Tumour Thrombi in the Suprahepatic Inferior Vena Cava: The Cardiothoracic Surgeons’ View

Abstract

Background. Retroperitoneal tumours propagate intrathoracic caval tumour thrombi (ICTT) of which we consider two subgroups: ICTT-III (extracardiac) and ICTT-IV (intracardiac). Methods. Case series review. Results. 29 series with 784 patients, 453 with extracardiac and 331 with intracardiac ICTT. Average age was 59 years. 98% of the tumours were RCC, 1% adrenal and Wilms' tumours, and 1% transitional cell carcinomas. The prevalent incision was rooftop with or without sternotomy. Mortality was 10% (5% for ICTT-III, 15% for ICTT-IV). Morbidity was 56% (36% for ICTT-III, 64% for ICTT-IV) and reoperation for bleeding was the commonest complication (14%). Mean Blood loss was 2.6 litres for ICTT-III and 3.7 litres for ICTT-IV. Mean blood product use was 2.4 litres for ICTT-III and 3.5 litres for ICTT-IV. Operative and anaesthetic times exceeded 5 hours. Hospital stay averaged 13 days. Variations in perioperative care included preoperative embolisation, perioperative transoesophageal echo, surgical incisions, and extracorporeal circulation. Brief Summary. Surgery for ICTT has high transfusion, operating/anaesthetic time, and in-hospital stay requirements, and intracardiac ICTT also attract higher risk. Preoperative tumour embolisation is controversial. The cardiothoracic team offers proactive optimisation of blood loss and preemptive management of intracardiac thrombus impaction: we should always be involved in the management the ICTT.

Synchronous nephrectomy and cavoatrial tumor thrombectomy under normothermic extracorporeal circulation and beating heart

“…To the presented case a Chevron/Kocher incision was performed first to allow mobilization of the liver and the right kidney and exposure of the IVC, followed by a separate median sternotomy. CPB with or without DHCA is the traditional approach to obtain a bloodless field for thrombectomy in patients with atrial involvement [ 2 , 5 ]. DHCA was questioned due to longer operative times, higher postoperative coagulopathy, renal failure and retroperitoneal hemorrhage but a recent review of the literature demonstrated no significant difference to the outcome with or without hypothermia [ 1 ].…”

“…Renal cell carcinoma (RCC) is characterized by its high metastatic index and its propensity to invade intravascular and generate tumor thrombi. Approximately 15% of all RCCs will invade the inferior vena cava (IVC) but only 1% of them will extend supradiaphragmatic into the right atrium, classified as a Level IV tumor thrombus according to the Neves and Zincke system [ 1 , 2 ]. Total surgical resection is the gold standard of therapy in these patients [ 3 ].…”

Diagnosis and surgical treatment of renal cell carcinoma with supradiaphragmatic level invasion of the inferior vena cava

“…Ñåðéîçíèì òåõí³÷íèì çàâäàííÿì º êîíòðîëü âåðõ³âêè ïóõëèííîãî òðîìáó ïðè éîãî íàää³àôðà´ìàëü-í³é ëîêàë³çàö³¿. Òðàäèö³éíî ó äàíî¿ êàòå´î𳿠õâîðèõ âèêîðèñòîâóþòü òåõíîëî´³¿ øòó÷íîãî êðîâîîá³ãó [2,5,6,7]. Çà îñòàíí³ ðîêè âñå ÷àñ-ò³øå ïîâ³äîìëÿþòü ïðî àëüòåðíàòèâí³ õ³ðóð-³÷í³ ï³äõîäè äî ñóïðàä³àôðà´ìàëüíîãî â³ää³ëó ÍÏ âèêëþ÷íî ç áîêó ÷åðåâíî¿ ïîðîaeíèíè [2,4,7].…”

“…²íòðàîïåðàö³éíà àâòîãåìîòðàíñôóç³ÿ ³ç çàñòîñóâàííÿì àïàðàòó "Ñell-Saver" (Íaemonetics) äîçâîëèëà ñóòòºâî çìåíøèòè îá'ºì êðîâîâòðàòè òà ïîòðåáó â äîíîðñüê³é êðîâ³, ³ ÿê íàñë³äîê öüîãî -çíèçèòè ðèçèê ³íôåêö³éíèõ óñêëàäíåíü, êîàãóëîïàò³é òà ³ìóíîñóïðåñ³é [1,6,8].…”

Tumor thrombosis of the inferior vena cava and right atrium in patients with renal cell carcinoma: 25-year experience of surgical treatment

“…Îïåðàö³éíà òàêòèêà ë³êóâàííÿ õâîðèõ íà ÍÊÐ ç âåíîçíèì òðîìáîçîì IV ð³âíÿ ïîòðåáóº ³íäèâ³äóàëüíîãî ï³äõîäó òà ïîâèííà âêëþ÷àòè îö³íêó îáñÿãó óðàaeåííÿ ÍÏ ïóõëèíîþ. Íàää³àôðàãìàëüíèé òà âíóòð³øíüîïåðåäñåðäíèé ð³âí³ ïóõëèííîãî òðîìáîçó âè-êëþ÷àþòü çàñòîñóâàííÿ êàâà-ô³ëüòðà òà âèìàãàþòü ïðîâåäåííÿ òîðàêî-àáî ñòåðíîëàïà-ðîòî쳿 ç âèêîðèñòàííÿì åêñòðàêîðïîðàëüíîãî êðîâîîá³ãó, îñîáëèâî ïðè ù³ëüíèõ ô³êñîâàíèõ, ôëîòóþ÷èõ âíóòð³øíüîïåðåäñåðäíèõ àáî ïðîëàáóþ÷èõ ó ïðàâèé øëóíî÷îê âåðõ³âêàõ òðîìá³â [2,3,9,11,17,18,20]. Âèêîðèñòàííÿ ãëèáîêî¿ ã³ïîòåð쳿 òà çóïèíêè êðîâî-îá³ãó äîçâîëÿº ïåâíîþ ì³ðîþ óíèêíóòè äî-…”