Right Nephrectomy With Inferior Vena Cava Tumor Thrombectomy Via A Right-sided Thoracoabdominal Approach
Hunter M. Ray, MD1, Joseph M. Besho, MD2, Hazim J. Safi, MD2, Kristofer M. Charlton-Ouw, MD1
1Gulf Coast Vascular, Houston, TX, 2McGovern Medical School, Department of Cardiothoracic and Vascular Surgery, Houston, TX
DEMOGRAPHICS: Renal cell carcinoma (RCC) represents 1-3% of all visceral cancers and 85 to 90% of malignant kidney tumors. Intravascular tumor growth along the renal vein into the inferior vena cava (IVC) occurs in up to 10% of all patients with RCC. Complete surgical resection is the gold standard of therapy in these patients; however, controversy exists regarding the optimal surgical approach.
HISTORY: The patient is a 61-year-old female with history of hypothyroidism and rheumatoid arthritis. One day prior to admission the patient developed severe hematuria and presented to an outside hospital where computed tomography angiography was performed demonstrating a large right renal mass measuring 9.7 x 7.6 x 7.6 cm with extensive tumor thrombus extending cranially into the IVC to the hepatic veins measuring 4.7 x 4.7 x 9.1 cm. A separate IVC tumor thrombus was observed extending from the right renal vein to the level of the third lumbar vertebral body caudally measuring 2.8 x 2 x 2.6cm.
PLAN: She was deemed to be a candidate for right radical nephrectomy and IVC tumor thrombectomy. A right thoracoabdominal incision was performed via 8th interspace and a medial visceral rotation was performed. A right radical nephrectomy was performed and the right common femoral artery and vein were then cannulated and cooling initiated via femorofemoral bypass circuit. Poor inflow to the venous cannula was noted, and a 10-French superior vena cava cannula was inserted via the right atrium with notable improvement in bypass flow rate. The patient was cooled to 21.0C and the suprahepatic IVC was occluded with a Rummel tourniquet. The posterior aspect of the medially rotated IVC was longitudinally incised and tumor thrombus was easily distracted from the vessel wall. The IVC was repaired primarily with a single running 4-0 poplypropylene suture in two layers during low-flow bypass (1 L/min). Rewarming was initiated and the IVC Rummel tourniquet was released. The patient was weaned from CPB with all cannulas removed and two chest tubes placed placed with the thoracoabdominal incision closed in the usual fashion.
DISCUSSION: This case demonstrates the benefits of a right-sided thoracoabdominal approach utilizing CPB and DHCA for resection of large renal tumors with extensive IVC tumor thrombus in terms of providing ample exposure while minimizing procedural morbidity
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