1065 Radical Nephrectomy and Inferior Vena Cava (IVC) Thrombectomy: Management of Level IV ThrombusM Larney, C O'Connor, P Collins, J McGuinness, J Conneely, S Connolly
IVC invasion with tumour thrombus occurs in 10-25% of renal cell carcinoma (RCC) patients (1). IVC thrombi are classified according to anatomical levels. Cardiopulmonary bypass is indicated for level IV thrombi which extend above the diaphragm, including atrial thrombi or when the reduction in cardiac output with IVC cross-clamping cannot be tolerated. This technique maintains haemodynamic stability and allows better vision during thrombectomy.
A 46-year-old male presented with a three-week history of vague abdominal pain and night sweats. Subsequent CT thorax, abdomen & pelvis, and MR venogram found a 10cm right renal tumour extending into the right renal vein, inferior vena cava and tumour thrombus extending 50% into the right atrium.
Following MDT discussion, this gentleman underwent right radical nephrectomy, IVC thrombectomy, sternotomy and retrieval of tumour thrombus from his right atrium. This was performed under approximately one hour of deep hypothermic circulatory arrest. The patient made an excellent recovery with 10 days spent in hospital post-operatively. His histology subsequently showed a clear cell renal carcinoma, ISUP grade 3, with positive vein margin. Its final staging was pT3cN0R1. Follow up was with three monthly surveillance CT scans.
The median survival of untreated RCC patients with venous thrombi is just 5 months, thus, this is lifesaving and very urgent surgery (2). Procedures for Level 4 IVC thrombi should take place in high volume centres with access to both cardiothoracics for cardiopulmonary bypass or veno-venous bypass and surgeons with expertise in vascular reconstruction and liver mobilization.