Level III-IV inferior vena caval thrombectomy without cardiopulmonary bypass: long-term experience with intrapericardial control.
OBJECTIVE
Inferior vena cava tumor thrombectomy requires experienced surgical teams due to complex hemodynamic considerations. The teams often use vascular bypass techniques that introduce additional risk. Inferior vena caval control in the pericardium obviates the need for cardiopulmonary bypass. We reviewed our experience with intrapericardial control during inferior vena caval tumor thrombectomy to evaluate perioperative outcomes and determine factors associated with overall survival.


METHODS
We retrospectively reviewed the records of 87 patients who underwent nephrectomy with inferior vena caval tumor thrombectomy using intrapericardial inferior vena caval control from 1978 to 2012. This technique was performed in all 43 and 35 cases of intrahepatic and supradiaphragmatic thrombi, respectively, and in 9 select cases of intra-atrial thrombi. Patient demographics, operative variables and postoperative outcomes were examined. Multivariate regression analysis was used to determine associations between clinical variables and overall survival.


RESULTS
Mortality 30 days perioperatively was 9.2% and the incidence of high grade complications was 19.5%. Median survival was 3.1 and 2.5 years in patients with pT3bN0 and pT3cN0, respectively. Extended regional lymphadenectomy, which was performed in all cases, revealed nodal metastasis in 38%. On multivariate analysis ECOG greater than 2 and pT3c stage were associated with worse survival. Histological grade, perinephric fat invasion and lymph node involvement were not associated with worse survival.


CONCLUSIONS
Intrapericardial control of the inferior vena cava enables a single surgical team to safely perform tumor thrombectomy for intrahepatic and supradiaphragmatic thrombi, eliminating the risk and morbidity related to cardiopulmonary bypass. Although supradiaphragmatic extent and ECOG greater than 2 are associated with worse survival, complete resection with lymphadenectomy can allow for long-term survival in patients with locally advanced disease.
Center for Comprehensive Urologic Oncology, University of Southern California Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California.
Mukul B
MB
Patil
Center for Comprehensive Urologic Oncology, University of Southern California Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California.
Jeremy
J
Montez
Center for Comprehensive Urologic Oncology, University of Southern California Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California.
Jeffrey
J
Loh-Doyle
Center for Comprehensive Urologic Oncology, University of Southern California Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California.
Jie
J
Cai
Center for Comprehensive Urologic Oncology, University of Southern California Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California.
Eila C
EC
Skinner
Center for Comprehensive Urologic Oncology, University of Southern California Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California.
Anne
A
Schuckman
Center for Comprehensive Urologic Oncology, University of Southern California Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California.
Duraiyah
D
Thangathurai
Center for Comprehensive Urologic Oncology, University of Southern California Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California.
Donald G
DG
Skinner
Center for Comprehensive Urologic Oncology, University of Southern California Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California. Electronic address: siadaneshmand@yahoo.com.
Siamak
S
Daneshmand
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002292:Carcinoma, Renal Cell / Q000556:secondary; D002315:Cardiopulmonary Bypass; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology; D008297:Male; D008875:Middle Aged; D009360:Neoplastic Cells, Circulating; D010496:Pericardium; D012189:Retrospective Studies; D015996:Survival Rate; D017131:Thrombectomy / Q000379:methods*; D013927:Thrombosis / Q000401:mortality* / Q000601:surgery*; D013997:Time Factors; D014682:Vena Cava, Inferior
carcinoma; inferior; kidney; mortality; renal cell; thrombosis; vena cava