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Anesthesiology pp 635-644 | Cite as

Anesthesia for Nephrectomy with Vena Cava Thrombectomy

  • Michael A. Evans
  • Francis A. Wolf
Chapter

Abstract

Up to 10% of renal cell carcinoma (RCC) tumors extend intravascularly from the kidney into the inferior vena cava (IVC) via the renal vein. Radical nephrectomy and vena cava thrombectomy is the therapy of choice for these patients. Surgical complexity and morbidity increases with cephalad extension of the tumor thrombus; Level I thrombus extends minimally into the IVC (≤2 cm) while Level IV extends into the IVC above the diaphragm. Anesthetic management varies based on extension of tumor and is often challenging due to IVC clamping, hemodynamic instability, potential for massive hemorrhage, and risk of intraoperative tumor embolization. Patients with high-level tumors should be managed in experienced centers with expertise in advanced techniques including transesophageal echocardiography (TEE), venovenous bypass, and cardiopulmonary bypass. A multidisciplinary team approach is important in the management of these patients.

Keywords

Nephrectomy Vena cava thrombectomy Inferior vena cava (IVC) Renal cell carcinoma Tumor thrombus 

References

  1. 1.
    Gupta K, Miller JD, Li JZ, Russell MW, Charbonneau C. Epidemiologic and socioeconomic burden of metastatic renal cell carcinoma (mRCC): a literature review. Cancer Treat Rev. 2008;34:193–205.CrossRefPubMedGoogle Scholar
  2. 2.
    Jonasch E, Gao J, Rathmell WK. Renal cell carcinoma. BMJ. 2014;349:g4797.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Hsieh JJ, Purdue MP, Signoretti S, Swanton C, Albiges L, Schmidinger M, et al. Renal cell carcinoma. Nat Rev Dis Primers. 2017;3:17009.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Psutka SP, Leibovich BC. Management of inferior vena cava tumor thrombus in locally advanced renal cell carcinoma. Ther Adv Urol. 2015;7:216–29.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Lardas M, Stewart F, Scrimgeour D, Hofmann F, Marconi L, Dabestani S, et al. Systematic review of surgical management of nonmetastatic renal cell carcinoma with vena caval thrombus. Eur Urol. 2016;70:265–80.CrossRefPubMedGoogle Scholar
  6. 6.
    Blute ML, Leibovich BC, Lohse CM, Cheville JC, Zincke H. The Mayo Clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumour thrombus. BJU Int. 2004;94:33–41.CrossRefPubMedGoogle Scholar
  7. 7.
    Chapman E, Pichel AC, et al. BJA Educ. 2015;16:98–101.CrossRefGoogle Scholar
  8. 8.
    Kirkali Z, Van Poppel H. A critical analysis of surgery for kidney cancer with vena cava invasion. Eur Urol. 2007;52:658–62.CrossRefPubMedGoogle Scholar
  9. 9.
    Haferkamp A, Bastian PJ, Jakobi H, Pritsch M, Pfitzenmaier J, Albers P, et al. Renal cell carcinoma with tumor thrombus extension into the vena cava: prospective long-term followup. J Urol. 2007;177:1703–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Reese AC, Whitson JM, Meng MV. Natural history of untreated renal cell carcinoma with venous tumor thrombus. Urol Oncol. 2013;31:1305–9.CrossRefPubMedGoogle Scholar
  11. 11.
    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;51:988–94; discussion 994–5.CrossRefPubMedGoogle Scholar
  12. 12.
    Tilki D, Hu B, Nguyen HG, Dall’Era MA, Bertini R, Carballido JA, et al. Impact of synchronous metastasis distribution on cancer specific survival in renal cell carcinoma after radical nephrectomy with tumor thrombectomy. J Urol. 2015;193:436–42.CrossRefPubMedGoogle Scholar
  13. 13.
    Abel EJ, Thompson RH, Margulis V, Heckman JE, Merril MM, Darwish OM, et al. Perioperative outcomes following surgical resection of renal cell carcinoma with inferior vena cava thrombus extending above the hepatic veins: a contemporary multicenter experience. Eur Urol. 2014;66:584–92.CrossRefPubMedGoogle Scholar
  14. 14.
    Parekh DJ, Cookson MS, Chapman W, Harrell F Jr, Wells N, Chang SS, et al. Renal cell carcinoma with renal vein and inferior vena caval involvement: clinicopathological features, surgical techniques and outcomes. J Urol. 2005;173:1897–902.CrossRefPubMedGoogle Scholar
  15. 15.
    Boorjian SA, Sengupta S, Blute ML. Renal cell carcinoma: vena caval involvement. BJU Int. 2007;99:1239–44.CrossRefPubMedGoogle Scholar
  16. 16.
    Wotkowicz C, Wszolek MF, Libertino JA. Resection of renal tumors invading the vena cava. Urol Clin North Am. 2008;35:657–71; viii.CrossRefPubMedGoogle Scholar
  17. 17.
    Boorjian SA, Blute ML. Surgery for vena caval tumor extension in renal cancer. Curr Opin Urol. 2009;19:473–7.CrossRefPubMedGoogle Scholar
  18. 18.
    Woodruff DY, Van Veldhuizen P, Muehlebach G, Johnson P, Williamson T, Holzbeierlein JM. The perioperative management of an inferior vena caval tumor thrombus in patients with renal cell carcinoma. Urol Oncol. 2013;31:517–21.CrossRefPubMedGoogle Scholar
  19. 19.
    Dominik J, Moravek P, Zacek P, Vojacek J, Brtko M, Podhola M, et al. Long-term survival after radical surgery for renal cell carcinoma with tumour thrombus extension into the right atrium. BJU Int. 2013;111:E59–64.CrossRefPubMedGoogle Scholar
  20. 20.
    Guzzo TJ, Pierorazio PM, Schaeffer EM, Fishman EK, Allaf ME. The accuracy of multidetector computerized tomography for evaluating tumor thrombus in patients with renal cell carcinoma. J Urol. 2009;181:486–90; discussion 491.CrossRefPubMedGoogle Scholar
  21. 21.
    Gohji K, Yamashita C, Ueno K, Shimogaki H, Kamidono S. Preoperative computerized tomography detection of extensive invasion of the inferior vena cava by renal cell carcinoma: possible indication for resection with partial cardiopulmonary bypass and patch grafting. J Urol. 1994;152:1993–6; discussion 1997.CrossRefPubMedGoogle Scholar
  22. 22.
    Zini L, Destrieux-Garnier L, Leroy X, Villers A, Haulon S, Lemaitre L, et al. Renal vein ostium wall invasion of renal cell carcinoma with an inferior vena cava tumor thrombus: prediction by renal and vena caval vein diameters and prognostic significance. J Urol. 2008;179:450–4; discussion 454.CrossRefPubMedGoogle Scholar
  23. 23.
    Gupta NP, Ansari MS, Khaitan A, Sivaramakrishna MS, Hemal AK, Dogra PN, et al. Impact of imaging and thrombus level in management of renal cell carcinoma extending to veins. Urol Int. 2004;72:129–34.CrossRefPubMedGoogle Scholar
  24. 24.
    Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, et al. 2014 ACC/AHA guidelines on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary. J Am Coll Cardiol. 2014;64:2373–405.CrossRefGoogle Scholar
  25. 25.
    Lee AYY. Anticoagulation in the treatment of established venous thromboembolism in patients with cancer. J Clin Oncol. 2009;27:4895–901.CrossRefPubMedGoogle Scholar
  26. 26.
    Lyman GH, Khorana AA, Falanga A, Clarke-Pearson D, Flowers C, Jahanzeb M, et al. American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol. 2007;25:5490–505.CrossRefPubMedGoogle Scholar
  27. 27.
    Yap SA, Horovitz D, Alibhai SMH, Abouassaly R, Timilshina N, Finelli A. Predictors of early mortality after radical nephrectomy with renal vein or inferior vena cava thrombectomy—a population-based study. BJU Int. 2012;110:1283–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Mandhani A, Patidar N, Aga P, Pande S, Tewari P. A new classification of inferior vena cava thrombus in renal cell carcinoma could define the need for cardiopulmonary or venovenous bypass. Indian J Urol. 2015;31:327–32.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Gaudino M, Lau C, Cammertoni F, Vargiu V, Gambardella I, Massetti M, et al. Surgical treatment of renal cell carcinoma with cavoatrial involvement: a systematic review of the literature. Ann Thorac Surg. 2016;101:1213–21.CrossRefPubMedGoogle Scholar
  30. 30.
    Toren P, Abouassaly R, Timilshina N, Kulkarni G, Alibhai S, Finelli A. Results of a national population-based study of outcomes of surgery for renal tumors associated with inferior vena cava thrombus. Urology. 2013;82:572–7.CrossRefPubMedGoogle Scholar
  31. 31.
    Shin S, Han Y, Park H, Chung YS, Ahn H, Kim C-S, et al. Risk factors for acute kidney injury after radical nephrectomy and inferior vena cava thrombectomy for renal cell carcinoma. J Vasc Surg. 2013;58:1021–7.CrossRefPubMedGoogle Scholar
  32. 32.
    Gettman MT, Boelter CW, Cheville JC, Zincke H, Bryant SC, Blute ML. Charlson co-morbidity index as a predictor of outcome after surgery for renal cell carcinoma with renal vein, vena cava or right atrium extension. J Urol. 2003;169:1282–6.CrossRefPubMedGoogle Scholar
  33. 33.
    Frank I, Blute ML, Cheville JC, Lohse CM, Weaver AL, Zincke H. An outcome prediction model for patients with clear cell renal cell carcinoma treated with radical nephrectomy based on tumor stage, size, grade, and necrosis: the SSIGN score. J Urol. 2002;168:2395–400.CrossRefPubMedGoogle Scholar
  34. 34.
    Huang WC, Levey AS, Serio AM, Snyder M, Vickers AJ, Raj GV, et al. Chronic kidney disease after nephrectomy in patients with renal cortical tumours: a retrospective cohort study. Lancet Oncol. 2006;7(9):735–40.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Najarian JS, Chavers BM, McHugh LE, Matas AJ. 20 years or more of follow-up of living kidney donors. Lancet. 1992;340:807–10.CrossRefPubMedGoogle Scholar
  36. 36.
    Fehrman-Ekholm I, Duner F, Brink B, et al. No evidence of accelerated loss of kidney function in living kidney donors: results from a cross-sectional follow-up. Transplantation. 2001;72:444–9.CrossRefPubMedGoogle Scholar
  37. 37.
    Eyraud D, Richard O, Borie DC, Schaup B, Carayon A, Vézinet C, et al. Hemodynamic and hormonal responses to the sudden interruption of caval flow: insights from a prospective study of hepatic vascular exclusion during major liver resections. Anesth Analg. 2002;95:1173–8, table of contents.CrossRefPubMedGoogle Scholar
  38. 38.
    Davis M, Sofer M, Gomez-Marin O, Bruck D, Soloway MS. The use of cell salvage during radical retropubic prostatectomy: does it influence cancer recurrence? BJU Int. 2003;91:474–6.CrossRefPubMedGoogle Scholar
  39. 39.
    Patil MB, Montez J, Loh-Doyle J, Cai J, Skinner EC, Schuckman A, et al. Level III-IV inferior vena caval thrombectomy without cardiopulmonary bypass: long-term experience with intrapericardial control. J Urol. 2014;192:682–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of AnesthesiologyEmory University School of Medicine, Emory University HospitalAtlantaUSA

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