Surgery for cavoatrial extension of renal malignant tumours using a veno‐venous shunt

Abstract

held in the IVC orifice. As the IVC was then occluded, Indications any embolic migration was prevented during removal of the kidneys. The right kidney was thus completely freed, Surgery for extensive cavoatrial extension of renal malignant tumours is a complex procedure [1] that is even being attached only by the renal vein. The portal vein and left renal vein were clamped. The IVC was incised more diÃcult to perform in the obese and elderly. A patient was admitted to our hospital with macroscopic in front of the right renal vein; this venotomy was extended for 5 cm downstream to gradually release the haematuria causing severe anaemia (haemoglobin 7.2 g/L, haematocrit 24%); the patient was a 78-yeartumour adhering to the first 3 cm of the IVC. The surgical specimen and thrombus could then be readily old woman, 1.63 m tall and weighing 78 kg. Ultrasonography of the abdomen detected a tumour of the upper pole of the right kidney with intracaval tumoral extension; the tumour measured 11×10×9 cm. Cavography (Fig. 1) revealed a mobile cavoatrial tumoral extension which appeared not to adhere to the inferior vena cava (IVC) in the retrohepatic area, particularly in the region of the suprahepatic veins. Transthoracic and transoesophageal cardiac ultrasonography revealed an extremely mobile, right, intra-atrial tumour impinging on the tricuspid valve in diastole. There was no evidence of metastases during the staging examination. The patient underwent surgery 5 days after admission. MethodThe incision combined a sternotomy with subcostal laparotomy on both sides. Two purse-string sutures were made in the right atrium, one for cannulation and the other to facilitate the introduction of a finger into the atrium (Fig. 2). The great vessels were exposed in the abdomen after displacing the hepatic flexure and the duodenum. The right renal artery was ligated. The sub-renal IVC, the left renal vein and the portal vein were then monitored.A veno-venous shunt (Biomedicus pump, France) was installed between the femoral vein and the atrium. The shunt was purged with heparinized saline (20 mg heparin) and the patient received 30 mg heparin. During surgery, a finger was introduced into the right atrium through the purse-string suture, the sub-renal IVC was clamped and the shunt made operational. The finger

Renal Cell Carcinoma with IVC Thrombi; Current Concepts and Future Perspectives

“…However, it markedly reduces the venous return causing profound hypotension. Hemodynamic stability is restored by: (1) creating a veno-venous bypass in which IVC distal to the thrombus is cannulated with inflow at the level of the right atrium or cephalic vein 20. With a more cephalad extent of tumor thrombi, a pump-driven veno-venous bypass (VVB) can be done in which the IVC and the inferior mesenteric vein (for portal decompression) are connected to the right atrium (Fig.3).…”

A new classification of inferior vena cava thrombus in renal cell carcinoma could define the need for cardiopulmonary or venovenous bypass

“…Conventionally, techniques described to treat thrombi above the hepatic vein and around the diaphragm involved complete liver mobilization and cardiopulmonary bypass with or without hypothermic circulatory arrest or venovenous bypass (VVB) by either open surgery or by the percutaneous method. [ 14 15 16 ] The problems with these two techniques are that cardiopulmonary bypass with hypothermia and use of heparin may result in platelet dysfunction and coagulopathy. This would increase the risk of bleeding, sepsis and multiorgan failure.…”

“…[ 20 21 ] Complications like infection, vessel access injury and air embolism have also been reported with VVB. [ 15 ] Most of the thrombi, where cephalad clamp on the IVC could be applied, would not need any VVB or cardiopulmonary bypass. For level I thrombus, cardiothoracic back up is not required but for level II and III thrombus, it is always recommended to keep the back up support of a cardiothoracic surgeon.…”

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

“…Aortic cross-clamping and the Pringle maneuver are applied to minimize bleeding from the hepatic vein and to prevent hepatic congestion when the segment of the suprahepatic IVC is clamped. Venovenous bypass is sometimes used instead of aortic cross-clamping by other groups to maintain the hemodynamic stability [18–20]. …”