INFRARENAL INFERIOR VENA CAVA CANNULATION DURING THE RESECTION OF RENAL TUMORS EXTENDING INTO THE RIGHT HEART – NO NEED FOR HYPOTHERMIC TOTAL CIRCULATORY ARREST

Abstract

Objective: Vena cava thrombectomy together with radical tumor excision in the case of cavoatrial tumor thrombosis is vitally important. In this document, we present the infrarenal inferior vena cava cannulation technique which overcomes the need of total circulatory arrest during the treatment of renal tumors extending into the right atrium. Methods: Between June 2013 and December 2017, 5 patients with renal tumors extending into the right atrium, were diagnosed. The mean age of the patients was 43.2 years. One pediatric and 1 adult patient were male, the other 3 were adult females. The three-venous cannulation system containing vena cava superior, infrarenal vena cava inferior and two-stage venous cannulae was used. The tumor thrombus was removed following vena cava superior and infrarenal vena cava inferior cannulations. A two-stage venous cannula was placed in the right atrium while closing atriotomy. The procedure was continued. Results: There was no mortality in the peroperative and postroperative period. The mean operation time was 465 minutes, the duration of cardiopulmonary bypass was 48 minutes and myocardial ischemia time was 27 minutes. The mean hepatic and renal ischemia time was 15.4 minutes. The mean intensive care unit and hospital stay were 28.4 hours and 9.3 days, respectively. The total follow-up period was 12 months. There was no mortality in long term follow-up. Conclusion: Complete tumor resection without any remnant is the main predictor of mortality in this particular patient population. This technique allows tumor resection in moderate hypothermia without needing hypothermic circulation and provides a safe procedure for complete resection.

Keywords

• Inferior vena cava,Kidney cancer,Tumor thrombus,Cardiopulmonary bypass

SAĞ ATRİUMA UZANIM GÖSTEREN RENAL TÜMÖRLERDE İNFRARENAL VENA KAVA İNFERİOR KANULASYONU – HİPOTERMİK DOLAŞIM DURDURULMASINI ENGELLEYEN YÖNTEM

Abstract

Amaç: Vena kava trombektomisi ile birlikte yapılan radikal tümör eksizyonu, kavoatrial tümör trombozlarının tedavisinde son derece önemlidir. Bu yazıda sağ atriuma uzanım gösteren renal tümörlerde uyguladığımız hipotermik dolaşım durdurulmasını engelleyen infrarenal vena kava inferior kanülasyon tekniğini anlatmaktayız. Yöntemler: Haziran 2013-Aralık 2017 tarihleri arasında intrakardiak uzanım gösteren böbrek kaynaklı tümör saptanan 5 hasta tarafımıza konsülte edilmiştir. Hastaların yaş ortalaması 43,2 yıl idi. Pediatrik ve 1 yetişkin hasta erkek, diğer 3 yetişkin hasta kadındı. Operasyonlarda vena kava superior, infrarenal vena kava inferior ve two-stage venöz kanüller takılı olan üçlü venöz kanülasyon sistemi kullanıldı. Vena kava süperior ve infrarenal vena kava inferior kanülasyonlarını takiben tümör trombüsü çıkarıldı. Atriotomi kapatılırken two-stage venöz kanül sağ atriuma yerleştirildi. Prosedüre usulünce devam edildi. Bulgular: Operasyon sırasında ya da sonrasında mortalite gözlenmedi. Ortalama operasyon süresi 465 dk, kardiyopulmoner bypass süresi 48 dk ve myokardial iskemi süresi 27 dk idi. Hepatik ve renal iskemi süreleri ortalama 15,4 dk oldu. Ortalama yoğun bakım ve hastanede kalış süreleri sırasıyla 28,4 saat ve 9,3 gün hesaplandı.Toplam takip süresi 12 ay idi. Hiç bir hastada uzun dönem takiplerde mortalite ile karşılaşılmadı. Sonuç: Tümörün tamamen çıkarılması ve rezidü trombüs bırakılmaması bu hasta grubunun mortalitesini belirleyen en önemli etkenlerdendir. Uyguladığımız teknikle birlikte hastalarda hipotermik dolaşıma gereksinim duyulmadan orta hipotermide tam bir tümör eksizyonu sağlanmış ve trombüs dokusu bırakılmadığından emin olunmuştur.

Keywords

• Vena kava inferior,Böbrek kanseri,Tümör trombüsü,kardiyopulmoner bypass

References

1. 1. Nouh MA, Inui M, Kakehi Y. Renal Cell Carcinoma with IVC Thrombi; Current Concepts and Future Perspectives. Clin Med Oncol 2008;2:247-56.
2. 2. Hatcher PA, Anderson EE, Paulson DF, Carson CC, Robertson JE. Surgical management and prognosis of renal cell carcinoma invading the vena cava. J Urol 1991;145(1):20-3;23-4.
3. 3. Ciancio G, Livingstone AS, Soloway M. Surgical management of renal cell carcinoma with tumor thrombus in the renal and inferior vena cava: the University of Miami experience in using liver transplantation techniques. Eur Urol 2007;51(4):988-94;994-5.
4. 4. Eryıldırım B, Kuyumcuoğlu U, İdiz M, Faydacı G, Erbay E. Sağ atriuma tümör trombüs uzanımı gösteren böbrek hücreli kanser olgusu. Turk J Urol 2005;31(1):142-5.
5. 5. Adams LC, Ralla B, Bender YY, Bressem K, Hamm B, Busch J, Fuller F, Makowski MR. Renal cell carcinoma with venous extension: Prediction of inferior vena cava wall invasion by MRI. Cancer Imaging 2018;18(1):17.
6. 6. Gedik HS, Alp İ, Arslan G, Dereli Y, Korkmaz K, Yılmaz AT. A different approach in the treatment of left renal cell carcinoma with tumor thrombus extension into the vena cava inferior. Turk Gogus Kalp Dama 2012;20(2):396-8.
7. 7. Rini BI, Rathmell WK, Godley P. Renal cell carcinoma. Curr Opin Oncol 2008;20:300-6.
8. 8. Noguchi K, Hori D, Nomura Y, Tanaka H. Renal cell carcinoma with tumor-thrombus extension into the right ventricle. Ann Vasc Dis 2012;5(3):376-80.

9. 9. Dedeilias P, Koletsis E, Rousakis AG, et al. Deep hypothermia and circulatory arrest in the surgical management of renal tumors with cavoatrial extension. J Card Surg 2009;24:617-23.
10. 10. Skinner DG, Pritchett TR, Lieskovsky G, et al. Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 1989;210:387-92, discussion 392-4.
11. 11. Kirkali Z, Van Poppel H. A critical analysis of surgery for kidney cancer with vena cava invasion. Eur Urol. 2007;52:658-62.
12. 12. Zini L, Haulon S, Decoene C, Amara N, Villers A, Biserte J, Leroy X, Koussa M. Renal cell carcinoma associated with tumor thrombus in the inferior vena cava: Surgical strategies. Ann Vasc Surg 2005;19:522-8.
13. 13. Kwon TW, Kim H, Moon KM, Cho YP, Song C, Kim CS, Ahn H. Surgical treatment of inferior vena cava tumor thrombus in patients with renal cell carcinoma. J Korean Med Sci 2010;25(1):104-9.
14. 14. Kaplan S, Ekici S, Dogan R, Demircin M, Ozen H, Pasaoglu I. Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus. Am J Surg 2002;183:292-9.
15. 15. Jibiki M, Iwai T, Inoue Y, Sugano N, Kihara K, Hyochi N, Sunamori M. Surgical strategy for treating renal cell carcinoma with thrombus extending into the inferior vena cava. J Vasc Surg 2004;39:829-35.
16. 16. Gallucci M, Borzomati D, Flammia G, Alcini A, Albino G, Caricato M, Esposito A, Vincenzi B, Rossi M, Coppola R, Berloco P. Liver harvesting surgical technique for the treatment of retro-hepatic caval thrombosis concomitant to renal cell carcinoma: perioperative and long-term results in 15 patients without mortality. Eur Urol 2004;45:194-202.
17. 17. Wellons E, Rosenthal D, Schoborg T, Shuler F, Levitt A. Renal cell carcinoma invading the inferior vena cava: use of a “temporary” vena cava filter to prevent tumor emboli during nephrectomy. Urology 2004;63:380-2.
18. 18. Hedderich GS, O’Connor RJ, Reid EC, Mulder DS. Caval tumor thrombus complicating renal cell carcinoma: A surgical challenge. Surgery 1987;102:614-21.
19. 19. Mavrigiannaki E, Fesatidis I, Kalogridaki E, Katralis IP, Filippou D, Skandalakis P, et al. Synchronous nephrectomy and cavoatrial tumor thrombectomy under normothermic extracorporeal circulation and beating heart. J Surg Case Rep 2018;2018(5):rjy095.
20. 20. Kayalar N, Özkaynak B, Gümüş F, Kuplay H, Nuhoğlu B, Erentuğ V. IVC Thrombus in Renal Cell Carcinoma. JAREM 2013;3:47-52.