Surgical treatment of renal cell carcinoma with right atrial thrombus: early experience and description of a simplified technique

Operative management of patients presenting renal cell carcinoma's (RCC) with right atrial tumor thrombus extension is a technical challenge. It requires the use of cardiopulmonary bypass (CPB). The aim of this study was to report our early experience and to describe a simplified CPB technique. 5 consecutive patients underwent surgical resection by a joint cardiovascular and urological team. The ascending aorta was canulated. The venous drainage was achieved using a proximal canula inserted in the superior vena cava and a distal canula inserted in the IVC below the renal veins. Right atrium thrombus extension was extracted under normothermic CPB without cross clamping or cardioplegic arrest. A cavotomy was performed at the ostium of the renal vein and an endoluminal occlusion catheter was introduced. The thrombectomy and the radical nephrectomy were then performed. The occurrence of gaseous or tumor embolism, operative time, perioperative bleeding, and post-operative complications were assessed. Mean patients age was 62.9 years. Atrial and caval thrombectomy were achieved successfully in all patients. Mean operative time was 206 min. Mean CPB time was 62 min. Mean hospital stay was 18.8 days. One death occurred, due to respiratory failure. An asymptomatic early thrombosis of the IVC was diagnosed by CT scan in 1 patient. The four remaining patients were alive 6 months after the surgical procedure. Minimally invasive CPB technique can be used to treat intra atrial thrombus tumor extension arising from renal cell carcinoma. It can be performed safely with acceptable complications rate.     

Use of a caval-atrial shunt for resection of a caval tumor thrombus in renal cell carcinoma

Extraction of a tumor thrombus in the vena cava from a renal cell carcinoma is a technically demanding but gratifying procedure. We describe a technique for isolation of the superior vena cava during thrombus extraction using an inferior vena caval to atrial shunt.     

Management under anesthesia of a patient with renal cell carcinoma extending into the retrohepatic inferior vena cava with the aid of partial cardiopulmonary bypass]

A 70-year-old male with renal cell carcinoma extending into the retrohepatic inferior vena cava was scheduled for radical nephrectomy with vena caval resection under general anesthesia. He had received partial gastrectomy for gastric cancer twelve years before. Computed tomography and inferior vena cavography confirmed that the vena cava was almost completely occluded and that a collateral venous network was well established. It was considered that the surgical approach to the retrohepatic cavals area was technically very difficult, and that there was a high possibility of a pulmonary embolus during the surgical manipulation. To prevent a pulmonary embolus and get good control of the vena cava above the tumor and below the hepatic vein, we decided to use a partial cardiopulmonary bypass (CPB) until the vena cava was clamping above the tumor. Anesthesia was induced with propofol and fentanyl, and maintained with fentanyl and isoflurane-N2O-O2. In the partial CPB blood from the hepatic vein was drained from the inferior vena cava cannula through right atrium, oxygenated by microporus membrane oxygenator, and returned to the left femoral artery. Cannulation to drain the venous circulation entering the vena cava below the tumor was abandoned because the extensive collateral venous network ultimately drains into the superior vena cava. The partial CPB time was 90 min, and the bladder temperature during the CPB was 35-36 degrees C. During the 7.3 hr procedure, the pulmonary embolus did not occur and the total blood loss was 5515 ml. The patient made an uncomplicated recovery and was discharged 30 days after the operation. This newly reported partial-CPB method may be safe and effective for the management under anesthesia of other patients.     

Laparoscopic radical nephrectomy with level II vena caval thrombectomy: survival porcine study

PURPOSE: Inferior vena caval tumor thrombus due to renal cell carcinoma generally precludes laparoscopic techniques for radical nephrectomy. We developed the technique of laparoscopic infrahepatic (level II) inferior vena caval thrombectomy in a survival porcine model. MATERIALS AND METHODS: Of the 7 female pigs used in the study 2 were acute and 5 were chronic animals which were allowed to survive for 6 weeks postoperatively. Laparoscopic right radical nephrectomy and inferior vena caval thrombectomy were performed in accordance with established open surgical principles, including vascular control and intracorporeal reconstruction of the vena cava and left renal vein. RESULTS: Complete removal of the simulated caval thrombus was successful in each case without intraoperative or postoperative complications. Average operative time was 160 minutes. Postoperatively inferior venacavography showed a patent vena cava and left renal vein in all animals. CONCLUSIONS: Laparoscopic radical nephrectomy was successful in an animal model simulating renal cell carcinoma with infrahepatic vena caval tumor thrombus. Clinical application of this technique appears possible.     

Total replacement of the suprarenal inferior vena cava with an expanded polytetrafluoroethylene tube graft in 2 patients with tumor thrombi from renal cell carcinoma

Total replacement of the suprarenal inferior vena cava using an expanded polytetrafluoroethylene vascular graft was successful in 2 renal cell carcinoma patients with extended tumor thrombi densely adherent to the vena caval wall. Right radical nephrectomy in 1 patient and enucleation of the tumor in the solitary right kidney were performed concomitantly. Both patients are well without tumor recurrence and with good vena caval patency 14 and 6 months postoperatively. This procedure could be a safer mode of operation in cases of extended vena caval involvement by malignant tumors. Total reconstruction of the inferior vena cava enables more radical resection of the tumor.     

Hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with inferior vena caval thrombus

PURPOSE: To our knowledge we present the initial clinical report of hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with tumor thrombus extending into the inferior vena cava. MATERIALS AND METHODS: A 76-year-old man was referred to our medical center with a 12.5 x 10 cm. stage T3b right renal tumor extending into the inferior vena cava. The caval thrombus was limited and completely below the level of the hepatic veins. After preoperative renal embolization via the hand assisted transperitoneal approach the right kidney was completely dissected with the renal hilum. Proximal and distal control of the inferior vena cava was obtained with vessel loops and a single lumbar vein was divided between clips. An endoscopic Satinsky vascular clamp was placed on the inferior vena cava just beyond its juncture with the right renal vein, thereby, encompassing the caval thrombus. The inferior vena cava was opened above the Satinsky clamp and a cuff of the inferior vena cava was removed contiguous with the renal vein. The inferior vena cava was repaired with continuous 4-zero vascular polypropylene suture and the Satinsky clamp was then removed. A literature search failed to reveal any similar reports of laparoscopic radical nephrectomy for stage T3b renal cell cancer. RESULTS: Surgery was completed without complication with an estimated 500 cc blood loss. Pathological testing confirmed stage T3b grade 3 renal adenocarcinoma with negative inferior vena caval and soft tissue margins. CONCLUSIONS: The introduction of vascular laparoscopic instrumentation and the hand assisted approach enabled us to extend the indications for laparoscopic radical nephrectomy to patients with minimal inferior venal caval involvement.     

Inferior vena caval resection for renal cell carcinoma: usefulness of renal venous pressure measurement]

Renal cell carcinoma with extended tumor thrombi densely adherent to the vena caval wall sometimes requires vena caval resection. If the tumor is on the right side and the collateral veins of the left renal vein are abundant, vena caval reconstruction may not be required. We recently performed radical nephrectomy and vena caval resection on 2 right renal cell carcinoma patients. To decide the necessity of vena caval reconstruction, left renal vein pressure was measured before and after clamping of the vena cava. In case 1, because the pressure was elevated from 21 cmH2O, to 61 cmH2O, total replacement with Gore-Tex graft was performed. In case 2, because the pressure change was from 22 cmH2O to 23 cmH2O, reconstruction was not performed. The most important test to decide the necessity of vena caval reconstruction is thought to be the change of renal venous pressure before and after clamping of the vena cava.     

Venacavoscopy during nephrectomy for renal cell carcinoma with inferior vena caval thrombus

PURPOSE: Renal cell carcinoma with inferior vena caval thrombus remains a complex challenge for the urologist. Aggressive surgery to remove all tumor can result in long-term survival. Liver transplant techniques, assistance from cardiac surgeons and bypass techniques can yield optimal vascular control but there is still a blind element inside the inferior vena cava when the thrombus is evacuated. We present data on a technique using a flexible cystoscope to evaluate the lumen of the intrahepatic and suprahepatic inferior vena cava after nephrectomy and tumor thrombectomy. MATERIALS AND METHODS: Seven patients underwent radical nephrectomy and tumor thrombectomy for renal cell carcinoma with inferior vena caval thrombus. During surgery and after removal of the tumor thrombus a flexible cystoscope was inserted into the venacavotomy for direct inspection of the inferior vena caval lumen. Any residual tumor was manipulated out of the lumen and removed. Patient records were reviewed for data on the time of this procedure, estimated blood loss, residual tumor, postoperative complications and survival. RESULTS: Venacavoscopy required an average additional 5.6 minutes and residual tumor was found in 3 of 7 patients. Average estimated blood loss was 1,170 cc and it was not affected by venacavoscopy. One patient experienced acalculous cholecystitis, possibly as a result of this procedure. Mean followup was 17.6 months with 5 of 7 patients alive. CONCLUSIONS: Venacavoscopy is a safe, reliable method of intraoperative inspection of the inferior vena cava that uses equipment and techniques familiar to every urologist. This can help prevent incomplete thrombectomy and disastrous pulmonary embolus.     

Renal pelvic cancer with tumor thrombus in the vena cava inferior: a case report

We report a case of right renal pelvic cancer with tumor thrombus in the inferior vena cava. A 65-year-old man with right flank abdominal pain and high fever was reffered to our hospital. Computed tomography showed right renal mass. Magnetic resonance imaging revealed tumor thrombus extending into the renal vein and the inferior vena cava. Preoperative diagnosis was renal cell carcinoma with vena caval thrombus. Radical nephrectomy with thrombectomy and lymphodenectomy was performed. Pathologic evaluation revealed transitional cell carcinoma with tumor thrombus into the vena cava. One course of M-VAC chemotherapy was added and he has been alive for 56 months without recurrence. A literature review of 15 cases of renal pelvic cancer with tumor thrombus in the vena cava in Japan revealed that 7 cases were diagnosed as renal cell carcinoma preoperatively.     

Resection of large inferior vena caval thrombi from renal cell carcinoma with the use of circulatory arrest

Removal of a large extension of renal cell carcinoma into the inferior vena cava can be a difficult operation. Circulatory arrest is an operative technique that recently has been used to assist in resection of tumors that extend into the vena cava above the level of the hepatic veins. At our clinic 18 patients were operated on with the intent of using circulatory arrest during radical nephrectomy and inferior vena caval thrombectomy. Of the 18 patients 13 ultimately underwent this procedure, since the remaining 5 had unresectable tumors. One patient died intraoperatively of an adverse reaction to protamine after technically successful removal of the tumor and thrombus. Resection was successful in 12 patients and 9 remained free of disease with short followup. We believe that the addition of circulatory arrest during resection of a large inferior vena caval thrombus allows for an opportunity to resect the tumor in a controlled situation that reduces the potential for sudden massive blood loss or a major vascular injury, and ultimately makes the operation safer.     

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.     

The use of natural veno-venous bypass during surgical treatment of renal cell carcinoma with inferior vena cava thrombus

Renal cell carcinoma associated with inferior vena cava thrombus complicates radical nephrectomy. Various approaches have been used to deal with this problem including veno-venous and cardiopulmonary bypass. Using natural veno-venous bypass may prevent the use of another type of bypass. A total of 16 patients underwent removal of renal cell carcinoma and an intracaval tumor thrombus without using veno-venous bypass. One of the natural veno-venous bypasses consisted in the mobilization of the liver off the retrohepatic inferior vena cava to allow enhanced access, vascular control, and hepatic venous drainage. The other natural bypass involved the preservation and use of collateral veins created by the longstanding obstruction of the inferior vena cava. In all 16 patients surgery was successful. Inferior vena cava clamping above and below the tumor thrombus did not result in systemic hypotension. There was no intraoperative mortality. There were no other complications. Mobilization of the liver off the retrohepatic inferior vena cava and preservation of collateral drainage (right testicular or ovarian veins and/or lumbar veins) were useful techniques in dealing with renal cell carcinoma with intracaval thrombus. These natural veno-venous bypasses allow vascular isolation of the inferior vena cava without disturbing the venous return to the heart and thereby help to prevent hemodynamic instability.     

Adrenocortical carcinoma extending into the inferior vena cava in a patient with right kidney agenesis: Surgical approach and review of literature

INTRODUCTIONAdrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis and the association with tumor thrombus into the inferior vena cava (IVC) is not common. The best treatment is represented by radical surgery.PRESENTATION OF CASEWe describe a case of a large ACC of the left adrenal gland extending into the IVC through the left renal vein in a young patient with agenesis of the right kidney and signs of acute renal failure. A midline laparotomy was performed, subsequently extended by a left thoracophrenotomy through the 7th intercostal space in order to control the proximal surface of the mass and the thoracic aorta. The tumor was completely excised preserving the kidney, and thrombectomy was performed by a cavotomy with a temporary caval clamping, without cardiopulmonary by-pass (CPB).DISCUSSIONWe discuss surgical approaches reported in literature in case of ACC with intracaval extension. The tumor must be completely resected and the thrombectomy can be performed by different approaches: cavotomy with direct suture, partial resection of caval wall without reconstruction, resection of vena cava with graft reconstruction. These procedures could require a CPB, with an increased mortality. In our case we preserved the kidney and a thrombectomy without CPB was performed.CONCLUSIONIntracaval extension of ACC does not represent a contraindication to surgery. The best treatment of intracaval thrombus should be the cavotomy with direct suture. The CPB is not always required. In presence of renal agenesis, the preservation of the kidney is mandatory.     

Preoperative magnetic resonance imaging of vena caval tumor thrombi: experience with 5 cases

Magnetic resonance scans were performed preoperatively in 5 patients who underwent surgical removal of renal or adrenal tumors with direct extension of the tumor into the vena cava. Of the patients 4 had renal cell carcinoma and 1 had adrenocortical carcinoma. Magnetic resonance imaging staged correctly the level of vena caval tumor thrombus involvement in 4 patients and missed the presence of right atrial tumor extension in 1. This noninvasive imaging modality can be used instead of contrast venography in most patients to assess the presence and extent of vena caval tumor involvement by renal cell carcinoma. Contrast venography should be used for those patients with suspected cardiac involvement and for those whose tumor thrombus extent remains unclear after magnetic resonance imaging.     

Suprarenal Greenfield filter placement to prevent pulmonary embolus in patients with vena caval tumor thrombi.

The presence of tumor thrombus secondary to inferior vena caval extension from renal carcinoma carries the threat of pulmonary tumor embolus. In theory, safe prophylaxis could be accomplished by placement of a Greenfield filter in the suprarenal vena cava, which has been accomplished without complication. We treated 6 patients with renal call carcinoma and extensive tumor thrombus of the vena cava with suprarenal filter placement as an adjunct to thrombectomy and nephrectomy. Clinically all 6 patients have done well. However, the over-all rate of vena caval thrombosis or occlusion associated with infrarenal filter placement is 3 to 5%. To investigate the potential risk to renal function if a vena caval occlusion occurred above a solitary kidney shortly after unilateral nephrectomy, we performed suprarenal inferior vena caval ligations after unilateral nephrectomy in 10 dogs. A total of 6 dogs suffered persistent loss of renal function and 3 of these 6 died of uremia. Of 4 dogs who underwent suprarenal inferior vena caval ligation only 1 (25%) had persistent compromise of renal function. A total of 2 dogs underwent unilateral nephrectomy only without compromise of normal renal function. We conclude that the risk of total vena caval occlusion after suprarenal Greenfield filter placement is small. However, should it occur in the setting of recent nephrectomy there is potential for significant renal morbidity. In selected patients this risk may be offset by the potential benefits that the filter offers in terms of protection against tumor and/or bland pulmonary embolus. Further clinical experience will be needed to strengthen and clarify the indications and benefits of preoperative or intraoperative filter placement as reported.     

Suprarenal vena caval occlusion. Principles of operative management.

Retrohepatic occlusion of the inferior vena cava caused by tumor complicates complete resection and not infrequently is associated with life-threatening symptoms that accelerate the lethality of the underlying malignant process. This report summarizes our experience with caval thrombectomy and reconstruction that allowed complete removal of all gross tumor in seven patients with malignant occlusion of the retrohepatic inferior vena cava. Included in this group are five patients with renal cell carcinoma and extension of tumor into the retrohepatic vena cava. Three of these patients had extension of tumor thrombus into the right atrium. A sixth patient had recurrent right adrenal cortical carcinoma with tumor invasion of the vena cava and occlusion to the right atrium. Associated hepatic vein occlusion and secondary Budd-Chiari syndrome also was successfully managed in this patient. The final patient with occlusion of the entire suprarenal vena cava required caval reconstruction after resection of a primary leiomyosarcoma of the retrohepatic portion of the vena cava. Careful planning of the operative procedure, adequate exposure, complete mobilization of the retrohepatic vena cava, and control of the hepatic venous effluent will allow patients with retrohepatic vena caval occlusions to be managed with safety and success.     

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.     

Inferior vena caval involvement by renal cell carcinoma. Use of venovenous bypass as adjunct during resection

Venovenous bypass allows the safe conduct of operation during resection of renal cell carcinoma with inferior vena caval involvement by allowing venous return when the inferior vena cava is clamped, thus preventing hypotension. It obviates the heparin required for full cardiopulmonary bypass and therefore decreases postoperative bleeding. A blood retrieval system decreases the volume of banked blood required. A Moretz clip placed early on the intrapericardial inferior vena cava allows adequate venous return and prevents a massive pulmonary tumor embolism.     

Hepatic Vascular Exclusion With Preservation of the Caval Flow for Liver Resections

OBJECTIVE: To report the technique and results of an alternative method of vascular clamping during liver resections. BACKGROUND: Most liver resections require vascular clamping to avoid excessive blood loss. Portal triad clamping is often sufficient, but it does not suppress backflow bleeding, which can be prevented only by hepatic vascular exclusion. The latter method adds clamping of the inferior vena cava, which results in hypotension, requiring invasive anesthetic management. There is growing evidence that intermittent clamping is better tolerated than continuous clamping, especially in the presence of underlying liver disease. METHODS: Hepatic vascular exclusion with preservation of the caval flow (HVEPC) involved conventional inflow clamping associated with outflow control by clamping the major hepatic veins, thus avoiding caval occlusion. HVEPC was used in 40 patients undergoing major or complex liver resection, including 16 with underlying liver disease. HVEPC was total (clamping of the porta hepatis and all major hepatic veins) in 20 cases and partial (clamping of the porta hepatis and the hepatic veins of the resected territory) in 20. Clamping was continuous in 22 cases and intermittent in 18. Resections included 12 hemihepatectomies, 12 extended hepatectomies, 3 central hepatectomies, and 13 uni- or bisegmentectomies. RESULTS: Hemodynamic tolerance of clamping was excellent in all cases, without the need for therapeutic adjustment. Median red cell transfusion requirements were 0 units, and 28 patients (70%) did not receive any transfusions during the hospital stay. There were no deaths, and the morbidity rate was 17.5%. Median hospital stay was 10 days. CONCLUSION: HVEPC is a safe and effective procedure applicable to liver tumors without invasion to the inferior vena cava. It offers the advantages of conventional hepatic vascular exclusion without its hemodynamic drawbacks, and it can be applied intermittently or partially.     

Surgical treatment of renal cell carcinoma involving the inferior vena cava

Renal cell carcinoma extends into the inferior vena cava in 5% of patients undergoing exploratory surgery for this malignancy. If the tumor is left unresected, death within 1 year is certain. In addition, caval occlusion may result in massive lower extremity edema, ascites, hepatic failure, and pulmonary embolus. During the past 17 years, 12 patients with renal cell carcinoma extending into the inferior vena cava were treated at a single institution by radical nephrectomy and caval tumor extraction. There were 10 men (83%) and ages ranged from 50 to 78 years (mean 63 years). There was one operative death (8%) caused by refractory coagulopathy. Long-term follow-up was achieved for all survivors. One- and 3-year survival rates by life-table method were 73% and 27%, respectively. Mean survival time after resection was 32 months. Careful preoperative planning is essential. The optimal approach for venacaval tumor extraction or resection is dictated by the cephalad extent of tumor seen on preoperative thoracoabdominal CT scan, ultrasound, or inferior venacavography. Disease limited to the infrahepatic vena cava is best approached with a thoracoabdominal incision through the eighth intercostal space. Extension of tumor to the hepatic veins or right atrium requires median sternotomy in combination with an abdominal incision for complete removal. An ellipse of vena cava around the origin of the renal vein is excised with the specimen. The resultant incision is closed by lateral phleborrhaphy. Late sequelae of the mild caval narrowing were not observed. An aggressive multispecialty surgical policy for caval extraction and resection of renal cell carcinoma resulted in extended patient survival and excellent palliation.