Surgical treatment of renal cell carcinoma with right atrial thrombus: Early experience and description of a simplified technique

Abstract

Operative management of patients presenting renal cell carcinoma's (RCC) with right atrial tumor thrombus extension is a technical challenge. It requires the use of cardiopulmonary bypass (CPB). The aim of this study was to report our early experience and to describe a simplified CPB technique. 5 consecutive patients underwent surgical resection by a joint cardiovascular and urological team. The ascending aorta was canulated. The venous drainage was achieved using a proximal canula inserted in the superior vena cava and a distal canula inserted in the IVC below the renal veins. Right atrium thrombus extension was extracted under normothermic CPB without cross clamping or cardioplegic arrest. A cavotomy was performed at the ostium of the renal vein and an endoluminal occlusion catheter was introduced. The thrombectomy and the radical nephrectomy were then performed. The occurrence of gaseous or tumor embolism, operative time, perioperative bleeding, and post-operative complications were assessed. Mean patients age was 62.9 years. Atrial and caval thrombectomy were achieved successfully in all patients. Mean operative time was 206 min. Mean CPB time was 62 min. Mean hospital stay was 18.8 days. One death occurred, due to respiratory failure. An asymptomatic early thrombosis of the IVC was diagnosed by CT scan in 1 patient. The four remaining patients were alive 6 months after the surgical procedure. Minimally invasive CPB technique can be used to treat intra atrial thrombus tumor extension arising from renal cell carcinoma. It can be performed safely with acceptable complications rate.

Renal tumor with tumor thrombus in inferior vena cava and right atrium: the report of five cases with long-term follow-up

“…Modine described simplified CPB technique with neither hypothermic circulatory nor cardioplegic cardiac arrest. Mean operative time in this study was similar like in our study (199 min), but the mortality rate was 20% [18]. The prognostic significance of the level of tumor thrombus in the IVC is still controversial.…”

Modified technique of cavoatrial tumor thrombectomy without cardiopulmonary by-pass and hypothermic circulatory arrest: a preliminary report

“…The presence of TT within the circulatory system can compromise venous return from the lower half of the body causing blood stasis, development of by-pass circulation, neovascularisation, and further thromboembolic complications [ 3 , 4 , 5 ]. If left untreated, TT can further cause massive pulmonary emboli, tricuspid valve obstruction, or Budd-Chiari syndrome [ 6 ]. The standard surgical management offered to patients with renal cell carcinoma (RCC) with concomitant cavoatrial TT involves median sternotomy and extracorporeal circulation [ 7 , 8 ].…”

Simultaneous nephrectomy, intracaval and right atrial tumor excision, caval patchplasty and coronary artery bypass grafting in patient with renal cell carcinoma

“…In the light of the literature data, we performed simultaneous nephrectomy, intracaval and right atrial tumor excision, caval patchplasty and CABG under normothermic CPB without cross clamping or cardioplegic arrest. [7] To the best of our knowledge, this is the first case reported in the literature in whom all the operations were performed simultaneously.…”

“…However, there is no consensus regarding the surgical technique of choice. [1][2][3][4][5][6][7] The major critical factor is successful surgery, mainly managing the interior vena cava. The main goals are to minimize bleeding and prevent embolism from the thrombus during surgery.…”