title: Perioperative outcomes following surgical resection of renal cell carcinoma with inferior vena cava thrombus extending above the hepatic veins: a contemporary multicenter experience.
abstract: BACKGROUND
  Surgery for renal cell carcinoma (RCC) patients with inferior vena cava (IVC) thrombus above the hepatic veins is technically complex and associated with an increased risk of perioperative morbidity and mortality. However, minimal data exist that describe contemporary perioperative outcomes at major referral centers or the prognostic factors associated with poor outcomes.
  
  
  OBJECTIVE
  To determine the preoperative predictors of major complications and 90-d mortality after surgery in RCC patients who have IVC thrombus above the hepatic veins.
  
  
  METHODS
  We reviewed medical records of all RCC patients who had IVC tumor thrombus above hepatic veins and had had surgery between January 2000 and December 2012 at the Mayo Clinic, M.D. Anderson Cancer Center, University of Texas Southwestern Medical Center, and the University of Wisconsin Hospital.
  
  
  METHODS
  Major complications recorded were defined as ≥ 3A according to the Clavien-Dindo system within 90 d of surgery. Univariate and multivariate analyses were used to evaluate associations of preoperative variables with risk of major complications or 90-d mortality.
  
  
  CONCLUSIONS
  A total of 162 patients were identified for study (level 3, 4 in 69, 93 patients, respectively, according to the Neves classification). Cardiopulmonary bypass was used in 60 of 162 patients (37.5%), and 40 patients (24.7%) had preoperative angioembolization. Major complications were reported in 55 patients (34.0%), with the most common being respiratory, cardiac, and hematologic issues. After multivariate analysis, preoperative systemic symptoms and level 4 thrombus were independently associated with increased risk of major complications. Mortality was reported in 17 patients (10.5%) within 90 d after surgery. After multivariate analysis, Eastern Cooperative Oncology Group (ECOG) performance status (PS) and low serum albumin were preoperative factors independently associated with increased risk of 90-d mortality.
  
  
  CONCLUSIONS
  Contemporary perioperative mortality and major complication rates for RCC patients who have upper-level thrombus are 10% and 34%, respectively. Patients who have ECOG PS >1 or low serum albumin have increased risk for perioperative mortality.
authors.affiliation: Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. Electronic address: abel@urology.wisc.edu.
authors.forename: E Jason
authors.initials: EJ
authors.lastname: Abel
authors.affiliation: Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, MN, USA.
authors.forename: R Houston
authors.initials: RH
authors.lastname: Thompson
authors.affiliation: Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
authors.forename: Vitaly
authors.initials: V
authors.lastname: Margulis
authors.affiliation: Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
authors.forename: Jennifer E
authors.initials: JE
authors.lastname: Heckman
authors.affiliation: Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
authors.forename: Megan M
authors.initials: MM
authors.lastname: Merril
authors.affiliation: Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
authors.forename: Oussama M
authors.initials: OM
authors.lastname: Darwish
authors.affiliation: Department of Urology, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
authors.forename: Laura-Maria
authors.initials: LM
authors.lastname: Krabbe
authors.affiliation: Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, MN, USA.
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Boorjian
authors.affiliation: Department of Urology, Mayo Medical School and Mayo Clinic, Rochester, MN, USA.
authors.forename: Bradley C
authors.initials: BC
authors.lastname: Leibovich
authors.affiliation: Department of Urology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.
authors.forename: Christopher G
authors.initials: CG
authors.lastname: Wood
mesh_terms: D000368:Aged; D002292:Carcinoma, Renal Cell / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D002315:Cardiopulmonary Bypass / Q000009:adverse effects; D004621:Embolization, Therapeutic / Q000009:adverse effects; D005260:Female; D006331:Heart Diseases / Q000209:etiology; D006503:Hepatic Veins; D006801:Humans; D007680:Kidney Neoplasms / Q000401:mortality / Q000473:pathology* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009392:Nephrectomy / Q000009:adverse effects* / Q000401:mortality; D059035:Perioperative Period; D019106:Postoperative Hemorrhage / Q000209:etiology; D011379:Prognosis; D012709:Serum Albumin / Q000378:metabolism; D012720:Severity of Illness Index; D014682:Vena Cava, Inferior / Q000473:pathology*; D054556:Venous Thromboembolism / Q000209:etiology; D020246:Venous Thrombosis / Q000473:pathology*
chemical_list: D012709:Serum Albumin
keywords: Cardiopulmonary bypass; Kidney cancer; Outcomes; Renal cell carcinoma; Thrombus