J Korean Med Sci.  2010 Jan;25(1):104-109. 10.3346/jkms.2010.25.1.104.

Surgical Treatment of Inferior Vena Cava Tumor Thrombus in Patients with Renal Cell Carcinoma

• Kwon TW
• Kim H
• Moon KM
• Cho YP
• Song C
• Kim CS
• Ahn H

• KMID: 1713839
• DOI: http://doi.org/10.3346/jkms.2010.25.1.104

Abstract

Radical nephrectomy with inferior vena cava (IVC) thrombectomy remains the most effective therapeutic option in patients with renal cell carcinoma and IVC tumor thrombus. Cephalic extension of the thrombus is closely related to perioperative morbidity. We purposed to design a safe and successful surgical strategy through a review of our surgical experience and treatment results in 35 patients (male:female=28:7, mean age=56 yr [32-77]) who underwent IVC thrombectomy with radical nephrectomy between January 1997 and December 2006. The limit of tumor extension was level I in 10 patients (28.6%), level II in 17 (48.6%), and level III and IV in 4 patients each (11.4%). Liver mobilization with hepatic vascular exclusion was performed in 12 patients and cardiopulmonary bypass in 7. Thirty-two primary closures, 2 patch closures, and 1 graft interposition were performed. One patient underwent simultaneous pulmonary embolectomy because of an operative pulmonary embolism. There was no operative mortality, and the overall survival at 5-yr was 50.8%. Complete thrombus removal without tumor fragmentation under long venotomy on fully exposed involved IVC is recommended for successful result in a bloodless operative field. The applicability of liver mobilization, hepatic vascular exclusion, and cardiopulmonary bypass, can be determined by the level of thrombus.

Keyword

Vena Cava, Inferior; Thrombectomy; Kidney Neoplasms

MeSH Terms

Adult
Aged
Carcinoma, Renal Cell/mortality/secondary/*surgery
Female
Humans
Kidney Neoplasms/complications/mortality/*surgery
Male
Middle Aged
Neoplasm Staging
Nephrectomy
Pulmonary Embolism/complications/surgery
Severity of Illness Index
Survival Rate
Tomography, X-Ray Computed
Vena Cava, Inferior/*surgery
Venous Thrombosis/etiology/*surgery

Figure

• 

  Fig. 1 Operative pictures. After full exposure of the involved segment of the inferior vena cava (IVC), upper margin of thrombus (A) and presence of remaining thrombus attached to the venous wall is identified under direct vision (B). Since invasion into the vein often starts from renal vein level, the venotomy site might be successfully repaired without narrowing in case of resection of IVC wall when incision was extended from renal vein ostium (C).

• 

  Fig. 2 Computed tomography of the patients with level IV thrombosis. Thrombus is extended to the suprahepatic IVC (A) and right atrium (B). Coronal reconstruction view demonstrates IVC thrombus extended from left renal vein to the right atrium (C).

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  Fig. 3 Cumulative survival rate of RCC with IVC thrombosis patients. Overall survival rate (A) and stratified data according to extent of tumor thrombus (B, P>0.05) and stage (C, P>0.05) are depicted.

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