Diagnosis and treatment strategies for intraoperative pulmonary embolism caused by renal tumor thrombus shedding

Abstract

Aim To provide an overview of techniques for prevention, immediate diagnosis, and treatment strategies of intraoperative pulmonary embolism caused by renal tumor thrombus shedding. Methods A total of 290 patients admitted into our medical center from March 2015 to May 2021 were retrospectively analyzed. All patients underwent radical nephrectomy with tumor thrombectomy. Six patients were diagnosed as pulmonary embolism during the perioperative period, of which two patients had tumor thrombus shedding. One patient underwent thoracotomy and thrombectomy, one patient underwent interventional thrombectomy, and four patients underwent conservative treatment. All patients have gone through our diagnosis and strategy flow chart. Demographic data, tumor characteristics, tumor thrombus characteristics, and follow‐up data were collected. Results In the preoperative risk factor assessment, of the 253 patients who entered the follow‐up, 163 were women, 48 were older than 60 years old, and 83 had a duration of more than 2 months. In addition, 27 patients had tumor thrombus with bland thrombus, and 43 patients had floating tumor thrombus. 78 patients underwent postoperative anticoagulation after evaluation. The average follow‐up time was 23.3 ± $\pm $ 8.6 months (range, 7–31 months). All patients were alive during the follow‐up period. Conclusion For acute pulmonary embolism during nephrectomy and tumor thrombectomy, management strategies can be used to deal with intraoperative emergencies and provide reference.

Experiences of robot assisted thrombectomy with 2‐year follow‐up

“…Although evidence supporting the use of preoperative anticoagulation is limited, several potential benefits include a reduced risk of pulmonary embolism and shrinkage of bland thrombus. 25,26 Temporary suprarenal IVC filters are also an option for patients with levels 0, I and II tumour thrombi. 27 However, because of the risk of contralateral renal and hepatic vein thrombosis, risk of provoking embolisation, and impediment that these devices can pose to future IVC thrombectomy, we do not recommend the use of suprarenal IVC filters.…”

“…We suggest that anticoagulation with intravenous or low‐molecular‐weight heparin should be started as soon as a bland thrombus is detected by MRI examination. Although evidence supporting the use of preoperative anticoagulation is limited, several potential benefits include a reduced risk of pulmonary embolism and shrinkage of bland thrombus 25,26 . Temporary suprarenal IVC filters are also an option for patients with levels 0, I and II tumour thrombi 27 .…”

Differentiation of solid and friable tumor thrombus in patients with renal cell carcinoma using volumetric analysis of computed tomography radiomic features

“…However, current approaches to this issue have undergone signi cant changes. Precise preoperative identi cation and differentiation between friable and solid tumour thrombi in patients with RCC that has spread into the inferior vena cava (IVC) are crucial for effective surgical treatment planning [22,23]. Failure to accurately diagnose a friable thrombus can result in severe complications, including life-threatening pulmonary embolism [24].…”

Long-term outcomes after cytoreductive nephrectomy and thrombectomy of patients with metastatic renal cell carcinoma with venous tumor thrombus: a retrospective study from a large Chinese center

“…Therefore, surgical treatment seems to be given unduly high status. However, it can cause pulmonary embolism due to the shedding of brittle tissue of TT, even causes sudden cardiac death because of the rapid growth of TT [ 7 ]. In addition, patients with IVC TT are prone to vena cava obstruction symptoms, such as lower limb edema, ascites, impaired renal function, and Bucha’s syndrome, which diminished the quality of life.…”