A Single-Center Experience of Caval Thrombectomy in Patients with Renal Cell Carcinoma With Tumor Thrombus Extension into IVC

OBJECTIVES:To describe a single-center experience of caval thrombectomy in patients with renal cell carcinoma (RCC) and tumor thrombus extension into the IVC .
METHODS: We retrospectively reviewed 23 patients undergoing radical nephrectomy with caval thrombectomy. Follow-up included an office visit and CT scan. Statistical comparisons were made using two-sample t-tests.
RESULTS: Patients’ages ranged from 32-83 yrs(mean 62;18male, 5female). Tumor size ranged from 3-21cm (mean 8.6 cm). Tumor thrombus staging was based on the Nevus classification: level I(2/23), II(6/23), III(13/26), IV(2/23). Tumor thrombi were removed via digital extraction(20), fogarty embolectomy(2), or endarterectomy(1-caval wall invasion). Lateral venorrhaphy was used for IVC repair in all cases. Hepatic mobilization and suprahepatic clamping were necessary in 14 patients. Clamp times were significantly different between the suprahepatic(SH) and infrahepatic(IH) groups(15vs 9.4minutes, p<0.012). Mean blood loss was also significantly different(3.2Lvs2L, p<0.045). In the SH group two patients developed postoperative atrial fibrillation and two patients died (respiratory failure; missed enterotomy). The IH group had no perioperative morbidity or mortality. Median followup was 15 months(1-54months). Follow-up imaging was available for 19/23 patients. Ninety-five percent of patients had a patent IVC(18). One SH patient developed an IVC stenosis/thrombosis 12 months postoperatively with successful thrombolysis and stenting. There was a 16%(3/19) recurrence rate in follow-up, with all patients demonstrating renal vascular invasion and high Fuhrman grade upon final pathologic evaluation.
CONCLUSIONS:
Caval thrombectomy can be performed safely during radical nephrectomy for RCC with tumor thrombus extension. The need for suprahepatic clamping is associated with longer clamp times, increased blood loss, and increased morbidity and mortality. Lateral venorraphy with primary repair avoids complicated caval reconstructions and results in high patency rates despite a not insignificant recurrence rate.