Level III-IV inferior vena caval thrombectomy without cardiopulmonary bypass: long-term experience with
Mukul B Patil1, Jeremy Montez1, Jeffrey Loh-Doyle1
1Center for Comprehensive Urologic Oncology, University of Southern California Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, California.
Insights
Intrapericardial inferior vena cava control simplifies tumor thrombectomy, avoiding cardiopulmonary bypass risks. Complete resection and lymphadenectomy offer long-term survival for advanced disease, despite factors like tumor extent impacting outcomes.
Area of Science:
- Cardiovascular Surgery
- Surgical Oncology
- Nephrology
Background:
- Inferior vena cava (IVC) tumor thrombectomy is complex, often requiring cardiopulmonary bypass.
- Vascular bypass techniques increase surgical risk and require specialized teams.
- Intrapericardial IVC control offers an alternative approach.
Purpose of the Study:
- To evaluate perioperative outcomes of IVC tumor thrombectomy using intrapericardial control.
- To identify factors associated with overall survival in these patients.
Main Methods:
- Retrospective review of 87 patients undergoing nephrectomy with IVC tumor thrombectomy and intrapericardial IVC control (1978-2012).
- Technique used for intrahepatic, supradiaphragmatic, and select intra-atrial thrombi.
- Multivariate regression analysis to assess survival predictors.
Main Results:
- Perioperative mortality was 9.2%; high-grade complications occurred in 19.5%.
- Median survival varied by stage (e.g., 3.1 years for pT3bN0).
- Nodal metastasis found in 38% despite extended lymphadenectomy; ECOG > 2 and pT3c stage predicted worse survival.
Conclusions:
- Intrapericardial IVC control allows safe tumor thrombectomy for intrahepatic and supradiaphragmatic thrombi without cardiopulmonary bypass.
- Complete resection with lymphadenectomy can achieve long-term survival in locally advanced cases.
- Supradiaphragmatic tumor extent and poor ECOG performance status are negative prognostic factors.
Purpose:
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.
Materials And 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.
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