Resection of abdominal inferior vena cava without graft interposition: Considerations in preserving renal function

Abstract

The management of tumors involving or infiltrating the inferior vena cava (IVC) constitutes a great surgical challenge, since radical resection affords patients the only possibility for long-term survival. These tumors can be resected without graft interposition, provided that there is adequate collateral circulation and that the renal function can be secured. Meanwhile, ligation of the left renal vein may be possible due to the existence of collateral circulation through the adrenal and gonadal veins. We briefly present our experience on renal outflow preservation through implantation of the right renal vein into the IVC stump or through diversion of the left renal vein into the inferior mesenteric vein.

En Bloc Resection of Right Renal Cell Carcinoma and Inferior Vena Cava Tumor Thrombus Without Caval Reconstruction: Is It Safe to Divide the Left Renal Vein?

“…While the right renal vein rarely develops adequate collaterals to redistribute venous return, the left renal vein develops sufficient collateral drainage in the setting of long-standing obstruction of the IVC through the left gonadal and adrenal veins, azygos–hemiazygos system, and occasionally through lumbar veins (which may be present on the posterior aspect of the left renal vein) ( 7 – 9 , 16 , 17 ). Of note, ligation of the right renal vein is generally not safe because sufficient collateral drainage does not develop.…”

“…This surgical approach represents a safe option that may also be used when using a robot-assisted approach ( 22 , 23 ). It simplifies the procedure, since diversion of the left renal vein into another vessel (such as the inferior mesenteric vein) or IVC reconstruction through grafting is not required ( 17 ), thus avoiding operative time-consuming procedures and the need for prolonged antibiotic and anticoagulation therapy to prevent graft infection and/or occlusion (particularly frequent in the setting of hypercoagulability of malignancy) ( 17 , 24 ). Although robotic assistance allows for increased precision in instrument management, smaller incisions, decreased blood loss, less pain, and earlier recovery ( 25 , 26 ), the need to rely on other specialists for damage control in the event of a possible complication is still necessary.…”

En Bloc Resection of Right Renal Cell Carcinoma and Inferior Vena Cava with Tumor Thrombus: Is It Safe to Divide the Left Renal Vein?

“…20,21 It simpli es the procedure since diversion of left renal vein into another vessel (such as the inferior mesenteric vein) or IVC reconstruction through grafting are not required, 15 thus avoiding operative time-consuming procedures and the need for prolonged antibiotic and anticoagulation therapy to prevent graft infection and/or occlusion (particularly frequent in the setting of hypercoagulability of malignancy). 15,22 Although this is the largest experience available to date in the literature for circumferential IVC resection without reconstruction for right-sided RCC with level II-IV tumor thrombus, these cases remain rare even in referral centers, limiting sample size. Pre-operative creatinine was not available for two patients who underwent surgery before implementation of an electronic medical record.…”