A 67-yr-old man presented for surgical resection of a left renal cell tumor with inferior vena cava (IVC) extension. Preoperative contrast-enhanced computed tomography (CT) revealed tumor involvement of the IVC to 3.5 cm below the confluence of the hepatic veins. Based on this imaging, limited mobilization of the liver with IVC cross-clamp inferior to the hepatic veins was planned.
Intraoperatively, transesophageal echocardiogram (TEE) examination of the IVC revealed the tumor margin to be at the hepatic vein ostia contrary to the preoperative CT examination (Fig. 1A) (Video 1; see Supplementary Digital Content 1, http://links.lww.com/AA/A25).* Attempts to place an IVC clamp above the tumor but below hepatic veins under real-time TEE visualization were unsuccessful (Fig. 1B). Entrapment of the tumor was clearly visible at the site of the attempted vascular clamp location. To ensure that the tip of the tumor was entirely below the vascular clamp, the IVC had to be clamped above the hepatic veins. The surgical plan was then changed to mobilize the liver using a “piggyback technique” (surgical maneuver to expose hepatic veins as they enter the IVC) followed by total vascular exclusion of the liver allowing clamping of the IVC above the hepatic veins (Fig. 2). In this situation, the piggyback technique enabled selective clamping of all 3 hepatic veins, so there was no bleeding when the IVC was opened to extract the tumor. After application of the IVC clamp superiorly to the hepatic veins under direct vision, TEE imaging confirmed that the tumor was entirely isolated below the clamp (Fig. 3) (Video 1; see Supplementary Digital Content 1, http://links.lww.com/AA/A25).* The IVC tumor resection proceeded uneventfully with TEE examination confirming complete resection of the mass from the IVC.
Surgical approach is dictated by the extent of IVC tumor involvement. Tumors extending below the hepatic veins (Levels 1 and 2) can be resected with the application of an infrahepatic IVC clamp. Tumors involving intrahepatic IVC (Level 3) require mobilization of the liver (piggyback technique, which has been previously described and used during liver transplantation1) often with total vascular exclusion of the liver. Tumors with intrathoracic and/or intracardiac extension require thoracotomy and in most cases cardiopulmonary bypass.1 The surgical approach for the majority of patients diagnosed with a tumor involving the IVC is developed based on preoperative imaging studies (CT or magnetic resonance imaging). Although reported in the past, currently TEE is rarely used in the preoperative period to delineate the extent of IVC tumors because less invasive and more precise techniques (CT, magnetic resonance imaging) are readily available. However, intraoperatively, TEE is the only practical real-time modality to visualize the extent of the IVC tumor extension, and its anatomic relationship to the IVC structures.
Literature reviews support the use of intraoperative TEE during similar cases.2–4 TEE has been shown to be accurate in monitoring intraoperative embolic phenomenon during tumor manipulation,3 evaluation of IVC tumor extension,4 recognition of the residual tumor after attempted resection,2 and assessment of preload/cardiac function during IVC clamping. Oikawa et al.5 described yet another application of intraoperative TEE to position an intracaval balloon above the tumor thrombus to enable successful resection without the need to mobilize the liver. Unlike previous reports, this case demonstrates the application of intraoperative TEE to alter the preoperative surgical plan and confirm complete isolation of a tumor inferior to the IVC clamp, thus preventing distal embolization.
Visualization and the anatomic relationship to the hepatic veins may be helpful in developing a safe approach to IVC tumor resection. It is possible to obtain adequate IVC visualization and visualization of the right hepatic vein in 95% and 87% of patients, respectively.6 Imaging of the IVC may be accomplished from the midesophageal bicaval view by rotating the angle of the probe to 40°–70°, while bringing the IVC to the center of the imaging sector and by advancing the probe along the IVC by 2–3 cm until the hepatic veins are identified. Alternatively, one can start, as suggested by Kirkeby-Garstad et al.,6 from the level of the aortic valve at 0° then advance and turn the probe clockwise until the tricuspid valve and coronary sinus are visualized. The probe is then further turned clockwise until (and advanced if required) the orifice of the IVC is seen. The IVC is then placed in the center of the imaging sector while the transducer plane is rotated to 40°–70°. As the probe is advanced further (2–3 cm), the hepatic veins should appear, joining the IVC.6 All 3 hepatic veins can be visualized at the same esophageal depth of the TEE probe: starting from the right hepatic vein, the middle hepatic vein can be imaged by rotating the transducer plane to 50°–90° and rotating the probe counterclockwise; to locate the left hepatic vein, the probe is further turned counterclockwise with the transducer plane adjusted to 80°–130°.6 Short-axis images of the IVC can be obtained by decreasing the angle of the transducer plane by 90°. Because of individual anatomic variation, the angles may need to be modified.
Intraoperative TEE has evolved as a standard practice modality in many institutions for monitoring and diagnostic purposes during the resection of tumors involving the IVC. In our presented case, intraoperative TEE visualization of the tumor reformulated the original surgical approach and prevented tumor entrapment within the IVC clamp, thus avoiding incomplete resection.
1. Ciancio G, Livingstone AS, Soloway M. Surgical management of renal cell carcinoma with tumor thrombus in the renal and inferior vena cava: the University of Miami experience in using liver transplantation techniques. Eur Urol 2007;51:988–94
2. Martinelli SM, Mitchell JD, McCann RL, Podgoreanu MV, Mathew JP, Swaminathan M. Intraoperative transesophageal echocardiography diagnosis of residual tumor fragment after surgical removal of renal cell carcinoma. Anesth Analg 2008;106:1633–5
3. Chen H, Ng V, Kane CJ, Russell IA. The role of transesophageal echocardiography in rapid diagnosis and treatment of migratory tumor embolus. Anesth Analg 2004;99:357–9
4. Treiger BF, Humphrey LS, Peterson CV Jr, Oesterling JE, Mostwin JL, Reitz BA, Marshall FF. Transesophageal echocardiography in renal cell carcinoma: an accurate diagnostic technique for intracaval neoplastic extension. J Urol 1991;145:1138–40
5. Oikawa T, Shimazui T, Johraku A, Kihara S, Tsukamoto S, Miyanaga N, Hattori K, Kawai K, Uchida K, Takeshima H, Saito S, Toyooka H, Akaza H. Intraoperative transesophageal echocardiography for inferior vena caval tumor thrombus in renal cell carcinoma. Int J Urol 2004;11:189–92
6. Kirkeby-Garstad I, Tromsdal A, Sellevold OF, Bjørngaard M, Bjella LK, Berg EM, Karevold A, Haaverstad R, Wahba A, Tjomsland O, Astudillo R, Krogstad A, Stenseth R. Guiding surgical cannulation of the inferior vena cava with transesophageal echocardiography. Anesth Analg 2003;96:1288–93
*Four consecutive video loops showing the following: long-axis view of infrahepatic inferior vena cava [IVC] with tumor originating from a renal mass, right hepatic vein indicated by arrow; short-axis view of distended IVC containing a tumor originating from a renal mass at the level of the right hepatic vein; short-axis view of palpation at the proposed site of IVC clamping [arrow indicates surgeon’s finger below the hepatic veins] demonstrating entrapment of the tumor; long-axis view of the IVC after application of the IVC clamp [clamp not visualized] above the hepatic veins; arrow indicates tip of the tumor well below the IVC clamp.
By Roman M. Sniecinski, MD, Kent H. Rehfeldt, MD, and Martin J. London, MD
- Intraoperative transesophageal echocardiography (TEE) is often helpful for confirming renal cell tumor extension in the inferior vena cava (IVC) before surgical manipulation and to evaluate possible embolic events, residual tumor, and hemodynamic disturbances associated with IVC clamping.
- The level of IVC tumor extension dictates the surgical approach; extension into the right atrium usually requires cardiopulmonary bypass.
- The IVC–right atrial junction is best visualized from the midesophageal (ME) bicaval view, or by slightly advancing the probe from an ME 4-chamber view until the tricuspid valve and coronary sinus are seen, then turning the probe clockwise.
- Three main hepatic veins (right, middle, and left) enter the IVC at approximately the same level; the right hepatic vein is usually the easiest to image by advancing the probe 2–3 cm from the IVC–right atrial junction at a multiplane transducer angle between 40° and 70°.
- Once the right hepatic vein is visualized, the middle and then left hepatic vein can be imaged by progressively increasing the multiplane transducer angle while rotating the probe counterclockwise.