Endoluminal occlusion of the inferior vena cava in renal cell carcinoma with retro‐ or suprahepatic caval thrombus

Abstract

OBJECTIVE To evaluate endoluminal occlusion of the inferior vena cava (IVC) during surgical treatment of renal cell carcinoma (RCC) with either retrohepatic (level II) or suprahepatic (level III) caval tumour thrombus. PATIENTS AND METHODS From January 2000 to February 2005, 31 patients with renal vein/IVC involvement (T3b/c) of 278 who had a radical nephrectomy, were selected for review. Of these 31, 13 consecutive patients with RCC presenting a thrombus level II or III were prospectively treated with endoluminal occlusion of the free IVC cranial to the thrombus, to avoid dissection of the suprahepatic IVC or the subdiaphragmatic IVC. The occlusion balloon was positioned using transoesophageal echocardiography (TEE) control through a cavotomy at the ostium of the renal vein. Thrombectomy and radical nephrectomy were then performed. The operative duration, peri‐operative bleeding, and complications during and after surgery were assessed. Overall patient survival time, disease‐free survival and development of metastasis were calculated. RESULTS Caval thrombectomy was successful in all patients. The IVC needed to be replaced with an expanded polytetrafluoroethylene graft in three patients and a patch closure after lateral cavectomy was used in four. There was no case of air embolism. One case of asymptomatic tumour migration was detected during the procedure by TEE. The mean (sd) and median (range) operative duration was 170 (29) and 170 (120–210) min, and the mean number of units of packed red cells transfused during hospitalization was 5 (5) and 3 (0–16). There was no peri‐operative mortality. The complications were one splenectomy and one early thrombosis of the IVC. The mean (range) follow‐up was 22.1 (2–50) months. Distant metastases occurred in seven patients; there was no local or IVC tumour recurrence. Four patients died from metastatic progression and six are alive with no progression. CONCLUSION Endoluminal occlusion of the IVC with TEE monitoring for level II and III thrombus avoided a suprahepatic or subdiaphragmatic approach to the IVC. This technique caused no major complications and was very reliable, due to TEE monitoring. Segmental resection and reconstruction of the IVC could also be used for adherent thrombi.

Inferior vena cava thrombosis: A review of current practice

“…Disadvantages include cost and accessibility, and there remains a risk of nephrogenic systemic fibrosis if gadolinium-based contrast agents are administered in patients with renal dysfunction. 25,62 Theoretically, IVC filter migration could also result from MRI but this has not been reported. Nevertheless, MRI should not be performed if there is any possibility that the IVC filter is not positioned correctly or is not firmly in place.…”

“…A primary IVC tumour and secondary malignancies such as renal cell carcinomas may also infiltrate or adhere to the IVC wall, leading to endothelial damage and subsequent thrombosis. 7,12,24,25 Intravascular tumour/ thrombus invasion may extend intraluminally along the renal vein into the IVC and can propagate as far as the heart, resulting in an occluding thrombosis or tumour emboli ( Figure 5). 3 Following interventional procedures, IVC thrombosis may result from extension of ilio-femoral DVT into the vena cava either in isolation or in association with DVT elsewhere.…”

Antegrade balloon occlusion of inferior vena cava during thrombectomy for renal cell carcinoma

“…Balloon occlusion reduces the risk of two potentially fatal complications: tumour embolism to the pulmonary arteries and air embolism. 10 The ability to easily and accurately reposition the balloon caudally after resection of the suprarenal thrombus should immediately reconstitute hepatic vein flow. Hepatic congestion occurs during occlusion over the hepatic veins, but is relieved by repositioning, and the risk of hepatic ischemia, that is otherwise associated with IVC thrombectomy, is avoided.…”

Anesthetic management for removal of adrenocortical carcinoma with thrombus in the inferior vena cava extending to the right atrium

“…[78] In liver mobilization technique, there is need for extensive caval mobilization which carries an even higher risk of embolization. [9]…”

“…TEE is useful in the preoperative evaluation of thrombus extent, intraoperative confirmation of complete thrombus removal and diagnosis of pulmonary embolism. [910]…”