Ann Thorac Surg 2001;71:733-734
© 2001 The Society of Thoracic Surgeons
How to do it
Resection of right atrial tumor thrombi without circulatory arrest
Marc Ruel, MDa,
Pierre Bedard, MDa,
Christopher G. Morash, MDa,
Mark Hynes, MDa,
Graeme G. Barber, MDa
a Department of Surgery and Anesthesia, University of Ottawa Heart Institute and Ottawa Hospital, Ottawa, Ontario, Canada
Accepted for publication July 27, 2000.
Address reprint requests to Dr Bedard, H207, University of Ottawa, Heart Institute, 40 Ruskin St, Ottawa, Ontario KIY 4W7, Canada
e-mail: pbedard{at}ottawaheart.ca
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Abstract
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Resectable retroperitoneal tumors with right atrial tumor thrombus extension have been excised previously using cardiopulmonary bypass and deep hypothermic circulatory arrest. We have used a technique involving clamping of the descending aorta with avoidance of deep hypothermic circulatory arrest in 6 patients. The approach provided a virtually bloodless field and allowed complete resection to be performed with low morbidity.
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Introduction
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Retroperitoneal tumors, characteristically renal cell carcinoma, may show tumor thrombus extension to the supradiaphragmatic inferior vena cava (IVC) and right atrium in 0.5% to 4% of patients considered for surgical resection [1]. Complete removal of these tumors is usually performed under cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA), which allow good tumor visualization during right atriotomy and cavotomy [1–3]. However, use of DHCA in patients with severe systemic illnesses such as advanced cancer carries the potential for significant morbidity [4].
We have used a different approach involving moderately hypothermic CPB and clamping of the descending aorta near the diaphragm. Venous return through the IVC and hepatic veins is diminished greatly, allowing optimal visualization and complete resection of the tumor without the need for DHCA.
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Technique
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Setup of cardiopulmonary bypass
Retroperitoneal dissection is carried out by the urology team by way of subcostal or midline laparotomy. A vascular surgeon exposes the infradiaphragmatic IVC. Median sternotomy is performed once the abdominal tumor is mobilized. Palpation of the mass is avoided to prevent tumor dislodgement. Cardiopulmonary bypass is established after ascending aortic cannulation and insertion of the tip of a venous cannula in the right atrium under transesophageal echocardiographic (TEE) guidance. The patient is cooled to 30°C to confer spinal cord and visceral protection, and facilitate further cooling to DHCA should visualization be inadequate.
Descending aortic clamping
The apex of the heart is retracted anteriorly and to the right. The descending aorta coursing along the left anterior thoracic spine is palpated behind the posterior pericardium. The esophagus lies on its right anterior aspect except for the last 2 cm of its course, where it crosses to the left before entering the esophageal hiatus. The posterior pericardium is incised vertically below the left inferior pulmonary vein. Blunt dissection is carried out on both sides of the aorta with care taken not to injure the esophagus or the vagi. The descending aorta is clamped at this site (Fig 1). Alternatively, the abdominal aorta may be exposed and clamped above the celiac trunk. The heart is kept beating throughout the procedure.
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Fig 1. Site for descending aortic clamping in relation to the esophagus and left inferior pulmonary vein (LIPV).
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Tumor excision
After descending aortic clamping, the right atrial cannula is repositioned in the superior vena cava and snared. The right atrium is incised inferolongitudinally while a vascular surgeon simultaneously opens the abdominal IVC from the renal vein to the lower edge of the liver. Venous return through the IVC and coronary sinus is minimal. Incision of the diaphragm is not necessary. Once en bloc removal of the tumor thrombus has been completed, rewarming is initiated, the IVC and right atrium are closed, the descending aortic clamp is released, and the patient is separated from CPB.
Patients
From August 1993 to April 1998, 6 patients with right atrial tumor thrombus from renal cell carcinoma underwent resection using CPB and clamping of the descending thoracic aorta. There were 5 men and 1 woman; mean age was 67.8 ± 3.7 years. Preoperatively, 3 patients had azotemia and 1 patient had liver failure with ascites. Coronary artery bypass grafting was performed concomitantly in 1 patient. Follow-up was complete (mean, 23 months).
Mean descending aortic clamp and CPB times were 31 ± 19 and 108 ± 35 minutes, respectively. Minimum bladder temperature was 29.8°C ± 2.5°C. One patient had tumor embolization to the right atrium recognized with TEE during dissection of the infradiaphragmatic IVC (Fig 2); cannulation, tumor thrombus recovery, and complete resection were achieved without complication under TEE guidance. Mean total operative time was 7 hours 20 ± 59 minutes.
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Fig 2. Intraoperative transesophageal echocardiographic scan showing a large tumor embolus to the right atrium (RA) that was successfully retrieved. (LA = left atrium; RV = right ventricle.)
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There was no perioperative mortality. Morbidity consisted of postoperative atrial fibrillation in 4 patients and bacterial pneumonia in 1 patient. In patients with preoperative renal or hepatic insufficiency, improvements in serum creatinine values and liver function tests were noted postoperatively. Total red cells and fresh frozen plasma transfusions averaged 7.8 ± 5 and 1.5 ± 1.7 units, respectively. One patient required platelet concentrates (6 units). All patients were extubated within 24 hours of operation. Median intensive care unit and hospital stays were 1.5 ± 0.8 and 14 ± 7 days, respectively. All patients were discharged home. Three-year survival using Kaplan-Meier life-table analysis was 67%.
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Comment
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Renal cell carcinoma is resistant to nonoperative treatment modalities such as radiotherapy and chemotherapy. Primary treatment is therefore surgical. Complete resection of caval or right atrial tumor thrombi has not been associated with decreased survival in the absence of distant metastases [2, 5]. Resection of right atrial tumor thrombi has traditionally been performed using CPB and DHCA [1–3]. Potential drawbacks of DHCA in cancer patients undergoing radical tumor resection include increased risks of coagulopathy/disseminated intravascular coagulation, and exacerbation of preoperative physiologic disturbances such as hepatic or renal insufficiency [4].
In an attempt to avoid DHCA, Stewart and colleagues [6] have reported 8 patients who underwent cavoatrial tumor thrombectomy using CPB without circulatory arrest, employing a cardiotomy suction to aspirate hepatic venous return. In our past experience, this technique does not provide optimal visualization, and carries the risks of leaving unrecognized tumor behind or facilitating pump recirculation of malignant cells. Cardiopulmonary bypass with clamping of the descending aorta near the diaphragm is technically simple, greatly diminishes lower body venous return, provides superb exposure, and avoids the need for DHCA with its potential drawbacks. Although the present series reports a small number of patients, our results suggest that resection of these tumors using descending aortic clamping can be performed with low morbidity and result in good intermediate-term outcome.
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References
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Shahian D.M., Libertino J.A., Zinman L.N., et al. Resection of cavoatrial renal cell carcinoma employing total circulatory arrest. Arch Surg 1990;125:727-732.[Abstract/Free Full Text]
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Glazer A.A., Novick A.C. Long-term follow-up after surgical treatment for renal cell carcinoma extending into the right atrium. J Urol 1996;155:448-450.[Medline]
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Almassi G.H. Surgery for tumors with cavoatrial extension. Semin Thorac Cardiovasc Surg 2000;12:111-118.[Medline]
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Zanardo G., Michielon P., Paccagnella A., et al. Acute renal failure in the patient undergoing cardiac operation. Prevalence, mortality rate, and main risks factors. J Thorac Cardiovasc Surg 1994;107:1489-1495.[Abstract/Free Full Text]
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Swierzewski D.J., Swierzewski M.J., Libertino J.A. Radical nephrectomy in patients with renal cell carcinoma with venous, vena caval, and atrial extension. Am J Surg 1994;168:205-209.[Medline]
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Stewart J.R., Carey J.A., McDougal W.S., et al. Cavoatrial tumor thrombectomy using cardiopulmonary bypass without circulatory arrest. Ann Thorac Surg 1991;51:717-722.[Abstract]
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Abstract
Introduction
