Management Of Inferior Vena Cava Research Articles

En Bloc Inferior Vena Cava (IVC) Resection Without Reconstruction With Right Hepatectomy and Right Nephrectomy for a Large IVC Leiomyosarcoma.

Radical resection remains the only potential cure in the management of inferior vena cava (IVC) leiomyosarcomas with multivisceral resections often needed (Borghi et al. in J Cardiovasc Surg (Torino) 63:649-663, 2022). This video describes the technical nuances of surgical resection of a large retrohepatic IVC leiomyosarcoma. Computed tomography of a 60-year-old woman revealed a 12 × 12 × 9.5 cm mass in the right suprarenal region infiltrating the IVC with intraluminal extension up to the hepatic venous confluence. The mass involved the right hepatic vein with infiltration of segment 7 of the liver and splaying of the right portal vein. Robust lumbar venous drainage from the infratumoral IVC was seen. En bloc IVC resection without reconstruction along with a right hepatectomy and right nephrectomy was performed via a right thoracoabdominal approach. After a Catell-Braasch maneuver, the surgery can be broadly divided into four major steps: (1) Right retroperitoneal mobilization of the tumor and right kidney with infratumoral IVC control, (2) mobilization of the right liver with suprahepatic IVC control, (3) division of the right portal structures with right hepatectomy, and (4) en bloc resection of the IVC tumor. Reconstruction of the IVC was not performed owing to the presence of venous collaterals (Langenbecks et al. in Arch Surg 407:1209-1216, 2022). Final histopathology showed a high-grade leiomyosarcoma with histologic organ invasion in the liver and right kidney with resected margins free of the tumor (R0). Meticulous preoperative planning and expertise in liver resection and retroperitoneal surgeries facilitates such radical yet safe multivisceral resection for a large retrohepatic IVC leiomyosarcoma without the need for a cardiopulmonary bypass.

The First Ever Robotic-Assisted Laparoscopic Radical Nephrectomy with Inferior Vena Cava Thrombectomy Performed in Thailand: A Case Report of Atypical Presentation of Urothelial Carcinoma with Tumor Thrombus

Background: Robotic-assisted surgery was proposed as an alternative to open surgery for management of inferior vena cava (IVC) thrombus together with radical nephrectomy in complex renal mass. Here, the authors reported the first case of this type to be managed via this surgical technique in Thailand. Case Report: A 76-year-old Thai female presented with right renal mass with tumor thrombus in the IVC extending 3 cm above the level of the renal vein. The presumed diagnosis was renal cell carcinoma of the right kidney with level 2 tumor thrombus in IVC, clinical staging T3bN0M0. The patient underwent robotic-assisted laparoscopic IVC thrombectomy together with right radical nephrectomy at Siriraj Hospital (Bangkok, Thailand) in May 2020. Results: The operation proceeded uneventfully without immediate complication. The postoperative reduction of IVC diameter was approximately 30%. Total IVC clamp time was 50 minutes, operative time was five hours, with docking time of 20 minutes and console time of 250 minutes, estimated intraoperative blood loss was 2,600 mL, and length of hospital stay was four days. At 30-days and 90-days postoperation, no thromboembolic event or compromising lower extremity venous return was detected. The pathological report revealed high-grade urothelial cell carcinoma with invasion into perinephric fat. Carcinoma involvement was observed in the tumor thrombus and IVC wall (T4N0M0). Conclusion: Robotic-assisted surgery of the IVC is a complex operation that requires robotic surgical proficiency and a highly experienced team. The observed success in the present case demonstrated the feasibly of this procedure in Thailand. Additional benefits include less postoperative pain, reduced blood loss, smaller surgical wound size, and shorter length of hospital stay. Keywords: Robotic-assisted laparoscopic radical nephrectomy; Inferior vena cava thrombectomy; Thailand

Cardiovascular surgical experiences of IVC tumor and thrombus: Operative strategies Based on 51 consecutive patients.

The only beneficial treatment option for the management of inferior vena cava (IVC) tumor thrombus is complete tumor removal. The aim of this study was to report our experience in surgical and clinical outcomes in patients with tumor thrombosis in IVC. A retrospective chart review of patients who underwent surgical resection of IVC tumor at our institution over the past 10 years was performed. The patients were identified using a prospectively maintained database. We identified 51 patients, the mean age was 53.4 ± 16.8 years, and 25.4% were female. They were divided into three groups based on tumor thrombosis level. Twenty patients (39.2%) required sternotomy, and cardiopulmonary bypass (CPB) was used in 19 (37.2%) patients, and 2 (3.9%) cases underwent coronary artery bypass graft. The perioperative complications were severe bleeding (3 patients), pulmonary embolism (2 patients), and duodenal perforation (1 patient). Three (5.8%) in-hospital deaths occurred, and all were due to severe abdominal bleeding. After a mean follow-up time of 46.5 ± 42.0 months, 29 (56.9%) patients were alive. The mean survival time was 75.2 ± 8.4 months. In multivariate analysis, higher age (p = 0.033) and male gender (p = 0.033) proved to be independent prognostic factors. Tumor thrombus extending to the IVC is a rare and challenging event. Although using CPB may be safe and result in long-term survival with acceptable function, excessive bleeding during surgery may limit the use of this method.

Surgical management of inferior vena cava: A decade-long experience

Surgical management of inferior vena cava: A decade-long experience

Initial piggyback technique facilitates late liver retransplantation - a retrospective monocentric study.

Optimal management of inferior vena cava (IVC) is crucial to ensure safety in late liver retransplantation (ReLT). The aim of this study was to evaluate different surgical strategies with regard to IVC in late ReLT. All consecutive late ReLT (≥90days from the previous transplant) from 2013 to 2018 in a single center was reviewed (n=66). Of them, 46 (69.7%) were performed without venovenous bypass (VVB) including 29 with caval preservation (CP) and 17 with caval replacement (CR). The remaining 20 cases (30.3%) required the use of VVB. Among ReLT without VVB, CP was associated with a lower number of packed red blood cells (median 4 vs. 7; P=0.016) and a lower incidence of post-transplant acute kidney injury (6.9% vs. 47.1%; P=0.003). The feasibility of CP was 95% (14/15) in patients with previous 3-vein piggyback caval anastomosis versus 48.3% (15/31) after other techniques (P=0.003). Indirect signs of portal hypertension (PHT) before retransplantation were predictive of VVB requirement. Early and long-term outcomes were similar across the three groups (CP without VVB, CR without VVB, and VVB). Preserving the IVC in late ReLT is associated with better postoperative renal function and is facilitated by a previous 3-vein piggyback. Routine CR is not justified in late ReLT.

The analysis of anesthetic management for renal cell carcinoma with associated inferior vena cava tumor thrombus

Objective: To explore the key points of anesthetic management for renal cell carcinoma combined with inferior vena cava (IVC) tumor thrombus. Methods: Twenty-seven cases of renal cell carcinoma with inferior vena cava (IVC) tumor thrombus underwent radical nephrectomy and inferior caval venous thrombectomy were reviewed retrospectively during January 2014 to January 2017 in our hospital.Analyzed data includs demographics, classification of tumor, perioperative anesthetic management and monitoring approaches, IVC clamping time , vital signs during cardiopulmonary bypass(CPB), estimated blood loss (EBL), usage of blood products, hospitalization time and ICU time , as well as postoperative outcomes. Results: Clinical staging revealed 5 patients(18.5%) with classⅠtumor thrombus, 11 patients(40.7%) with levelⅡtumor thrombus, 6 patients (22.2%) with level Ⅲ tumor thrombus and 5 patients (18.5%) with level Ⅳ tumor thrombus. All patients had underwent a balanced general anesthesia technique with volatile agents, opioids and muscle relaxants. In addition to standard ASA monitors, all patients had direct arterial pressure and central venous pressure monitoring, and blood warming and infusing system. TEE was utilized in 9(33.3%)patients and in which contains all 5 patients(100%)with level Ⅳ tumor thrombus. Intraoperative TEE guidance resulted in a significant surgical plan modification in 1 patient(11.1%). Compared to patients with class Ⅰ(313 (136, 346) min), classⅡ(302(245, 393)min)and classⅢthrombus tumor(391(272, 505)min), patients with Class Ⅳ had longer operating time (525(481, 647)min, P<0.05). Compared to patients with Class Ⅰ(600(500, 850)ml), Class Ⅱ(1 700(750, 3 000)ml), and Class Ⅲ(1 775(1 500, 3 000)ml), patients with Class Ⅳ had more blood loss(4 000(2 000, 7 000)ml, P<0.05). The clamping time of Class Ⅰ, Class Ⅱ and Class Ⅲ was 8(8, 9)min, 20(13, 26)min and 10(6, 25)min, respectively, and there is no significant difference (P>0.05) within theses group. The probability of pumping norepinephrine of Class Ⅰ(8(8, 9)min), Class Ⅱ(20(13, 26)min), and Class Ⅲ(10(6, 25)min)had no significant difference (χ(2)=5.147, P>0.05). Perioperative mortality was 7.4%. Conclusions: The anesthetic management of Inferior vena cava (IVC) tumor thrombus is rather challenging.The preoperative evaluation with accurate classification of the tumor and the intraoperative intense monitoring of vital signs with appropriate reaction are the key points of anesthetic management for this kind of surgery.

Surgical removal of an inferior vena cava thrombus

Studies on the management of inferior vena cava (IVC) thrombosis have rarely focused upon the risk of later development of post-thrombotic syndrome of the lower limbs. From 1983-1989, 52 patients with ilio-femoral thrombosis with an extension of thrombus into the IVC were treated. In addition to lower limb pain and swelling, 12 (23%) patients had symptomatic pulmonary embolism on admission. Perfusion/ventilation pulmonary scans were positive in 63%. Twelve patients received only anti-coagulant treatment. Thrombectomy was attempted in 40 patients, but failed in 13 patients due to old thrombi. Twenty-seven patients had surgical removal of thrombus combined with anti-coagulation [temporary arterio-venous fistula (AVF) and IVC interruption (n = 15); AVF alone (n = 9); and without fistula n = 3)]. The mortality and morbidity were low and hospital stay was not prolonged. Thirty-eight legs were examined at 7-66 months (mean: 23 +/- 3) after initial treatment. The limbs in which the IVC thrombus could not be removed (n = 20) were symptomatic in 25% of patients, venous ulcer developed in 4 of 20 limbs. The ilio-femoral segment was patent in only 35%. The thrombectomised limbs (n = 18) were asymptomatic in 56%; none had developed ulcer and iliac patency was 72%. Doppler investigations and refilling times were normal in 39% of the thrombectomised limbs. All patients without surgical IVC thrombus removal developed contralateral deep venous thrombosis during the follow-up period. This study shows that femoro-ilio-caval thrombectomy is successful only in patients with a short history and fresh clot, and can be safely performed with low morbidity and mortality.(ABSTRACT TRUNCATED AT 250 WORDS)