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Keywords:

  • cardiopulmonary bypass;
  • inferior vena cava tumor thrombus;
  • intraoperative pulmonary embolism;
  • renal cell carcinoma

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

Abstract  We report herein on a case of renal cell carcinoma with retrohepatic inferior vena cava tumor thrombus in which intraoperative cardiac arrest from a massive pulmonary embolism was managed successfully with emergency sternotomy and cardiopulmonary bypass, followed by the removal of the primary site and pulmonary artery embolus.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

Tumors extending into the inferior vena cava (IVC) from renal cell carcinomas (RCC) have the potential risk of pulmonary embolism resulting in sudden death.1 Despite high mortality and morbidity, aggressive surgery is the treatment of choice for RCC with IVC tumor thrombus.2 Pulmonary artery embolism can occur during radical nephrectomy combined with IVC thrombectomy. Although massive pulmonary embolism is often fatal, some surviving cases have been reported.3 Herein, we report on a case of intraoperative massive pulmonary embolism from an RCC with IVC thrombus that was managed successfully with emergency initiation of cardiopulmonary bypass (CPB).

Case report

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

An 81-year-old woman presented with anemia and a 1-month weight loss of 4 kg. Physical examination revealed a stiff mass of the right flank and mild edema of the lower extremities. Blood tests revealed hemoglobin of 9.6 g/dL, hematocrit at 29% and C-reactive protein of 7.8 IU. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) showed a large right renal tumor extending into the IVC at the level of the hepatic vein (Fig. 1) with no lymphadenopathy. Bone scintigraphy, chest radiogram and CT revealed no distant metastasis. The American Society of Anesthesiologists risk score for the patient was 2.4

image

Figure 1. Contrast-enhanced computed tomography of the abdomen (a,b) shows a right renal tumor with an inferior vena cava (IVC) thrombus extending to the hepatic vein level (arrow). Frontal view of T1-weighted magnetic resonance image (c) shows extension of the IVC thrombus (arrowheads).

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Transperitoneal radical right nephrectomy and thrombectomy with the support of a cardiovascular surgeon were planned. Although sternotomy and CPB were prepared, initially they were not planned and transesophageal echocardiography (TEE) was not performed. The right renal artery was ligated at its origin from the abdominal aorta. The right kidney, covered with Gerota fascia without adhesion to adjacent structures, was dissected easily with minimal manipulation of the tumor and IVC. Sudden cardiac arrest and a marked decrease of arterial and central venous pressure, as well as end-tidal carbon dioxide tension, occurred when cardiovascular surgeons were preparing for removal of the IVC thrombus. Emergency sternotomy and open cardiac massage were performed and a palpable mass was found in the pulmonary artery trunk.

A massive pulmonary artery embolism resulting in cardiac arrest was diagnosed and CPB was initiated with cannulation of the right femoral artery, IVC and the superior vena cava. The time from the beginning of hypotension and commencement of CPB was 45 min and the rectal temperature was 36°C. An incision was made in the IVC and the primary tumor, along with the right kidney and IVC thrombus, was removed. While the ascending aorta was being clamped for antegrade cardioplegia, pulmonary arteriotomy was performed and the tumor thrombus in the main pulmonary trunk was removed (Fig. 2). It was confirmed visually that there was no residual tumor thrombi in the main pulmonary trunk or bilateral pulmonary arteries. Cardiopulmonary bypass was discontinued and the operation was completed uneventfully.

image

Figure 2. (a) Macroscopic appearance of the resected right kidney occupied by necrotic tumor and the inferior vena cava tumor thrombus (arrowheads). (b) A massive tumor embolus was removed from the main pulmonary trunk. (c) Macroscopic appearance of the very brittle tumor embolus.

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Pathological diagnosis was a renal granular cell carcinoma with extrarenal invasion and vascular permeation (Fig. 3). Central necrosis with hemorrhage was not noted in the tumor thrombus, but was in the main tumor. Convalescence was uneventful, except for transient hyperbilirubinemia and azotemia, which were managed conservatively. The patient remained in the intensive care unit for 6 days after the operation and recovered without any neurological deficit. Pulmonary perfusion scintigraphy performed 5 weeks after the operation demonstrated no defect. Although the 6-month postoperative period was uneventful, the patient developed recurrent disease in the liver and lungs and died 9 months after surgery.

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Figure 3. Photomicrograph of (a) the main tumor (hematoxylin and eosin; original magnification ×200) and (b) tumor thrombus (hematoxylin and eosin; original magnification ×200) shows grade 2 renal granular cell carcinoma with papillary growth.

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Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

Involement of the IVC with intraluminal extension has been reported to occur in 5.6% of patients diagnosed with RCC, even in the modern era.2 In patients without evidence of disseminated disease, surgical removal of the primary lesion, including any tumor thrombus, is desirable for improved survival, as well as avoiding sudden death from pulmonary embolism.1 However, mortality and morbidity have been reported to be 0–9.1% and 0–27.3%, respectively.1,2,5–11 To our knowledge, there have been seven reports in the English literature of cases surviving after intraoperative massive pulmonary embolism from an IVC tumor thrombus.3 In most cases, the pulmonary embolism occurred during abdominal manipulation and CPB was necessary.

Once cardiac arrest from a massive pulmonary embolism occurs, the time from the cardiac arrest to the commencement of CPB is the most important factor determining the extent of postoperative complications. It has been reported that CPB should be initiated within 30 min from the beginning of hypotension.3 Rapid diagnosis and commencement of CPB are essential to shorten ischemic time. In addition, TEE has been reported to be useful for the diagnosis of massive pulmonary thrombus.3,5 It may also be useful for monitoring the site of the tumor thrombus and for confirming its complete removal.

Prevention of intraoperative pulmonary embolism is very important. In the present case, IVC filter placement could have been considered or, alternatively, the surgical procedure should have started on the IVC thrombus prior to manipulation of the kidney. Indication of this sort of aggressive surgery in a patient over 80 years of age may be controversial. Considering that the present patient had no coexisting disease and good performance status, the authors believed that radical surgery was the treatment of choice if complete removal was possible.

Planning for the use of CPB in surgery for retrohepatic IVC tumor thrombus remains controversial. Some investigators have reported that CPB should be used in all5,6 or selected7–10 cases of RCC with retrohepatic IVC tumor thrombus, whereas recent studies concluded that total vascular exclusion of the IVC enabled the safe removal of retrohepatic thrombus without instituting CPB.1,2,11 In the present case, because vascular exclusion of the IVC was considered possible, at the preoperative settings CPB was not set to be available on standby. In the event, emergency initiation of CPB took 45 min, even though cardiovascular surgeons were ready when the pulmonary thrombus occurred.

In conclusion, recovery without neurological deficit after significant duration of intraoperative hypotension due to pulmonary artery obstruction from a renal tumor with IVC thrombus is documented with an immediate sternotomy followed by successful removal of the entire pulmonary tumor thrombus using CPB. Although prevention and rapid diagnosis by close monitoring of the IVC thrombus is desirable, sternotomy should be performed without hesitation in the case of intraoperative pulmonary embolism.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References