena caval occlusion, less than 12% of inflow returned to the descending aorta and only 0.01% of microspheres. CONCLUSIONS: The paucity of microspheres trapped within the brain indicates that retrograde cerebral perfusion, either alone or combined with inferior vena caval occlusion, does not provide sufficient cerebral capillary perfusion to confer any metabolic benefit. The slightly improved outcome previously reported with retrograde cerebral perfusion during prolonged circulatory arrest in this model may be a consequence of enhanced cooling resulting from perfusion of nonbrain capillaries and from venoarterial and venovenous shunting.     

Prevention of paraplegia in transluminally placed endoluminal prosthetic grafts for descending thoracic aortic aneurysms.

OBJECTIVE: To evaluate the efficacy of a temporary balloon occlusion test for the prevention of paraplegia following transluminally placed endoluminal prosthetic grafts for descending thoracic aortic aneurysms. SUBJECTS AND METHODS: Two occlusion balloons were inserted via the brachial and femoral arteries and positioned in the proximal and distal neck of the descending thoracic aortic aneurysms using fluoroscopy. After temporary occlusion of the thoracic aorta by inflation of both the proximal and distal balloons, the evoked spinal potential was measured for 15 mins. A maximum amplitude during temporary balloon occlusion test decreasing by more than 20% of the pre-balloon occlusion level was considered to be significant, enough to not perform transluminally placed endoluminal prosthetic grafts, but instead an open repair. The test was applied in 12 cases (9 males and 3 females, 50-86 years old). All aneurysms were located between the Th6 and Th12 with a maximum diameter of 40-70 mm, and average of 56 mm. RESULTS: The changes in maximum amplitude of evoked spinal potential remained within 20% of the value before balloon occlusion in 11 cases. Transluminally placed endoluminal prosthetic grafts were performed in these 11 cases and no instance of paraplegia or other complication relating to the test was observed. Deployment of stent-grafts was successful in 10 cases (91%). CONCLUSION: It is suggested that the preoperative measurement of evoked spinal potential during temporary balloon occlusion is clinically useful for the assessment of the risk to paraplegia occurring in transluminally placed endoluminal prosthetic grafts.     

布—加综合征的介入或半介入治疗

目的　探讨布 加综合征的介入或半介入治疗方法。方法　自 1986年起 ,我们采用多种介入或半介入方法治疗该病 173例 :①下腔静脉PTA76例 ;②下腔静脉PTA加支架置放术 5 9例 ;③经皮经肝静脉再通术 3例 ;④下腔静脉置管溶栓 4例 ;⑤经右心房及股静脉联合破膜、扩张2 2例 ;⑥联合破膜、扩张加支架置入术 17例 ;⑦根治术加支架置放 3例 ;⑧下腔静脉单纯介入治疗后附加其它手术 2 3例。结果　介入治疗即时技术成功率 90 .1% ,半介入治疗技术成功率 10 0 %。治疗前后下腔静脉压力下降范围为 3～ 2 9cmH2 O。发生并发症者 8例。死亡 5例。随访结果 ,下腔静脉单纯PTA后复发率 14.5 % ,下腔静脉PTA加支架置放组复发率仅 1.7% ,联合破膜组复发率18.2 % ,其余各组尚未发现复发。结论　①下腔静脉或肝静脉膜性阻塞或狭窄且无继发新鲜血栓者 ,PTA应为首选疗法。②下腔静脉破膜、扩张后出现弹性回缩者 ,应放置支架。③对于破膜困难者 ,应改行经右心房和股静脉联合破膜术。④下腔静脉病变合并肝静脉闭塞者 ,行下腔静脉介入治疗后可附加降低门脉高压的手术。     

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.     

Antegrade balloon occlusion of inferior vena cava during thrombectomy for renal cell carcinoma

Nephrectomy with inferior vena cava (IVC) thrombectomy for advanced renal cell carcinoma (RCC) is a challenging and morbid surgical case. We describe the use of a simple endoluminal technique to occlude the suprahepatic IVC during thrombectomy. A 60-year-old male presented with a large right-sided RCC and IVC tumour thrombus. The tip of the thrombus, which was non-adherent to the caval wall, extended to the level of the hepatic veins. After complete dissection of the kidney, we obtained suprahepatic control of the IVC by a large compliant balloon, introduced through the right internal jugular vein and inflated just below the level of the diaphragm. The IVC thrombectomy was performed in a bloodless field. Mean blood pressure remained stable during IVC balloon inflation with a total occlusion time of 10 minutes. Intraprocedural completion cavogram and postoperative Doppler ultrasonography showed no residual IVC clot. Blood loss during the thrombectomy portion of the case was scant. The patient’s postoperative course was uncomplicated and, at the last follow-up, he had stable metastatic disease on sunitinib therapy. For the surgical treatment of RCC with retrohepatic IVC tumour extension, transjugular balloon occlusion of the suprahepatic IVC offers an alternative to extensive hepatic mobilization to obtain suprahepatic thrombus control. Advantages over traditional surgical methods may include decreased surgical time, lower risk of liver injury and tumour embolism. We suggest this method for further evaluation.