Balloon Control of the Suprahepatic Inferior Vena Cava: A Novel Technique for Renal Cell Carcinoma Tumor Thrombus
Article Outline
Renal cell carcinoma has a tendency to extend via the renal vein into the inferior vena cava (IVC), and we describe a novel approach to this situation. A 64-year-old male presented with metastatic right renal cell carcinoma and tumor thrombus extending into the retrohepatic IVC. Preoperative imaging revealed a large hemangioma adjacent to the IVC, potentially complicating hepatic mobilization. Instead, we used a compliant balloon to occlude the suprahepatic IVC, securing the wire in the right hepatic vein. With the infrarenal IVC and left renal vein occluded, the thrombus was extracted via a right renal venotomy/partial cavotomy with minimal bleeding. Balloon occlusion of the suprahepatic IVC offers a safe alternative to surgical control of this vessel in difficult situations. In addition, it allows for nephrectomy through a conventional, small retroperitoneal incision rather than the extended exposure needed for the IVC. Hepatic vein positioning of the wire prevents thrombus manipulation during balloon placement.
Renal cell carcinoma (RCC) is known to spread via direct extension into the renal vein and inferior vena cava (IVC) in 5-15% of cases.1, 2 Recent treatment strategies stress the need for complete primary tumor and tumor thrombus resection so that immunotherapy treatments have a chance of success.3 Various techniques have been employed for IVC control, depending on the level of tumor extension. These include direct control at the suprarenal level, suprahepatic control, and, when necessary, partial cardiopulmonary bypass and atriotomy when there is involvement of the right heart.4, 5 Temporary IVC filter placement has also been described to reduce the risk of tumor dislodgment leading to massive pulmonary embolism.6 We report here a novel technique for IVC control in these cases that allows for minimal dissection and safe tumor removal.
Case Report
An asymptomatic 64-year-old male patient presented with a lesion on his lower lip; biopsy revealed a clear cell myoepithelial carcinoma consistent with a renal cell tumor, and work-up with magnetic resonance and computed tomographic imaging demonstrated a large right renal mass as well as extension of the mass into the infrahepatic IVC (Fig. 1, Fig. 2). Pulmonary metastases were also noted. The urologic oncology recommendation was to perform a cytoreductive nephrectomy so that the patient could receive high-dose interleukin-2 (IL-2) therapy. The vascular service was involved to control the IVC during this procedure. Preoperative imaging identified a large hemangioma adjacent to the infrahepatic IVC and led us to seek a method that did not require mobilization of the liver (Fig. 3). We used balloon occlusion to control the IVC, and the procedure was performed as follows. The patient was put in the left lateral decubitus position to facilitate retroperitoneal renal exposure. His right neck was included in the sterile field. The right internal jugular vein was punctured with an 18-gauge needle, and a 14-French sheath was placed. A venogram was obtained via a pigtail catheter, and using the combination of a 0.035 angled guidewire and a 60-cm angled glide catheter, we cannulated the right hepatic vein under fluoroscopy. Great care was taken during this maneuver to prevent the wire from going into the infrahepatic IVC and possibly dislodging the tumor thrombus. A 27-mm compliant balloon was then positioned at the right hepatic vein origin and gently test-inflated under fluoroscopic guidance. The patient tolerated the occlusion without adverse hemodynamic consequences. The balloon was then deflated and secured to the sheath. Retroperitoneal dissection of the tumor was carried out via a ninth rib flank incision by the urology service, with control of the infrarenal IVC and contralateral renal vein as well as ligation of the right renal artery. A window was created in the peritoneum, and the hepatic artery and portal vein were encircled with vessel loops. Just before the tumor was resected, the C-arm was brought into the field and the balloon inflated under direct vision. The C-arm was removed, and the infrarenal IVC and left renal vein were clamped. The right kidney was removed along with the ipsilateral renal vein and a cuff of IVC. There was no back-bleeding from the IVC, and the hepatic artery and portal vein did not require compression for hemostasis. The tumor thrombectomy was carried out under direct vision, including the passage of a Foley catheter to ensure clearance. The IVC was closed primarily, and the balloon was deflated. Flow was restored after venting the IVC. The patient's recovery from surgery was uneventful, and he is currently undergoing IL-2 therapy for his metastatic disease.
Fig. 1
Magnetic resonance study demonstrating orientation of the hepatic veins (A) as well as their relationship to the distal extent of the tumor thrombus (C) and the primary right RCC (B).
Fig. 2
Computed tomographic scan at the level of the renal cell mass showing replacement of the kidney by the neoplastic process.
Fig. 3
This magnetic resonance image shows the large hepatic hemangioma (A) and its close proximity to the infrahepatic IVC (B). The aorta is also shown (C).
Discussion
RCC tumor thrombus extension can provide a surgical challenge, directly related to the level of IVC involvement. Control of the IVC is required both for hemostasis during tumor thrombus removal and to prevent pulmonary embolism during manipulation as deaths from this complication have been reported.7 Traditional open surgical approaches to IVC control significantly increase the magnitude of these operations since the primary tumor can usually be removed via a small flank incision. Our balloon occlusion technique appears to allow for safe tumor thrombus extraction via this limited approach.
There are several keys to our strategy. The IVC must be very carefully measured via preoperative imaging modalities to ensure that the compliant balloon is correctly sized. Great care needs to be taken so that the wire does not cross the tumor; this requires that the tumor thrombus does not extend above the highest hepatic vein. Therefore, this approach is limited to patients with level II disease according to Neves and Zincke.8 While it may be possible to gently cross the tumor thrombus with a wire without dislodging any material, further study is needed to confirm this. Cannulation of a hepatic vein is straightforward, and it is clearly advantageous to use the right internal jugular approach. Hepatic vein cannulation is used to anchor the balloon catheter with the wire secured from contacting the tumor thrombus.
After the balloon is positioned, test inflation should be performed to ensure that the patient tolerates occlusion. Several authors have noted the need for either venovenous bypass during suprahepatic IVC control or even aortic cross-clamping to prevent hemodynamic collapse.9, 10 Although the percentage of patients requiring this is not clearly known, it is important to evaluate for this early in the operation so that preparations for these maneuvers can be undertaken well before the IVC is opened.
It is possible to gain access to the hepatic artery and portal vein via a flank incision, with essentially no additional dissection through a small window in the peritoneum. Although control of these vessels was not needed in this case, it may prove necessary if there is significant back-bleeding from the IVC via hepatic veins that are not adequately covered.
Balloon occlusion of the suprahepatic IVC allows for removal of RCC tumor thrombus while avoiding liver mobilization or dissection in the chest. This technique offers the potential to minimize surgical morbidity in a group of patients often needing to start postoperative adjuvant therapy in a timely manner. Further work in this area may reveal the safety of this procedure with suprahepatic tumor. Consideration should be given to this novel approach before undertaking traditional open operations for IVC control for infrahepatic RCC tumor thrombus resections.
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PII: S0890-5096(08)00004-6
doi:10.1016/j.avsg.2007.12.003
© 2008 Annals of Vascular Surgery Inc. Published by Elsevier Inc All rights reserved.
