Radical nephrectomy with ivc thrombectomy (level-III) conducted on veno-veno bypass

Abstract

Introduction: We report a 43 year old man who was diagnosed with a level-I thrombus and was managed on oral sunitinib for two months by a community Urologist. The thrombus progressed to a level-III and he subsequently developed a pulmonary embolus, which required oral anticoagulation. He was then referred to our facility for definitive surgical care. A computed tomography scan demonstrated a 12 by 15 centimeter right renal mass and on magnetic resonance venography of the abdomen a tumor-thrombus extending into the infradiaphragmatic inferior vena cava was noted. Pre-operatively consults with hepatobiliary, vascular, and chest surgeons were obtained. Methods: The patient's surgery was performed by means of an open right extended subcostal incision. Prior to incision, the veno-veno access sites were obtained and an intraoperative transesophageal echocardiography was performed to rule out thrombus in the atria. The right kidney was dissected out and mobilized. The renal artery and vein were dissected, ligated and the en bloc kidney was removed. Control of the inferior vena cava (IVC) was maintained proximally and distally during thrombectomy while tissue perfusion was maintained on veno-veno bypass, no circulatory arrest was required. The estimated blood was 2300 cc; the total bypass time was 25 minutes and the patient was discharged from the hospital after 7 days. Conclusions: It is feasible to perform a radical nephrectomy and IVC thrombectomy while on veno-veno bypass provided the appropriate multi-disciplinary team is standing by. Veno-veno bypass offers the advantage of minimizing the large hemodynamic drops attributed with suprahepatic IVC clamping. Such high-risk operations requiring skilled surgical teams must only be performed at tertiary care referral centers with extensive experience in the surgical management of such patients.