Asian Cardiovasc Thorac Ann 1999;7:321-323
© 1999 Asia Publishing EXchange Pte Ltd
Right Heart Bypass for Inferior Vena Cava Tumor Thrombus Extending into Heart
Bhuvnesh Kumar Aggarwal, MCh,
Pitambar Shatapathy, MCh,
Sevagur Ganesh Kamath, MCh,
Gulam Ali Yawari, MS,
Sasidharan Krishnapillai, MCh,1
Department of Cardiovascular and Thoracic Surgery
1 Department of Urology Kasturba Medical College & Hospital Manipal, India
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For reprint information contact: Bhuvnesh Kumar Aggarwal, MCh Tel: 91 8252 71551 Fax: 91 8252 70061 Department of Cardiovascular and Thoracic Surgery, Kasturba Medical College & Hospital, Manipal, Karnataka 576119, India.
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Abstract
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Radical nephrectomy with en bloc inferior vena caval tumor thrombectomy improves survival in patients with renal cell carcinoma with a tumor thrombus extending into the inferior vena cava. Cardiopulmonary bypass with or without deep-hypothermic circulatory arrest is advocated when the tumor thrombus extends into the right heart chambers. Right heart bypass was used to remove such a tumor thrombus successfully for the first time in a patient with renal cell carcinoma.
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Introduction
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Renal cell carcinoma is known to extend into the inferior vena cava (IVC) as a tumor thrombus.1 Radical nephrectomy with en bloc IVC tumor thrombectomy has been shown to improve survival.1,2 Cardiopulmonary bypass alone or with deep-hypothermic circulatory arrest has been advocated when the tumor thrombus extends into the right heart chamber because it grows to a large size, making it hazardous to pull it out through the IVC by alternative maneuvers.3–5 Recently, our team (lead by Dr. Pitambar Shatapathy) used right heart bypass to remove such a tumor thrombus in a patient with renal cell carcinoma in whom the tumor thrombus extended into the right ventricle.
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Case Report
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A 72-year-old male presented with right renal cell carcinoma and no clinical or radiological evidence of metastatic disease. A chest skiagram was normal but a computed tomography scan showed tumor extension into the IVC. While the inferior venogram confirmed the findings of the computed tomography scan, the right atrial frame established the continuity of the IVC tumor thrombus as an intracardiac mass (Figure 1
). Real-time two-dimensional echocardiography revealed the presence of a large mass in the right atrium, measuring 3.5 x 4.7 cm, protruding into the right ventricle during each period of systole. The patient underwent a right radical nephrectomy and removal of the tumor thrombus by a combined team of cardiovascular surgeons and urologists.
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Figure 1. Inferior venacavogram with right atriogram frame showing a large tumor thrombus in the inferior vena cava (arrowhead) and its extension into the right atrium (arrow).
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The patient was positioned supine with a left decubitus tilt of 45° at the chest. En-bloc dissection of the right kidney in preparation for the right radical nephrectomy was carried out through a right lumbar incision by the urology surgical team. The right renal vein was left attached to the IVC. The infrarenal IVC and the contralateral renal vein were looped. The right pleural cavity was entered through the 4th intercostal space by a submammary anterolateral thoracotomy. The hilum of the right lung was dissected and the right pulmonary artery (RPA) and its primary branches were looped. A 5/0 polypropylene pursestring suture was placed on the RPA just lateral to the superior vena cava (SVC). The pericardium was then opened anterior to the phrenic nerve and the SVC was taped. After systemic heparinization (3 mg•kg–1), RPA cannulation was performed with a 24F angled multi-holed left atrial-left ventricular vent (USCI-24; Bard, Inc., Billerica, MA, USA). The SVC was cannulated with a 28F venous cannula passed through the right atrial appendage and held by a pursestring suture. The infrarenal IVC was cannulated likewise with a 32F metal-tipped angled USCI Pacifico cannula (Bard, Inc., Billerica, MA, USA). The SVC and IVC cannulae were then connected to the cardiotomy reservoir to drain systemic venous blood by gravity. The cardiotomy reservoir was connected to the patient by a tube passed through a roller pump to the RPA cannula (Figure 2). The bevelled tip of the angled RPA cannula reached the bifurcation of the main pulmonary artery to ensure even distribution of the returned blood. Oxygenation was maintained by the patient's lungs.
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Figure 2. Diagram of the right heart bypass system with arrows indicating the direction of blood flow. IVC = inferior vena caval, RA = right atrium, RCC = renal cell carcinoma, RPA = right pulmonary arterial, RV = right ventricle, SVC = superior vena caval, TTh = tumor thrombus, TV = tricuspid valve.
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Right heart bypass was initiated by tightening the tape around the SVC over the cannula and by crossclamping the IVC just caudal to the junction of the renal veins. The right atrium was opened and the venous return from the coronary sinus and the suprarenal IVC was evacuated using cardiotomy suckers. The tumor thrombus was held and extracted from the right ventricle after transecting it as low as possible in the IVC. The right renal vein was detached from the IVC along with a cuff of the vena cava and a 20-cc Fogarty occlusion balloon catheter was passed well into the right atrium, alongside the tumor thrombus. The free tumor thrombus in the IVC was extracted along with the radical nephrectomy specimen. The balloon of the catheter was inflated in the right atrium and the catheter was pulled down to just above the vena cavotomy to prevent back bleeding. The catheter was withdrawn after controlling the vena cavotomy with a side-biting clamp. The right atrium was closed using 4/0 poly-propylene suture and the left renal vein was de-looped. The incision in the IVC was closed with 5/0 polypropylene suture. The venae cavae and the RPA were then decannulated. Heparinization was reversed with protamine and intercostal drains were placed in the pericardial and right pleural spaces. After confirming hemostasis, the pericardium was closed with interrupted sutures and the thoracotomy and laparotomy wounds were closed in layers. The patient had a smooth postoperative course and was discharged after 2 weeks. He has been regularly followed up and was doing well when last seen 10 months after the operation. There was no overt evidence of pulmonary or distant metastasis.
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Discussion
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Surgical management of renal cell carcinoma with intraluminal IVC extension poses a technical challenge when the tumor thrombus extends to the level of the hepatic veins, into the suprahepatic IVC, or the right atrium. Although several methods for removing a tumor thrombus extending into the IVC have been described, cardiopulmonary bypass, alone or with deep-hypothermic circulatory arrest, becomes mandatory once the tumor thrombus extends into the heart because it assumes a bulbous shape due to uninhibited growth in the right atrial cavity.3,4 Expansion of the tumor thrombus in the right atrium makes it impossible to remove through the vena caval route without hazardous fragmentation.
Although cardiopulmonary bypass has been advocated in such cases, it has limitations. In addition to increased morbidity, the cost factor is also significant. Right heart bypass not only obviates the need for an oxygenator but also avoids the known deleterious effects of total cardiopulmonary bypass and hypothermia, as well as markedly reducing the cost of surgery. The method provides equally good exposure for the intracardiac procedure by using cardiotomy suckers in the right atrium to clear coronary sinus and hepatic venous return. An additional venting catheter in the IVC cranial to the vena caval crossclamp can further improve intracardiac exposure by diverting hepatic venous return away from the heart. This step can avoid the need for clamping the contralateral renal vein.
We concluded that right heart bypass is a useful alternative to cardiopulmonary bypass with deep-hypothermic circulatory arrest for removal of a tumor thrombus extending into the heart chambers in patients who are at a higher risk due to associated systemic illness or who cannot afford the high cost of surgery. It can be conducted safely and with minimal morbidity. To our knowledge, this is the first report of the use of right heart bypass for removal of an IVC tumor thrombus extending into the heart chambers.
Presented at the 44th Annual Conference of the Indian Association of Cardiovascular and Thoracic Surgeons, Jaipur, India, March 19–22, 1998.
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References
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Skinner DG, Vermillion CD, Colvin RB. The surgical management of renal cell carcinoma. J Urol 1972;107: 705–7.[Medline]
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Skinner DG, Pritchet TR, Lieskovsky G, Boyd SD, Stiles QR. Vena caval involvement by renal cell carcinoma. Surgical resection provides meaningful long-term survival. Ann Surg 1989;210:387–92.[Medline]
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Klein FA, Smith MJV, Greenfield LJ. Extracorporeal circulation for renal cell carcinoma with supradia-phragmatic vena caval thrombi. J Urol 1984;131:880–3.[Medline]
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Novick AC, Kaye MC, Cosgrove DM, Angermeier K, Pontes JE, Montie JE, et al. Experience with cardio-pulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi. Ann Surg 1990;212:472–6.[Medline]
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Aggarwal BK, Shatapathy P, Kamath SG, Venugopal P, Sasidharan K. Removal of inferior vena cava tumor thrombus: a simple technique. Indian J Urol 1998;14: 120–4.
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Abstract
Introduction
