Invasive renal cell carcinoma with inferior vena cava tumor thrombus: Cardiac anesthesia in liver transplant settings

Objectives Resection of renal cell carcinomas (RCC) with tumor thrombus invasion into the inferior vena cava (IVC) is associated with significant perioperative morbidity and mortality. This study examined the intra- and inter-departmental collaboration among cardiac, liver transplantation, and urologic surgeons and anesthesiologists in caring for these patients. Design After IRB approval, medical records of patients who underwent resection of RCC tumor thrombus level III and IV, from 1997 to 2010 in this institution, were reviewed. Data were collected and analyzed by one way-ANOVA and chi-square test. Setting Major academic institution, tertiary referral center. Participants This was a retrospective study based on the medical records of patients who underwent resection of RCC tumor thrombus level III and IV, from 1997 to 2010. Interventions None. Measurements and Main Results Fifty-eight patients (82.9%) with level III thrombus and 12 patients (17.1%) with level IV thrombus were analyzed. Sixty-five (92.9%) did not require any extracorporeal circulatory support; 5 (2 with level III and 3 with level IV; 7.1%) required cardiopulmonary bypass. No patients required veno-venous bypass. Compared to patients with level III thrombus extension, patients with level IV had higher estimated blood loss (6978±2968 mL v 1540±206, p<0.001) and hospital stays (18.8±1.6 days v 8.1±0.7, p<0.001). Intraoperative transesophageal echocardiography (TEE) was utilized in 77.6% of patients with level III thrombus extension and in 100% of patients with level IV thrombus extension. Intraoperative TEE guidance resulted in a significant surgical plan modification in 3 cases (5.2%). Short-term mortality was low (n = 3, 4.3%). Conclusions Utilization of specialized liver transplantation and cardiac surgical techniques in the resection of RCC with extension into the IVC calls for a close intra-and interdepartmental collaboration between surgeons and anesthesiologists. The transabdominal approach to suprahepatic segments of the IVC allowed avoidance of extracorporeal circulatory support in most of these patients. Perioperative management of these patients reflected the critical importance of TEE-proficient practitioners experienced in liver transplantation and cardiac anesthesia.