You have accessJournal of UrologyKidney Cancer: Advanced (II)1 Apr 20131905 INTRAPERICARDIAL CONTROL DURING INFERIOR VENA CAVAL THROMBECTOMY WITHOUT CARDIOPULMONARY BYPASS Mukul Patil, Jeremy Montez, Jeffrey Loh-Doyle, Eila Skinner, Donald Skinner, Anne Schuckman, and Siamak Daneshmand Mukul PatilMukul Patil Los Angeles, CA More articles by this author , Jeremy MontezJeremy Montez Los Angeles, CA More articles by this author , Jeffrey Loh-DoyleJeffrey Loh-Doyle Los Angeles, CA More articles by this author , Eila SkinnerEila Skinner Stanford, CA More articles by this author , Donald SkinnerDonald Skinner Los Angeles, CA More articles by this author , Anne SchuckmanAnne Schuckman Los Angeles, CA More articles by this author , and Siamak DaneshmandSiamak Daneshmand Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.2324AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Inferior vena cava (IVC) tumor thrombectomy is an advanced procedure requiring experienced urologic & anesthesia teams due to complex hemodynamic considerations. Cardiopulmonary bypass is often used by a second surgical team, but introduces additional risk. Control of the IVC within the pericardium obviates the need for CP bypass for intrahepatic (Level II), supradiaphragmatic (Level III) & selected intra-atrial (Level IV) cases. We present our experience with intrapericardial control during IVC tumor thrombectomy. METHODS From 1978 to 2012, 101 patients underwent extirpative surgery with intrapericardial IVC control. This technique was performed in all cases of Level II (n=38) and III (n=37) thrombi, and in select cases of Level I (infrahepatic, n=7) & Level IV (n=17). Surgical approach was through a right thoracoabdominal incision, allowing access to the pleural cavity & pericardium. Intrapericardial control was obtained with a Rumel tourniquet with test occlusion to confirm hemodynamic stability. Splanchnic arteries, contralateral renal vein, and infrarenal IVC were controlled prior to occlusion of the porta hepatis. IVC tumor thrombectomy was then completed, followed by additional procedures when indicated (ie, IVC resection/partial interruption, filter placement, cavoscopy). RESULTS Of 101 patients, 98 underwent successful extirpation (97%). Intraoperative mortality occurred in three patients (massive pulmonary embolism, n=2, uncontrollable hemorrhage, n=1). Median Pringle maneuver time was 14 min (3-30). Additional procedures included IVC resection or partial interruption (n=41), IVC filter placement (n=9) and vena cavoscopy (n=16). Cavoscopy permitted visualization of residual tumor thrombus in 3 patients. Median length ventilator dependence was 1 day, median ICU stay was 5 days, and median length of stay was 11 days. Pathology revealed renal cell carcinoma (n=92), adrenocortical carcinoma (n=1), urothelial carcinoma (n=1), and nephroblastoma (n=1). Extensive lymphadenectomy was performed in 96 patients, revealing nodal metastasis in 35 patients (38%). Thirty-two patients with RCC were alive at an average of 35.7 months after surgery (0.3-198). Of those deceased, mean overall survival after surgery was 24.2 months (0.03-117). CONCLUSIONS Intrapericardial control of the IVC allows a single surgical team to safely perform tumor thrombectomy for intrahepatic and supradiaphragmatic thrombi. This approach obviates the need for cardiopulmonary bypass and eliminates associated morbidity. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e781 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mukul Patil Los Angeles, CA More articles by this author Jeremy Montez Los Angeles, CA More articles by this author Jeffrey Loh-Doyle Los Angeles, CA More articles by this author Eila Skinner Stanford, CA More articles by this author Donald Skinner Los Angeles, CA More articles by this author Anne Schuckman Los Angeles, CA More articles by this author Siamak Daneshmand Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...
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