Intraoperative migration of an inferior vena cava tumour detected by transesophageal echocardiography
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KeywordsRenal Cell Carcinoma Inferior Vena Cava Inferior Vena Cava Obstruction Retrohepatic Inferior Vena Cava Suprahepatic Inferior Vena Cava
Direct extension of renal cell carcinoma into the inferior vena cava (IVC) is observed in 3% to 25% of cases.1 Based on the extent of IVC involvement, these tumours are classified as level I (infrahepatic IVC), level II (retrohepatic IVC to hepatic veins), and level III (right atrium). The surgical approach varies for each level. Level I and II tumours are commonly resected through a laparotomy, with an infrahepatic or suprahepatic IVC clamp with or without liver mobilization. Level III tumours require a multidisciplinary surgical approach that involves cardiac and hepatobiliary surgeons in order to gain access to the proximal IVC. Cardiopulmonary bypass standby is often made available for these cases. Tumour disruption and pulmonary embolization is a rare but well-recognized complication that occurs in up to 5.4% of resections of renal cell carcinoma with IVC involvement.2 There have been reports regarding the benefit of intraoperative transesophageal echocardiography (TEE) for these cases in order to provide real-time hemodynamic monitoring during IVC clamping and to detect occurrences of tumour embolization and incomplete resection.2- 5
A 58-year-old female patient presented to our hospital for surgical resection of a right renal cell carcinoma. Preoperative magnetic resonance imaging demonstrated tumour extension into the proximal IVC up to the level of the hepatic veins. Her medical history was notable for previous episodes of pulmonary embolism in the absence of any heart disease that mandated chronic anticoagulation therapy. No evidence of distant metastatic disease was found. Cardiac surgery was involved, and a request was made for cardiopulmonary bypass standby.
In this case, continuous intraoperative TEE monitoring promptly identified the etiology of sudden intraoperative hypotension during kidney mobilization. Furthermore, TEE helped to guide the surgical intervention, ensuring safe application of the IVC snare prior to tumour extraction and potentially minimizing the chances of tumour fragmentation and embolization. Consideration should be given to performing TEE in all cases of IVC tumour resection.
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During kidney mobilization, this modified bicaval view shows further inferior vena cava (IVC) mass cephalad displacement to occlude the IVC-right atrial junction. For abbreviations, refer to legend of Fig. 1 (WMV 4960 kb)
Modified bicaval view showing the inferior vena cava (IVC) tumour during right kidney-IVC tumour en-block surgical removal (WMV 5632 kb)
Modified bicaval view showing no residual tumour and laminar inferior vena caval (IVC) flow after IVC tumour removal (WMV 5888 kb)