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

Dionysios Dellaportas,Georgia Kostopanagiotou,George Gemenetzis,Evgenios Bairamidis,Constantinos Nastos,Nikolaos Arkadopoulos,Vassilios Smyrniotis,Ioannis Vassiliou,Ioannis Tzanoglou,Pantelis Xanthakos

doi:10.3389/fsurg.2017.00048

Dionysios Dellaportas, Georgia Kostopanagiotou + Show 8 more

Open Access

https://doi.org/10.3389/fsurg.2017.00048

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Abstract

Renal 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. Between 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. The 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. The 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.

Highlights

About 4–10% of renal cell carcinoma (RCC) patients present with invasion of the renal vein or the inferior vena cava (IVC) with neoplastic cells, forming a thrombus [1]
At level 0, the thrombus extends to the renal vein only; at level I, the neoplastic emboli extends into the IVC to no more than 2 cm above the renal vein; at level II, the thrombus reaches into the IVC to more than 2 cm above the renal vein but not to the hepatic vein; at level III, the thrombus reaches into the IVC above the hepatic veins but not above the diaphragm; and at level IV, the thrombus extends into the supradiaphragmatic IVC or the right atrium
The proximal extent of the neoplastic thrombus may have a role as a prognostic factor [11], thrombus extraction in conjunction with radical nephrectomy is considered the standard of care

Summary

Introduction

About 4–10% of renal cell carcinoma (RCC) patients present with invasion of the renal vein or the inferior vena cava (IVC) with neoplastic cells, forming a thrombus [1]. Surgical management of these tumors is challenging and associated with significant morbidity and mortality [2], while neoplastic pulmonary embolus is reported in 2–3.4% of cases [3]. RCC thrombus in the large veins is a floating neoplastic lesion. Invasion or dense attachment to the wall of the vessels are rare incidents, and radical nephrectomy combined with extraction of the neoplastic thrombus is an oncologically sound approach that can result in long-term survival, even in cases with distant metastasis [4, 5]. At level 0, the thrombus extends to the renal vein only; at level I, the neoplastic emboli extends into the IVC to no more than 2 cm above the renal vein; at level II, the thrombus reaches into the IVC to more than 2 cm above the renal vein but not to the hepatic vein; at level III, the thrombus reaches into the IVC above the hepatic veins but not above the diaphragm; and at level IV, the thrombus extends into the supradiaphragmatic IVC or the right atrium

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