Level III-IV inferior vena caval thrombectomy without cardiopulmonary bypass: long-term experience with intrapericardial control
- PMID: 24704114
- DOI: 10.1016/j.juro.2014.03.112
Level III-IV inferior vena caval thrombectomy without cardiopulmonary bypass: long-term experience with intrapericardial control
Abstract
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.
Keywords: carcinoma; inferior; kidney; mortality; renal cell; thrombosis; vena cava.
Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
Comment in
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Editorial comment.J Urol. 2014 Sep;192(3):688; discussion 688-9. doi: 10.1016/j.juro.2014.03.123. Epub 2014 Jun 12. J Urol. 2014. PMID: 24931703 No abstract available.
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Re: Level III-IV inferior vena caval thrombectomy without cardiopulmonary bypass: long-term experience with intrapericardial control: M. B. Patil, J. Montez, J. Loh-Doyle, J. Cai, E. C. Skinner, A. Schuckman, D. Thangathurai, D. G. Skinner and S. Daneshmand.J Urol. 2015 Jun;193(6):2150-1; discussion 2151. doi: 10.1016/j.juro.2014.10.127. Epub 2015 Mar 11. J Urol. 2015. PMID: 25769551 No abstract available.
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