Infrahepatic IVC Resection and Prosthetic Reconstruction for Renal Cell Carcinoma

Renal cell carcinoma (RCC) may result in venous tumor thrombus (VTT) extension into the inferior vena cava (IVC) in 4-36% of cases, with 20-25% requiring IVC resection or reconstruction. Here, we report a case of a 50-year-old man with right RCC and level II VTT who underwent radical nephrectomy and en bloc infrahepatic IVC resection for unexpected lateral wall invasion in the setting of clinically silent pulmonary tumor emboli (PTE). Despite the low embolic risk of level I-II thrombi (<3%), this patient presented with a significant burden of PTE. This case challenges the assumption that lower-level tumors as currently imaged and classified imply minimal risk of tumor embolism or venous wall invasion. Our experience underscores the necessity of pre-operative chest imaging to detect occult PTE, the limitations of imaging for assessing tumor vessel wall invasion, and the need to adequately prepare for unexpected circumstances when resecting RCC with VTT.