Ann Thorac Surg 2006;81:1887-1888
© 2006 The Society of Thoracic Surgeons
Case report
Cavo-Atrial Tumor Resection Under Total Circulatory Arrest Without a Sternotomy
Thomas Kleisli, BS
a
,
Sharo S. Raissi, MD
a
,
*
,
Nicholas N. Nissen, MD
d
,
Wen Cheng, MD
a
,
Louis Cohen, MD
b
,
Stephen A. Sacks, MD
c
,
Alfredo Trento, MD
a
a Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
b Division of Vascular Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
c Division of Urology, Cedars-Sinai Medical Center, Los Angeles, California, USA
d Center for Liver and Kidney Diseases and Transplantation, Cedars-Sinai Medical Center, Los Angeles, California, USA
Accepted for publication May 17, 2005.
* Address correspondence to Dr Raissi, Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, North Tower, Suite 6215, Los Angeles, CA 90048 (Email: sharo.raissi{at}cshs.org).
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Abstract
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Surgical management of intracardiac tumors arising in the inferior vena cava often requires total circulatory arrest for safe and adequate resection. Total circulatory arrest has traditionally been accomplished by accessing the great vessels through a sternotomy. Combination of a sternotomy and a large abdominal incision results in excellent exposure but also creates the potential for significant morbidity. We report here the resection of cavoatrial tumors by achieving total circulatory arrest through femoral arterial and venous cannulation without requiring a sternotomy. This minimal-access total circulatory approach has the potential to greatly diminish morbidity when managing tumors of the inferior vena cava.
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Introduction
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The traditional surgical approach to exposing the heart and great vessels is through a median sternotomy. Tumors of the inferior vena cava (IVC) that extend to the right atrium have also required mediastinal access to allow atrial visualization when cardiopulmonary bypass is required. Unfortunately, the addition of a sternotomy to the abdominal incision to manage intraabdominal pathology may result in increased pain and postoperative complications. Less invasive techniques have become important for the management of patients with renal cell carcinoma with vena caval or atrial extension, and have yielded quicker recovery times [1–3]. The concomitant use of cardiopulmonary bypass and deep hypothermia with a period of total circulatory arrest (TCA) facilitates the clearance of tumor and tumor thrombus from the IVC, while providing a bloodless surgical field [4–7]. This report describes 3 patients with IVC tumors extending into the right atrium, in whom resection was accomplished through TCA without a sternotomy.
Three patients underwent cavoatrial tumor resection under TCA without a sternotomy between February 2002 and November 2003. Patient 1 was a 76-year-old woman with renal cell carcinoma and IVC tumor thrombus extending to the mid-portion of the right atrium. Patient 2 was a 58-year-old man with renal cell carcinoma and tumor thrombus extending to the atriocaval junction. Patient 3 was a 37-year-old woman with a primary leiomyosarcoma of the IVC originating at the level of the right renal vein and extending to the atriocaval junction.
In each case the operative technique began with a bilateral subcostal abdominal incision and mobilization of the affected kidney and liver. The IVC was mobilized to the level of the diaphragm. In patient 3, the retro-hepatic IVC was separated from the liver to allow complete IVC resection (Fig 1). After exposing the right femoral artery through cutdown, patients were systemically heparinized. The femoral artery was accessed using a No. 21 Bio-Medicus arterial cannula (Medtronic, Minneapolis, MN), and the femoral vein was accessed through a No. 21 Bio-Medicus short cannula. The right jugular vein was accessed with a No. 21 Bio-Medicus short venous cannula using a low stick Seldinger technique and transesophageal ultrasound guidance. Cardiopulmonary bypass was established and the patient was cooled to 12°C to 13°C esophageal temperature.
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Fig 1. Primary leiomyosarcoma of the inferior vena cava (IVC), extending from the right kidney (RK) to the diaphragm (arrow).
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Left ventricle decompression can be a concern in patients with moderate-to-severe aortic insufficiency when the heart fibrillates. All our patients had transesophageal echocardiography performed during surgery, and none had more than mild aortic insufficiency. However, in the unlikely event of moderate-to-severe aortic insufficiency on transesophageal echocardiography, we perform gentle manual massage of the left ventricle every 5 to 10 seconds until the temperature is cold enough for TCA.
After the electroencephalogram was isoelectric, the patient received 40 mEq of potassium added to the pump by the perfusionist for hyperkalemic myocardial arrest. Under TCA, the kidney was removed and the IVC was opened just inferior to the hepatic veins to allow removal of tumor or thrombus under direct visualization. In patients 1 and 3, the IVC was chronically occluded and a long segment of IVC was resected en bloc along with the kidney (patient 1) and retro-hepatic IVC. In these two cases, the IVC was not reconstructed because of the presence of well-established collateral venous drainage. In patient 2, the retro-hepatic IVC was repaired primarily after tumor thrombectomy without the need for an interposition graft. After 1 minute of retrograde body perfusion and air removal of the venous and arterial system, the patient was re-warmed on cardiopulmonary bypass. With warming the patient had a spontaneous normal sinus rhythm develop with good hemodynamics and oxygenation.
All 3 patients were extubated within the first 24 hours postoperatively and discharged from the intensive care unit to the surgical wards within the first 48 hours. The mean cardiopulmonary bypass time was 127.7 minutes (range, 123 to 134 min), and the mean circulatory arrest time was 23.7 minutes (range, 13 to 44 min). The mean hospital stay was 6.3 days (range, 4 to 8 days). There were no neurologic complications. At last follow-up (February 2005), patients 1 and 3 were alive without any recurrence of disease, whereas patient 2, who had brain metastasis at the time of surgery, expired 12 months after the operation.
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Comment
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Several techniques can be utilized to manage tumors of the IVC that extend to the right atrium [5, 7]. In our institution the standard approach in the past had been to perform TCA through a midline sternotomy in conjunction with a midline abdominal incision. This approach allowed for exploration of the IVC and right atrium and for cannulation to perform TCA. This approach was used in 8 patients at our center between 1988 and 2001. In this small series there was no 30-day mortality, but the mean hospital stay was 25 days (range, 3 to 73). With the introduction of parasternal and "J" incisions for the treatment of IVC tumors, Svensson and colleagues [3] reported hospital stays that averaged 18 days and minimal morbidity. The minimal-access femoral cannulation approach described here provides an excellent option for TCA when it is necessary to open the IVC and extract a clot from the region of the hepatic veins or the right atrium.
Femoral cannulation TCA may allow resection of suprahepatic IVC tumors without the need for sternotomy. In each case described here the surgical exposure was excellent and was not compromised by the lack of a sternotomy. Two cases did not require pericardiotomy because the tumor was easily extracted through an opening in the IVC below the diaphragm. In larger tumors or those with significant atrial extension, a subxyphoid pericardiotomy may allow additional exposure. However, sternotomies may continue to be required in rare cases in which tumors are densely adherent or invasive at or above the atriocaval junction. Surgeons preparing to resect IVC tumors should consider all these options when planning an operative approach. We propose that many cases of intraatrial IVC tumor extension previously treated with sternotomy can be effectively managed without sternotomy by establishing TCA through femoral cannulation.
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References
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- Svensson LG. Minimal-access "J" or "j" sternotomy for valvular, aortic, and coronary operations or reoperations Ann Thorac Surg 1997;64:1501-1503.[Abstract/Free Full Text]
- Fitzgerald JM, Tripathy U, Svensson LG, Libertino JA. Radical nephrectomy with vena caval thrombectomy using a minimal access approach for cardiopulmonary bypass J Urol 1998;159:1292-1293.[Medline]
- Svensson LG, Libertino JA, Sorcini A, Kaushik SD, Marinko E. Minimal-access right atrial exposure for tumor extensions into the inferior vena cava J Thorac Cardiovasc Surg 2001;121:589-590.[Free Full Text]
- Okamoto H, Ito T, Morita S, Matsuura A, Yasuura K. Intravenous leiomyomatosis extending into the right ventricleone-stage radical excision during hypothermic circulatory arrest. Thorac Cardiovasc Surg 1994;42:361-363.[Medline]
- Chiappini B, Savini C, Marinelli G. Cavoatrial tumor thrombussingle-stage surgical approach with profound hypothermia and circulatory arrest, including a review of the literature. J Thorac Cardiovasc Surg 2002;124:684-688.[Abstract/Free Full Text]
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- Vaidya A, Ciancio G, Soloway M. Surgical techniques for treating a renal neoplasm invading the inferior vena cava J Urol 2003;169:435-444.[Medline]
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Abstract
Introduction
