A 65-year-old male presented with hematuria secondary to a 10-cm renal cell carcinoma. A magnetic resonance scan demonstrated tumor extension into the left renal vein and the inferior vena cava (IVC) up to the level of the hepatic venous confluence. Imaging studies revealed no evidence of metastatic disease. Therefore, he was considered a candidate for radical nephrectomy and tumor thrombectomy.
After induction of general anesthesia, the patient was positioned supine and underwent a bilateral anterior subcostal incision. Cardiopulmonary bypass was not considered necessary for this procedure as there was no atrial involvement demonstrated on preoperative imaging. The surgeons requested intraoperative transesophageal echocardiography (TEE) for confirming and monitoring the extent of tumor thrombus. TEE was performed using a multiplane, phased array TEE probe (T6210 Omniplane II transducer, Phillips Medical Systems, Andover, MA). Images were digitally acquired on a Phillips Sonos 7500 Ultrasound Imaging System (Phillips Medical Systems, Andover, MA). Initial examination of the heart confirmed normal cardiac structures and function without a patent foramen ovale. The tumor was well visualized in the IVC distal to the hepatic vein-IVC confluence approximately 6 to 8 cm from the IVC-right atrial junction (Fig. 1 and Video clip 1; please see video clip available at www.anesthesia-analgesia.org) without involvement of the heart or pulmonary circulation. The surgery was technically difficult, with significant blood loss. At the completion of the nephrectomy and thrombectomy, the TEE examination revealed residual fragments in the IVC (Fig. 2 and Video clip 2; please see video clip available at www.anesthesia-analgesia.org). These fragments were mobile echogenic masses located in the area where the tumor thrombus was previously identified. This finding was discussed with the surgeons who determined that surgical re-exploration was not indicated and that an IVC filter was the most appropriate next step. The vascular radiology team was consulted and the patient was taken directly to the radiology suite while still anesthetized. The radiologists easily placed an OptEase IVC Filter (Cordis Warren, NJ). The patient had an uneventful postoperative course and was discharged home on the eighth postoperative day.
Newly diagnosed renal cell carcinoma invades the IVC to some degree with a 4% to 10% incidence. Pulmonary embolus (PE) is a rare but well-known complication that occurs in up to 5.4% of resections of renal cell carcinoma with IVC involvement. There have been case reports describing both intraoperative1 and postoperative2 PE as potentially fatal complications of this procedure.
Intraoperative TEE is gaining support in perioperative monitoring of noncardiac surgery patients3 and, accordingly, is being used more frequently during IVC tumor resections. TEE has been reported to be accurate in determining the level of IVC tumor thrombus involvement,4 can assist with diagnosis of intraoperative PE during tumor manipulation, and can monitor heart function and recognize air embolus.1 In a recent Echo Rounds report, Komanapalli et al.5 demonstrated the importance of TEE monitoring for intraoperative tumor embolization to the heart. In our case, TEE provided an additional role: the recognition of residual tumor fragments in the IVC after attempted surgical resection. Although there was no pathologic diagnosis of the fragments we observed, it is reasonable to speculate that these were indeed remnants of the resected tumor thrombus. The exact nature of the fragments, whether tumor, thrombus, or hepatic tissue, is not clinically relevant to the subsequent management of the case.
Intraoperative imaging of the hepatic veins or liver is not a part of the comprehensive TEE examination as prescribed in the American Society of Echocardiography/Society of Cardiovascular Anesthesiologists guidelines. However, imaging the IVC may be performed with reasonable ease in most patients. From the mid-esophageal four-chamber view, the probe is rotated slightly towards the right to bring the right atrium in the center of the image. The probe is then again rotated towards the right to image the IVC-right atrial junction. The probe is then advanced further into the esophagus keeping the IVC in view at all times. The IVC is seen in long axis at the top of the image while the hepatic parenchyma is seen as a homogenous mass below the IVC with a characteristic echogenic pattern. About 4 to 6 cm from the IVC-right atrial junction, the hepatic vein may be seen at its confluence with the IVC (Video clip 3; please see video clip available at www.anesthesia-analgesia.org). It is difficult to view the IVC below the level of the liver due to the anatomical divergence of the esophagus/stomach and the IVC. The hepatic vein may be interrogated in this view by pulsed wave Doppler for assessment of hepatic venous flow. The IVC may also be evaluated in several settings: for presence or progress of catheters and wires in minimally invasive surgery, diameter in cases of chronic right-sided heart failure and to assess extent of IVC involvement in tumors.
In this reported case, TEE provided surveillance to determine that there was residual tumor in the IVC at the conclusion of the operation. This was crucial in directing the postoperative management of this patient, which included placement of an IVC filter that could have prevented significant morbidity and mortality in the form of PE. Prophylactic, preoperative, temporary IVC filter placement for these patients has been previously advocated, but it must be considered as an additional invasive procedure that may be complicated by filter dislocation/migration, equipment fracture, infection, and PE on device explantation.
Our case highlights the benefits of TEE monitoring in cases of IVC tumor excision and suggests that TEE should be considered in perioperative management of these patients. By recognizing that this patient had residual tumor fragments in his IVC, protective interventions were undertaken against potentially significant short-term morbidity or mortality. Patients with these tumors should undergo a complete TEE, including a thorough IVC examination before and after surgical excision. The heart should also be monitored during the procedure to look for evidence of emboli. Intraoperative TEE is a low risk procedure that can have a major impact when used in the perioperative management of patients with tumors involving the IVC.
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