Removal of the Tumor Thrombus from the Right Atrium without Extracorporeal Circulation: Emphasis on the Displacement of the Tumor Apex.

D. V. Shchukin,V. N. Lesovoy,A. V. Maltsev,P. V. Mozzhakov,M. M. Polyakov,A. I. Harahatyi,R. V. Stetsyshyn,O. O. Makovozov,M. P. Kopytsya,G. G. Khareba

doi:10.1155/2020/6063018

Abstract

Objectives To assess the outcomes of cavoatrial tumor thrombus removal using the liver transplantation technique for thrombectomy, a retrospective study was conducted. Materials and Methods Five patients with atrial tumor thrombi who underwent piggy-back mobilization of the liver, surgical access to the right atrium from the abdominal cavity, and external manual repositioning of the thrombus apex below the diaphragm (milking maneuver) were included into the study. Extracorporeal circulation was used in none of the cases. The average length of the atrial component of the tumor was 20.0 ± 11.7 mm (10 to 35 mm), and the width was 14.8 ± 8.5 mm (10 to 30 mm). In this work, the features of patients and surgical interventions as well as perioperative complications and mortality were analyzed. Results External manual repositioning of the tumor thrombus apex below the diaphragm was successfully performed in all patients. Tumor thrombi with the length of the atrial part up to 1.5 cm were removed through the extrapericardial approach. For evacuation of the thrombi with the large atrial part (3.0 cm or more), a transpericardial surgical approach was required. Specific complications associated with the access to the right atrium from the abdominal cavity (paresis of the right phrenic nerve, pneumothorax, and mediastinitis) were not detected in any case. The average clamping time of the supradiaphragmatic inferior vena cava (IVC) was 6.3 ± 4.6 min. The volume of intraoperative blood loss varied from 2500 to 5600 ml (an average of 3675 ± 1398.5 ml). Conclusion Our work represents the initial experience in the liver transplantation technique for thrombectomy in distinct and well-selected patients with atrial tumor thrombi. The effectiveness of this approach needs further study. The video presentation of our research took place in March 2019 at the 34th Annual EAU Congress in Barcelona.

Highlights

One of the most important aspects of surgical treatment for renal tumors extending into the inferior vena cava (IVC) is control of the apical part of the tumor thrombus. is stage can be quite challenging in case of “high” localization of the thrombus apex and mainly depends on the type of surgical approach selected
We retrospectively evaluated our own experience in the surgical treatment of renal cell carcinoma spreading to the IVC and the right atrium with the use of the liver transplantation technique described by Ciancio et al [10]. e features of this surgical technique, including access to the right atrium through the diaphragm from the abdominal cavity, and complications were analyzed
E study included only those patients in whom the tumor thrombus apex was located in the lumen of the right atrium. is was confirmed by abdominal and chest multidetector computed tomography (MDCT) with contrast enhancement, as well as abdominal ultrasound examination

Summary

Introduction

One of the most important aspects of surgical treatment for renal tumors extending into the inferior vena cava (IVC) is control of the apical part of the tumor thrombus. is stage can be quite challenging in case of “high” localization of the thrombus apex (retrohepatic or intrapericardial IVC and right atrium) and mainly depends on the type of surgical approach selected. Is stage can be quite challenging in case of “high” localization of the thrombus apex (retrohepatic or intrapericardial IVC and right atrium) and mainly depends on the type of surgical approach selected. For these patients, cardiopulmonary bypass with or without deep hypothermic circulatory arrest is used [1]. There have been more and more reports on alternative surgical approaches without use of cardiopulmonary bypass and circulatory arrest in patients with the tumor thrombi extending above the mouths of the major hepatic veins [4,5,6,7,8,9,10]. Particular attention was paid to the manual repositioning of the tumor thrombus apex below the diaphragm

Objectives

Methods

Results