Abstract
Surgical management of renal cell carcinoma (RCC) with tumor thrombus (TT) extending into the inferior vena cava (IVC) and up to the hepatic veins and right atrium (RA) continues to be problematic and a challenging surgical operation. It becomes even more complicated when performing a re-sternotomy and cardiopulmonary bypass (CPB) in patients with previous coronary artery bypass grafting (CABG). Here, we report on two patients with previous CABG who presented with RCC and TT extending into the hepatic vein and above the diaphragm. These two patients underwent successful surgical resection and TT thrombectomy without the need of CBP. Recommendations are made for successfully accomplishing such surgical resections, including adequate prior preparation for the possible need to perform re-sternotomy and CPB with a coordinated team effort.
Highlights
Renal cell carcinoma (RCC) infrequently extends into the renal vein and inferior vena cava (IVC) [1, 2], and surgical removal is the mainstay treatment of this complex tumor [3, 4]
There are no surgical approaches or techniques described for surgical management without using cardiopulmonary bypass (CPB) of large renal masses with tumor thrombus (TT) inferior and superior to the diaphragm in patients with a previous coronary artery bypass graft (CABG)
Dealing with RCC and TT either below or above the diaphragm forced us to think how to resect them without using CBP [9, 10]
Summary
Renal cell carcinoma (RCC) infrequently extends into the renal vein and inferior vena cava (IVC) [1, 2], and surgical removal is the mainstay treatment of this complex tumor [3, 4]. Surgery for Renal Cell Carcinoma lying underneath the sternum, e.g., grafts, right ventricle and others clearly exist [5] In both patients, the TT was removed trans-abdominally, avoiding sternotomy and CPB. For Patient #1 with level IIIb TT, once the liver and IVC were completely mobilized via the Piggyback technique, vascular clamps were placed in the infra-renal vena cava followed by the left renal vein. Intraop Pringle’s Maneuver Blood transfusion Estimated blood loss (cc) Postop Pathological diameter (cm) Pathological staging Follow up
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