Review articleThe perioperative management of an inferior vena caval tumor thrombus in patients with renal cell carcinoma
Introduction
Renal cell carcinoma (RCC) has a unique propensity to develop local extension via tumor thrombus (TT) into the venous system in 10% of patients with extension into the right atrium in 1% [1]. Fortunately, less than 6% of patients with inferior vena cava (IVC) TT experience perioperative pulmonary embolism (PE), which carries a mortality rate of 60%–75% [2]. With recent improvements in treatment of patients with advanced RCC, the scenario of operative intervention in patients with TT is becoming more common. Despite multiple publications outlining surgical approaches and outcomes [3], [4], [5], [6], there have been few studies that evaluate perioperative management of a patient with inferior vena cava tumor thrombus (IVC TT). Therefore, we have attempted to create a clinical pathway for perioperative management of patients with RCC and IVC TT, based on recommendations from a multispecialty panel combined with supporting literature when available. The results presented in this paper are a “best practice guidelines” based on consensus of panel members and evidence-based recommendations found in the literature.
Section snippets
Materials and methods
Our panel consisted of experts from the fields of Urology, Hematology/Oncology, Interventional Radiology, Cardiothoracic Surgery, and Pulmonary Critical Care. An extensive literature review was carried out utilizing PubMed and the Cochrane Database. Search terms included “inferior vena cava,” “tumor thrombus,” “renal mass,” “renal cell carcinoma,” “venous thromboembolism,” “vena cava filter,” “renal embolization,” “renal imaging,” “computed tomography,” and “magnetic resonance imaging,” alone
Results
Guidelines were organized as follows:
Discussion
Patients with RCC and associated IVC TT represent a challenging set of management issues. Due to the nature of the problem, they are high risk for perioperative complications. Historically, these patients have had a 30% perioperative mortality rate either due to bleeding or intraoperative embolization of the thrombus. More recent series suggest mortality rates on the order of 2%–10.5% [1], [8], [9], [10], mainly due to improvements in technique, instrumentation, and recognition of high risk and
Conclusion
Patients with RCC and TT remain complex patients with high risk of perioperative morbidity and potential mortality. We recognize other institutions and practitioners vary in their practice and may disagree with the guidelines we have presented. Lack of prospective research has led to a great deal of variability in perioperative management of these patients. Thus, development of guidelines based on currently available literature and multispecialty expert opinion is a first step in
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