The authors report a multi-institutional experience with nephrectomy/thrombectomy for RCC with level IV tumour thrombus . The benefit of deep hypothermic circulatory arrest (DHCA) with cardiopulmonary bypass (CPBP) was evaluated. The overall perioperative mortality was 22.2% but it was lower in patients undergoing DHCA with CPBP than those undergoing CPBP alone (8.3% vs 37.5%, P= 0.006).
At the University of Miami, we have been using liver transplant (‘piggyback’ style mobilization) [2–7] techniques to gain adequate exposure of the upper abdomen and retroperitoneum when dealing with urological tumours with caval involvement. We have controlled the intrapericardial inferior vena cava (IVC) and the atrium transabdominally [2–7]. We had reported our experience removing an adherent  and nonadherent [4,5,7] level IV (intra-atrial thrombus) tumour thrombus without a thoracoabdominal approach, median sternotomy, or CPBP.
Therefore, it would be appropriate to mention that these difficult tumours extending into the atrium can be resected without the use of CPBP, which is beneficial in diminishing perioperative mortality and avoiding the attendant risks of CPBP along with DHCA [2–7].
Finally, it is important to mention that there will be patients with RCC with bulky or adherent intra-atrial tumour thrombus and CPBP with or without DHCA will be required; therefore CPBP should always be available. These patients should be referred to facilities with expertise in dealing with RCC with IVC tumour thrombus to maximize potential for complete surgical management.