Renal cell carcinoma with inferior vena caval (IVC) extension presents several challenges in management, including radiographic characterization, intraoperative monitoring, and surgical excision. Advantages of using transesophageal echocardiography (TEE) during renal cell carcinoma excision include evaluating the cephalad-most extension of tumor in the IVC, monitoring the tumor during surgical mobilization, and assessing cardiac function (1,2). Although embolization of a renal cell tumor remains a risk, <0.4% of all renal cell carcinomas and <5% of those involving the IVC embolize during surgery (3–7). This case report describes the role of TEE in diagnosing a migratory embolus from the IVC to the pulmonary artery (PA) and provides both single-frame photographs and Internet-accessible video images of the event. Continuous TEE monitoring allowed rapid intraoperative diagnosis of pulmonary embolism (PE) and facilitated the approach for its removal. This case makes an argument for routine use of TEE during renal cell excision involving the IVC.
Our patient was a 57-yr-old woman recently diagnosed with renal cell carcinoma, stage T3cNxM0 (T3c tumor grossly extends into the vena cava above the diaphragm, Nx-regional lymph nodes cannot be assessed, and M0 indicates no distal metastasis), who was scheduled for radical right nephrectomy with IVC thrombectomy (8). Her medical history included hypertension and four prior orthopedic surgeries. Medications on admission were terazosin 5 mg daily, TriEst® combination estrogen therapy 3.75 mg daily, and testosterone 1.75 mg daily. Her preoperative physical examination was notable for a palpable right-sided abdominal mass extending below her right costal margin and a grade III/VI systolic ejection murmur. Magnetic resonance imaging (MRI) of the abdomen 6 days before surgery revealed a 14.2 × 12.0-cm mass in her right kidney and a thrombus within the IVC to the level of the hepatic veins.
Our patient was premedicated with 2 mg of midazolam IV, and general anesthesia was induced with 150 mg of propofol, 250 μg of fentanyl, and 50 mg of rocuronium. Anesthesia was maintained with air/oxygen/desflurane and supplemented with fentanyl and vecuronium. Initial TEE examination showed normal global ventricular function and valvular function, no patent foramen ovale, and extension of the IVC thrombus to 2 cm from the IVC to the right atrium (RA) junction (Acuson adult multiplane probe; Mountain View, CA) (Fig. 1A), as well as a normal-appearing main PA and its branches (Fig. 1B).
After mobilization of the liver and vascular control of small veins draining into the retrohepatic IVC, TEE was used to continuously monitor the cavoatrial junction (Video 1) as tourniquets were placed on the IVC proximally at the level of the hepatic veins and distally at the level of the renal veins. Just as the kidney was being lifted, the mass in the IVC suddenly vanished from the bicaval view. Rapid TEE examination illustrated that the tumor had become mobile within the RA (Video 2) and then lodged in the right PA (Fig. 1C). The thrombus had fractured at the level of the renal vein, allowing migration through the open proximal control. Peak inspiratory pressure increased from 12 to 20 cm H2O, ETCO2 decreased from 29 to 14 mm Hg, and arterial blood gas analysis revealed severe respiratory and metabolic acidosis, adequate oxygenation, and a large PCO2/ETCO2 gradient, consistent with dead space ventilation and low cardiac output. During this time, the patient was transiently hypotensive with systolic blood pressure in the 60s, and her blood pressure was supported with fluids, 5 10-μg boluses of epinephrine, and 100-μg boluses of phenylephrine so that the systolic blood pressure remained in the 90s for the remainder of the case. TEE was performed at the first opportunity after resuscitative efforts to assess cardiac function and guide further therapy. Both the right and left ventricles were normal to hyperdynamic in function after epinephrine administration, and there was only trivial tricuspid regurgitation, making estimation of right ventricular systolic pressure difficult. The renal vein and artery were ligated and transected, and the radical nephrectomy specimen was removed.
After a cardiothoracic surgeon was consulted, the chest was prepared, and the initial bilateral subcostal incisions were extended with median sternotomy. After the administration of 32,000 U of heparin and 100 mL of aprotinin, the aorta was cannulated, followed by placement of bicaval RA cannulas. Cardiopulmonary bypass was initiated without event. Main pulmonary arteriotomy was performed, and the tumor thrombus was extracted (Fig. 1D). The cardiothoracic surgeon examined the two main branches of the PA as far distally as possible, and TEE also confirmed that the thrombus had been completely removed. The patient was brought to the intensive care unit tracheally intubated, sedated, and not requiring any inotropic support. The trachea was extubated the next morning, and the patient was discharged from the intensive care unit on postoperative Day 2 and discharged to home on postoperative Day 7. Pathology revealed Grade 2 clear cell renal cell carcinoma with renal vein extension.
The advantages of using TEE during surgical management of renal cell carcinoma invading the IVC were manifold. The cephalad extent of the thrombus was accurately localized closer to the RA than was detected by MRI. TEE is known to be superior to computed tomography (CT), MRI, or inferior venacavography in identifying the most cephalad extent of the tumor thrombus, as was the case in our patient (9–11). The surgical approach begins with either a bilateral subcostal or triradiate (an additional midline vertical excision up to the xiphoid process) incision with subsequent mobilization of the liver by dissection of the ligamentum teres. After the falciform ligament is divided, the incision is continued until the suprahepatic and infrahepatic IVC are visualized. Staging dictates the surgical approach at this point: if there is no IVC involvement, this exposure is usually adequate for placement of vascular clamps (12). If there is IVC involvement, the hepatic veins must be visualized completely, and the IVC must be dissected away from the posterior abdominal wall. In the case of a Stage 3c tumor, which extends above the diaphragm, the surgeon then “milks down” the thrombus to below the level of the hepatic veins. The proximal tourniquet is then placed below the hepatic veins (13). TEE can also play a crucial role in monitoring the progress of the tumor being “milked down” and helps to confirm the absence of residual tumor (1,14).
Continuous monitoring of the intracaval thrombus during its surgical manipulation allowed immediate identification of embolization and proper notification of the surgeons. A case of intraoperative renal cell carcinoma embolization has been described, in which the embolism was not confirmed until the pulmonary arteriotomy was performed. That case did not use intraoperative TEE monitoring, and the decision to initiate emergency cardiopulmonary bypass resulted only after a series of troublesome signs had been observed, including diminishing cardiac index and ETCO2, hepatic engorgement, and persistent hypotension despite multiple fluid boluses and inotropes (15). The use of TEE during our case allowed rapid initiation of cardiopulmonary bypass and enabled the identification of the thrombus in the right pulmonary artery, thus guiding the cardiothoracic surgeon’s approach for arteriectomy (12). TEE has the added benefit of monitoring the severity and clinical significance of embolism, as well as the presence of interatrial communications, the presence of visible thrombus, and surgical accessibility (16–19). TEE has been compared with spiral CT for diagnostic power during hemodynamically significant acute or chronic PE and has been shown to be comparable. Although CT was slightly more sensitive than TEE (90% and 80%, respectively), both had a specificity of 100% (20). Echocardiography has also been shown useful in the localization and removal of PE (21). Finally, continuous monitoring after the PE allowed assessment of overall ventricular function and confirmed that the initial choice of supportive treatments with inotropes and fluids was effective and that cardiac function was not compromised.
Our case not only illustrates the aforementioned roles of TEE during tumor extraction, but also makes an argument for its routine use for renal cell carcinomas invading the IVC (Stage 3b and 3c, tumor extending into the vena cava below and above the diaphragm, respectively). Currently, there are no guidelines for the use of intraoperative TEE in renal cell carcinoma cases. It is important for the anesthesiologist to realize that the tumor may extend more cephalad in the IVC than previously staged by MRI or venography, even if the study is performed only days before the surgery. For this reason, it would be reasonable to also have TEE available for Stage T2 (tumor more than 7 cm in largest diameter, confined to the kidney) or Stage T3a (tumor invades the adrenal gland or perinephric tissues) tumors, so that if there is a question during surgery about whether the tumor extent is more than that revealed by MRI, intraoperative TEE can assess whether there is actual IVC involvement. Unfortunately, even in the postoperative period, embolization can occur. In one case report, a patient on postoperative Day 1 after nephrectomy for renal cell carcinoma had fatal cardiac arrest after a massive thromboembolism, and the authors advocate the routine prophylactic placement of an infrarenal Greenfield filter at the end of the operation (22). Routine TEE use for renal cell carcinoma cases may also diminish the incidence of postoperative embolization by confirming absence of residual renal tumor. This case illustrates the diagnostic power of TEE and its crucial role in the management of a migratory tumor embolus and advocates its routine use during resection of Stage 3b and more advanced renal carcinomas.
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