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2017 ; 4
(ä): 48
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Technical Intraoperative Maneuvers for the Management of Inferior Vena Cava
Thrombus in Renal Cell Carcinoma
#MMPMID28932737
Dellaportas D
; Arkadopoulos N
; Tzanoglou I
; Bairamidis E
; Gemenetzis G
; Xanthakos P
; Nastos C
; Kostopanagiotou G
; Vassiliou I
; Smyrniotis V
Front Surg
2017[]; 4
(ä): 48
PMID28932737
show ga
INTRODUCTION: Renal vein or inferior vena cava (IVC) invasion by neoplastic
thrombus in patients with renal cell carcinoma (RCC) is not an obstacle for
radical oncological treatment. The aim of this study is to present our technical
maneuvers for complete removal of the intracaval thrombus without compromising
hemodymanic stability of the patient. MATERIALS AND METHODS: Between 2000 and
2014, 15 RCC patients with IVC involvement of levels I-III were treated with
curative intent and were prospectively studied. The operative technique varied
according to thrombus extent. For type I, extraction of the thrombus is
facilitated by a 2-3?cm longitudinal incision on the IVC that begins at the level
of the renal vein and extends cranially, encompassing a vessel wall rim of the
orifice of the resected renal vein. For type II cases, the IVC is clamped above
the neoplastic thrombus, and for type III, the IVC clamping is combined with
hepatic blood flow control with "Pringle maneuver." For type IV, the IVC is
clamped above the diaphragm, or if the thrombus extends into the right atrium
cardiothoracic input is appropriate. RESULTS: The main operative steps include
preparation and control of the renal vessels and the IVC. Occasionally, for type
III tumor thrombi, the patient becomes hemodynamically unstable when IVC is
clamped suprahepatically. In such a case, a novel operative maneuver of milking
the thrombus below the orifice of the hepatic veins, and subsequently the IVC
clamp also beneath the hepatic veins, allowing release of the "Pringle maneuver"
is performed. This operative step restores hepatic blood flow and hemodynamic
stability and is based on the floating nature of the thrombus into the IVC. Mean
operative time was 120?min (range from 90 to 180?min), and average liver and
renal warm ischemia time was 20?min (range from 15 to 35?min). Postoperative
overall hospital stay ranged from 7 to 13?days. CONCLUSION: The technical
solutions employed in the current study allow successful removal of neoplastic
thrombi from the IVC in most cases, associated with minimal perioperative
complication rate even for patients who due to multiple comorbidities would be
considered otherwise inoperable.