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Extracorporeal methods of vascular control for difficult IVC procedures
F Baumgartner1, J Milliken, C Scudamore
1Department of Surgery, Harbor-UCLA Medical Center, Division of Cardiothoracic Surgery, Torrance, California.
Insights
Managing juxtahepatic and intrapericardial inferior vena cava (IVC) tumors requires advanced techniques. Venovenous bypass (VVB) and cardiopulmonary bypass with hypothermic circulatory arrest (CBCA) offer effective surgical solutions for complex IVC pathologies.
Area of Science:
- Vascular Surgery
- Surgical Oncology
- Cardiothoracic Surgery
Background:
- Juxtahepatic and intrapericardial inferior vena cava (IVC) surgeries present significant vascular control challenges.
- Complex pathologies in this region necessitate specialized surgical approaches.
Purpose of the Study:
- To describe surgical strategies for managing juxtahepatic and intrapericardial IVC pathologies.
- To evaluate the efficacy of venovenous bypass (VVB) and cardiopulmonary bypass with hypothermic circulatory arrest (CBCA) in these complex cases.
Main Methods:
- Retrospective review of 10 patients with diverse IVC pathologies.
- Surgical interventions included VVB for cases without atrial involvement.
- CBCA with deep hypothermia was employed for tumors extending into the right atrium.
Main Results:
- Eight out of ten patients had successful outcomes and were discharged within 4 weeks.
- VVB was used in patients without atrial involvement (mean bypass time: 40 minutes).
- CBCA was used for right atrial tumor extension (mean bypass, aortic cross-clamp, and arrest times: 152, 92, and 36 minutes, respectively).
Conclusions:
- VVB and CBCA are viable and effective surgical options for complex IVC pathologies.
- Careful patient selection and tailored surgical techniques are crucial for successful outcomes.
- Despite challenges, a high success rate was achieved in this patient cohort.
Abstract:
Surgical procedures in the juxtaheptic and intrapericardial inferior vena cava (IVC) are difficult because of the complexity of achieving vascular control in the area. We describe 10 patients with a variety of pathologies in this region who underwent venovenous bypass (VVB) or cardiopulmonary bypass with hypothermic circulatory arrest (CBCA). Renal cell carcinoma with IVC extension was present in three patients (with tumor extension into the right atrium in two), adrenal adenocarcinoma in one, septic IVC thrombus in one, and blunt IVC/hepatic trauma in five. Those patients without atrial involvement underwent VVB with a mean bypass time of 40 minutes (range 12-144). Those patients with tumor extension into the right atrium underwent CBCA with systemic hypothermia to 18(0)C, total body exsanguination for a bloodless field, and removal of the tumor by cavotomy and right atriotomy. The mean bypass, aortic cross-clamp, and circulatory arrest times were 152, 92, and 36 minutes, respectively. Eight of the 10 patients did well and went home within 4 weeks of surgery. Two patients died, one from metabolic sequelae of exsanguinating IVC injury (VVB) and one from sepsis 2 weeks postoperatively (CBCA).