OncologyVascular Stapling of the Inferior Vena Cava: Further Refinement of Techniques for the Excision of Extensive Renal Cell Carcinoma With Unresectable Vena-caval Involvement
Section snippets
Patients and Methods
From July 2005 to August 2008, a total of 6 patients underwent a right radical nephrectomy with vascular stapling and en bloc removal of the IVC, which contained a thrombus. The study protocol was approved by the Institutional Review Board and written informed consent was obtained from all patients. None of the patients had lower extremity edema preoperatively. None of them had undergone preoperative angioembolization of tumor. Radiographic imaging was consistent with a completely obstructing
Surgical Technique
The surgical approach was similar for each patient. All had an extended subcostal or “Chevron” incision. The initial step was to mobilize the liver sufficiently to place the Rochard retractor. This included division of the triangular and falciform ligaments and medial mobilization of the right lobe of the liver. Subsequently, the right colon was mobilized off Gerota fascia, which allowed mobilization of the right kidney and ligation of the renal artery from the posterior approach. The
Results
Of the 6 patients, 1 was female. The mean age was 60 years (range, 53-70). All tumors were right sided. Average length of surgery was 7 hours. No patients needed cardiopulmonary bypass or deep hypothermic circulatory arrest. Average blood loss was 6350 mL. Excluding patient 1, whose blood loss was 25 000 mL, the average estimated blood loss was 2620 mL. Including patient 1, the average number of units of red blood cells transfused was 13. Excluding this patient the mean was 7.4 U. Average
Comment
Although there has been a well-documented shift toward earlier detection of RCC with resultant downstaging,11 extensive RCC with IVC tumor thrombus is not rare.12 Accurate staging of these lesions is vitally important in planning treatment strategy. The most widely used system for reporting the level of IVC thrombus has been reported.9
The management paradigm of RCC with tumor thrombus in the IVC has undergone major shifts. Initially, such lesions were felt to be incurable and often palliative
Conclusions
Six patients have undergone vascular stapling and resection of the IVC for RCC with an adherent, completely obstructing, tumor thrombus. Since significant collateralization has occurred in these patients, the IVC may be removed without sequelae. This technique is somewhat simpler to perform than suture ligation, requires less operative time, and is consistently reproducible. It is safe, with no patients demonstrating postoperative hemorrhage or renal failure. No complications were noted in this
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Robot-assisted Cavectomy Versus Thrombectomy for Level II Inferior Vena Cava Thrombus: Decision-making Scheme and Multi-institutional Analysis
2020, European UrologyCitation Excerpt :RAT-IVCT was performed with satisfactory outcomes in most cases [1,10]. However, IVC resection is justified in some circumstances, including distal unresectable bland thrombosis and tumor infiltration into the IVC wall, to avoid thrombus shedding and achieve satisfactory tumor control [10–14]. Nevertheless, decisions on whether to perform partial or circumferential IVC resection (the latter is known as cavectomy) are generally made intraoperatively during thrombectomy [10].
Inferior Vena Cava Repair Using Diaphragm in Animal Model
2020, Annals of Vascular SurgeryCaval replacement strategy in pediatric retroperitoneal tumors encasing the vena cava: a single-center experience and review of literature
2019, Journal of Pediatric SurgeryCitation Excerpt :We decided to use prosthetic material (Polytetrafluoroethylene – Teflon®) instead of homograft (such as the patient's internal jugular vein) as we considered both the presence of a permanent central venous line in the contralateral vein as a relative contraindication, and the need for preserving central venous access in the long-term a priority for this type of patient. In a few words, the strategy was not to obtain a long-term patency (knowing that a progressive thrombosis of the prosthesis would be likely asymptomatic and associated with a compensatory development of collaterals), but targeting both a radical resection not guaranteed otherwise together with straightforward recovery after the operation with subsequent quick restarting of adjuvant chemotherapy [7–9]. This strategy was decided on the basis that the intervention itself (the access to the area, the regional dissection and resection of regional tissues around the tumor) likely compromises the already existing retroperitoneal collateral compensatory drainage.