Caval Reconstruction after Suprarenal Inferior Vena Cava Transection During Nephrectomy
Anand Parikh, MD, Benjamin Jackson, MD, Grace Wang, MD, Ronald Fairman, MD, Paul Foley, MD.
Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
DEMOGRAPHICS: 67-year-old healthy male with renal cell carcinoma s/p open right nephrectomy at an outside facility complicated by IVC injury.
HISTORY: The patient underwent right nephrectomy from lateral approach during which a vascular stapler was fired across the right renal vein, but was in fact the suprarenal IVC. The injury went undetected, however postoperatively, the patient became progressively hemodynamically unstable, anuric, and acidotic. CT scan identified IVC transection above the left renal vein. He was emergently transferred to our OR the same night. Upon arrival, he was acidotic and unstable on four pressors.
PLAN: Due to his hemodynamic instability despite pressors, anuria, and acidosis in the setting of obstructed central venous return, the decision was made to place the patient on veno-veno bypass and initiate hemodialysis before incision. This allowed correction of his acidosis and improved venous return to better optimize him for surgery. After four hours on veno-veno bypass and hemodialysis, he demonstrated clinical improvement with improving acidosis and decreasing pressor requirement. We proceeded through a midline laparotomy, obtaining control of the infrarenal IVC, left renal vein, and suprarenal IVC, which had retracted cephalad into a retrohepatic position. Thoracic aortic homograft was used to reconstruct the IVC end-to-end to both the retrohepatic and infrarenal cava. The prior staple line extended across the confluence of the left renal vein and the IVC and so the left renal vein was reimplanted end-to side to the homograft.
This patientís critical condition upon arrival presented a dilemma - proceed with reconstruction to fix the underlying problem or first medically optimize him by correcting his acidosis and initiating veno-veno bypass. Ultimately, given the patientís worsening hemodynamics and resistance to vasopressors in the setting of significant acidosis, we believe that the patient would not have been able to tolerate the caval reconstruction until he was first medically optimized. The decision to reconstruct the IVC with homograft was made because the right nephrectomy bed was presumed to be contaminated after ureteral transection. The patientís hospital course was complicated by VDRF requiring tracheostomy and renal injury requiring hemodialysis, though he was ultimately discharged off of dialysis.
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