Annals of Vascular Surgery
Volume 20, Issue 2 , Pages 223-227, March 2006

Surgical Treatment of Renal Neoplasmatic Thrombi Extending into the Inferior Vena Cava

  • Dimitrios K. Papadimitriou, MD, PhD

      Affiliations

    • Vascular Unit, 2nd Surgical Department, Aristotle University of Thessaloniki, “G. Gennimatas” Hospital, Thessaloniki, Greece
    • ,
  • Georgios A. Pitoulias, MD, PhD

      Affiliations

    • Vascular Unit, 2nd Surgical Department, Aristotle University of Thessaloniki, “G. Gennimatas” Hospital, Thessaloniki, Greece
    • Corresponding Author InformationCorrespondence to: Georgios A. Pitoulias, MD, PhD, Department of Surgery, Vascular Unit, Aristotle University of Thessaloniki, “G. Gennimatas” Hospital, Ethnikis Aminis 41, 54635, Thessaloniki, Greece
    • ,
  • Maria D. Tachtsi, MD

      Affiliations

    • Vascular Unit, 2nd Surgical Department, Aristotle University of Thessaloniki, “G. Gennimatas” Hospital, Thessaloniki, Greece
    • ,
  • Stylianos G. Koutsias, MD

      Affiliations

    • Vascular Unit, 2nd Surgical Department, Aristotle University of Thessaloniki, “G. Gennimatas” Hospital, Thessaloniki, Greece
    • ,
  • Dimitrios K. Radopoulos, MD, PhD

      Affiliations

    • 1st Urological Department, Aristotle University of Thessaloniki, “G. Gennimatas” Hospital, Thessaloniki, Greece

Article Outline

Renal cell carcinoma produces neoplasmatic thrombus that usually invades and progressively grows into the endorenal veins. The thrombus may extend into the ipsilateral renal vein or the inferior vena cava in 15–20% and 8–15% of cases, respectively. These tumors are classified into four categories (I, II, III, and IV) according to the level of cephalad extension of thrombus into the inferior vena cava. The purpose of this study was to assess the surgical strategy for cases of renal tumor thrombus invading the vena cava. We retrospectively reviewed the records of 10 patients with renal cell carcinoma, who underwent in our institution radical nephrectomy and resection of vena cava thrombus between January 1997 and December 2004. Four patients were classified as level I, four were level II, and two were level III. In all cases, the thrombus was removed through a small cavotomy without cardiopulmonary bypass and the cavotomy was closed primarily. Pringle's maneuver was performed in the two level III cases. There were no perioperative pulmonary embolisms or deaths, and the mean hospital stay was 8 ± 1.1 days. The mean survival was 21.8 ± 8 months, and the vena cava remained patent for this period. Tumor thrombectomy improves the prognosis and the quality of life of these patients, and in most of cases the surgical technique, although challenging, carries a low morbidity and mortality rate.

 

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INTRODUCTION 

Neoplasmatic thrombus from renal cell carcinoma (RCC) usually occupies the endorenal veins and progressively extends into the ipsilateral renal vein or inferior vena cava (IVC) in 15–20% and 8–15% of cases, respectively. Tumor thrombectomy improves the prognosis of these patients. Current surgical techniques allow thrombus resection, even when it extends up to the level of the right atrium.1, 2 Nephrectomy and IVC thrombectomy, as well as capsular invasion, regional lymph node involvement, and distant metastasis, are important for determining the response to adjuvant immunotherapy and patient survival.3, 4 Usually, the tumor thrombus is floated in the IVC, with no severe signs of caval lumen obstruction. Very rarely, the venous wall is invaded, and this condition is related to poor prognosis.5, 6

These tumors are classified into four categories, according to the thrombus cephalad extension into the venous system, as described by Neves and Zincke7 (Fig. 1).

We report our experience in the surgical management of 10 patients who underwent neoplasmatic thrombus resection and radical nephrectomy for RCC.

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PATIENTS AND METHODS 

Ten patients with RCC and tumor thrombus into the venous system were treated in our hospital between January 1997 and December 2004. Eight patients were men and two were women, and the mean age [± standard error (SE)] was 64 ± 5 years (range 57–72). Four patients had level I disease, two with the right renal vein involved and two with the left. Four patients had level II disease, originated from the right kidney in three cases. In the last two patients, the thrombus, also from the right kidney, was extended to the level of the suprahepatic vena cava (level III). None of our patients was classified as level IV disease (Fig. 1).

The standard preoperative workup included intravenous urography, echo ultrasound, and computed tomographic (CT) scan for tumor-node-metastasis classification. Intravenous urography revealed pelviocalyceal distortion in seven cases and nonfunctional kidney in three patients. In all cases, the ultrasound showed a solid renal tumor and the CT scan revealed the presence of tumor thrombus extended into the venous system (Fig. 2).

Following the indication from the CT scan, the exact determination of thrombus extension level was evaluated for the first six patients with veno-cavography (Fig. 3) and recently with the less invasive magnetic resonance imaging (MRI) tomography (Fig. 4). Leg edema or any other sign of venous insufficiency was not observed in our patients.

In all cases, radical nephrectomy and venous thrombectomy were performed through a midline laparotomy and retroperitoneal approach (right in seven and left in three cases). Initially, the involved kidney was mobilized with the perinephric fat, the fascial envelope, and the regional lymph nodes. The ipsilateral renal artery was ligated, and venous thrombectomy was performed. For this purpose, the IVC was dissected and encircled with vessel loops below the level of renal vessels and above the upper limit of thrombus cephalad extension. The contralateral renal vein was also dissected and encircled with vessel loops. The lumbar veins were ligated with clips. In level III cases, the liver was mobilized and rotated left for adequate hepatic vein exposure and Pringle's maneuver was performed for backbleeding control. With the patients in a 20° Trendelenburg position, a longitudinal cavotomy was performed, which facilitated the complete removal of the tumor thrombus under direct vision. In all cases, the cavotomy was closed primarily using a running (polypropylene 4/0) suture and the stump of the renal vein was ligated (silk 3/0) (Fig. 5). Then, the previously mobilized kidney was dissected in its entirety and delivered.

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  • Fig. 5. 

    Technique of IVC thrombus resection. (a) proximal and distal caval control-contralateral renal vein control, (b) longitudinal cavotomy and thrombus removal, (c) cavotomy's primary closure using running suture.

In all cases, heparin anticoagulation was not used intraoperatively but low-molecular weight heparin was used routinely (100 anti-Xa i.u./kg) at 2 hr before the operation, at the first 6 hr postoperatively, and once daily thereafter until patient discharge.

Follow-up included blood chemistry, chest X-ray, and abdominal CT scan at 6 months and every 6 months thereafter. Also, bone scintigraphy was performed at 6 months and thereafter only in cases of clinical suspicion of recurrence. The patency of repaired vena cava was confirmed in all cases by duplex ultrasound at 1 and 6 months postoperaiively.

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RESULTS 

No perioperative deaths or pulmonary embolisms were observed, and the mean hospital stay was 8 ± 1.1 days, including 2 days in the intensive care unit. Table I shows the operative data of these 10 patients. The mean survival of our patients was 21.8 ± 8 months (range 7–44) and was better in level I cases with negative regional lymph nodes. Using clinical and duplex ultrasound criteria, none of our patients had signs of IVC obstruction during the follow-up period.

Table I. Operative data
Mean ± SERange
Caval interruption time (min)15.5 ± 3.212–21
Total operating time (min)113 ± 1990–145
Blood loss (mL)354 ± 128.9200–600
Fluid replacement volumes
Blood (units of packed red blood cells)1 ± 0.70–2
Electrolyte solutions (mL)2,670 ± 336.82,200–3,100
Plasma expanders (mL)680 ± 226.3500–1,100
Mean systemic arterial pressure (mm Hg, in precaval interruption period)114.5 ± 8.0100–125
Mean systemic arterial pressure (mm Hg, during caval interruption period)83.5 ± 7.595–70
Drop of mean systemic arterial pressure (%, during caval interruption period)26.7 ± 8.710–42

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DISCUSSION 

Neoplasmatic thrombi in the IVC develop due to various types of tumors, such as pheochromocytoma, adrenocorticoid carcinoma, uterine sarcoma, embryosarcoma, and teratosarcoma, but most often from RCC. In 15–20% of large (>4.5 cm) renal tumors, especially of the right kidney, thrombi may grow into the venous system. In half of cases, the thrombus occupies only the renal vein (level I). In 40%, the thrombus extends to the suprarenal or infrahepatic IVC (levels II and III), and in only 10% is the cephalad extension up to the right atrium (level IV).1, 2, 5

Although the term used in the literature for this situation is tumor thrombus, histological examination usually reveals the presence of neoplasmatic tissue which grows endoluminally into the venous system and sometimes is surrounded by secondary blood thrombus (Fig. 6).

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  • Fig. 6. 

    Histological examination of renal vein tumor thrombus. rv, renal vein; t.thr, tumor thrombus; vw, venous wall; vl, venous lumen. (b) Enlargement of inset in (a).

Patients' symptoms and signs are related mainly to the kidney's involvement and rarely to invasion of the spinal cord or lumbosacral plexus. Paradoxically, leg edema and deep vein thrombosis are observed rarely, probably because of the rich collateral circulation via the lumbar veins, the left ascending lumbar vein, and the hemiazygos or left phrenic vein.1, 5, 8

Cavography is the gold standard diagnostic method, but the less invasive duplex ultrasound and CT scan are accurate for preoperative evaluation in 50–70% and 65–85% of cases, respectively. Also, MRI cavography with very high sensitivity and specificity is the method of choice for the confirmation of thrombus extension level.1, 2, 6 Transesophageal echocardiography can provide accurate information regarding the presence and extent of thrombus up to the right atrium and is recommended for pre- and intraoperative use for level IV cases.6, 9, 10

In 1963, Robson defined RCC staging.11 According to this classification system, all of our cases should be considered as Robson IIIA. This raises the question of the usefulness of resection. Statistical analysis of the reported survival rate showed that the prognosis is improved after radical nephrectomy and venous thrombectomy. In some series, the 5-year survival was as high as 50%. Distant metastasis and caval wall invasion should be considered the worst prognostic factors.1, 2, 3, 4, 6

For the level I–III cases, a midline laparotomy or thoracoabdominal approach could be performed, and the choice is dependent on the surgeon's experience. When hepatic veins are involved, liver mobilization and left rotation seem to be necessary for the exposure and control of backbleeding from these vessels using Pringle's maneuver. For the rare level IV cases of cavoatrial thrombus, a cardiopul-monary bypass with or without hypothermic cardiac arrest has been reported as the method of choice, with low morbidity and mortality rates.7, 8, 12, 13, 14, 15, 16, 17

In our cases, the caval interruption interval was short (Table I) because in all patients the tumor thrombus was floated and not adherent to the caval wall. The patients were stable hemodynamically for this short period, but in the two level III cases more aggressive fluid replacement was needed in order to obtain hemodynamic stability. Some authors report that in case of systemic blood pressure below 80 mm Hg, because of the decreased venous return during caval interruption, partial or total aortic cross-clamping might be effective as an alternative to cardiopulmonary bypass.15

In the majority of cases, removal of the floated thrombus from a short (6–8 cm long) cavotomy allows primary closure. The use of a venous or polytetrafluoroethylene (PTFE) patch is necessary in few cases only, when the thrombus is adherent to the invaded caval wall and a partial vena caval resection is unavoidable.1, 2, 14, 15, 16, 17 In some very rare cases, complete resection and replacement of the vena cava with two ringed expanded PTFE grafts (8 mm) is the preferable technique when the caval wall is extensively and circumferentially invaded.18 Finally, in cases of complete obstruction of the vena cava, even resection of the invaded caval segment without replacement might be well tolerated because of the rich venous collateral circulation.

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CONCLUSIONS 

Resection of tumor thrombus from the IVC is the most commonly performed operation in the vena cava for neoplasmatic disease. The surgical strategy depends on the level of IVC involvement and the experience of the surgical team. The technique in 90% of cases is simple, the perioperative morbidity and mortality are relatively low, and when properly performed it offers significant improvement in the survival rate and quality of life.

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REFERENCES 

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PII: S0890-5096(06)60035-6

doi:10.1007/s10016-006-9001-7

Annals of Vascular Surgery
Volume 20, Issue 2 , Pages 223-227, March 2006

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