Technical Intraoperative Maneuvers for the Management of Inferior Vena Cava Thrombus in Renal Cell Carcinoma

Abstract

IntroductionRenal vein or inferior vena cava (IVC) invasion by neoplastic thrombus in patients with renal cell carcinoma (RCC) is not an obstacle for radical oncological treatment. The aim of this study is to present our technical maneuvers for complete removal of the intracaval thrombus without compromising hemodymanic stability of the patient.Materials and methodsBetween 2000 and 2014, 15 RCC patients with IVC involvement of levels I–III were treated with curative intent and were prospectively studied. The operative technique varied according to thrombus extent. For type I, extraction of the thrombus is facilitated by a 2–3 cm longitudinal incision on the IVC that begins at the level of the renal vein and extends cranially, encompassing a vessel wall rim of the orifice of the resected renal vein. For type II cases, the IVC is clamped above the neoplastic thrombus, and for type III, the IVC clamping is combined with hepatic blood flow control with “Pringle maneuver.” For type IV, the IVC is clamped above the diaphragm, or if the thrombus extends into the right atrium cardiothoracic input is appropriate.ResultsThe main operative steps include preparation and control of the renal vessels and the IVC. Occasionally, for type III tumor thrombi, the patient becomes hemodynamically unstable when IVC is clamped suprahepatically. In such a case, a novel operative maneuver of milking the thrombus below the orifice of the hepatic veins, and subsequently the IVC clamp also beneath the hepatic veins, allowing release of the “Pringle maneuver” is performed. This operative step restores hepatic blood flow and hemodynamic stability and is based on the floating nature of the thrombus into the IVC. Mean operative time was 120 min (range from 90 to 180 min), and average liver and renal warm ischemia time was 20 min (range from 15 to 35 min). Postoperative overall hospital stay ranged from 7 to 13 days.ConclusionThe technical solutions employed in the current study allow successful removal of neoplastic thrombi from the IVC in most cases, associated with minimal perioperative complication rate even for patients who due to multiple comorbidities would be considered otherwise inoperable.

Surgical Treatment Strategy with Combined Cardiopulmonary Bypass for Renal Cell Carcinoma with Tumor Embolism Developed in Inferior Vena Cava

“…The use of CPB is involved in the surgical procedures for RCC removal. Surgical options for IVC reconstruction include (1) direct repairment for small defects of IVC, (2) patch repair for large defects of IVC, and (3) graft replacement for severe invasion to the IVC wall [Dellaportas 2017]. Although direct repair is appropriate for patients with a small defect and mild invasion of IVC after RCC removal, patch repair and graft replacement with CPB are suitable in cases of severe and extensive IVC invasion to help stabilize the fluctuation of circulatory dynamics by IVC cross-clamp.…”

Perioperative and oncologic outcome in patients treated for renal cell carcinoma with an extended inferior vena cava tumour thrombus level II-IV

“…For preparation of the tumor thrombectomy, the hilar vessels (renal artery and vein) and the vena cava inferior were exposed. Several publications exists about the various approaches for TT thrombectomy [16]. In case of level II TT in our department, the IVC proximally and distally from the thrombus was clamped, before cavotomy and thrombectomy were performed.…”

Technical Tips for Performing Suprahepatic Vena Cava Tumor Thrombectomy in Renal Cell Carcinoma without Using Cardiopulmonary Bypass

“…In many cases, the liver parenchyma must be dissected to clamp the hepatic veins separately at the level just before their junction with the IVC. Therefore, performing the Pringle maneuver to reduce blood flow from the hepatic veins to the IVC during cavotomy is easier than clamping the hepatic veins [ 43 , 44 ]. After clamping the hepatic pedicle for the Pringle maneuver, the surface of the liver is gently squeezed to remove any remaining blood inside the liver.…”

“…There are a few studies on surgery for level III or IV tumor thrombi without CPB, but the rates of perioperative complications and mortality are not high compared with those of CPB [ 43 , 54 ]. Complications include an embolism of tumor thrombus during IVC manipulation or clamping and massive blood loss.…”