Ann Thorac Surg 2007;83:1564-1565
© 2007 The Society of Thoracic Surgeons
How To Do It
Cavoatrial Tumor Thrombectomy With Systemic Circulatory Arrest and Antegrade Cerebral Perfusion
Alessandro Mazzola, MDa,*,
Renato Gregorini, MDa,
Carmine Villani, MDa,
Laura B. Colantonio, MDa,
Raffaele Giancola, MDa,
Giovanni L. Gravina, MDb,
Carlo Vicentini, MD, FPb
a Department of Cardiac Surgery, Giuseppe Mazzini Hospital, Teramo, Italy
b Department of Urology, University of L’Aquila, L’Aquila, Italy
Accepted for publication April 6, 2006.
* Address correspondence to Dr Mazzola, Ospedale G. Mazzini, Piazzale San Padre Pio, Teramo, 64100 Italy (Email: sandromaz{at}tin.it).
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Abstract
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Renal carcinoma extending into the inferior vena cava can be excised with a good early-term and long-term prognosis. Cardiopulmonary bypass and deep hypothermic circulatory arrest are used to resect intracardiac extension of the tumor. We propose antegrade selective cerebral and cardiac perfusion associated with systemic circulatory arrest to protect the brain and the abdominal viscera while obtaining a bloodless surgical field for tumor thrombus removal.
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Introduction
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Renal carcinoma, as uterine and adrenal tumors, characteristically grows into the inferior vena cava and extends to the right heart chambers. In spite of the impressive extension of the tumor thrombus into the venous system, surgical resection of renal cell carcinoma can result in prolonged survival even in the presence of metastatic disease [1–3]. Conventional cardiopulmonary bypass is necessary for intracardiac tumors resection [2, 4]. Chiappini and coworkers [3] associate deep hypothermic circulatory arrest (DHCA) to improve the safety and the efficacy of the surgical procedure. To extend the safe period of DHCA, Ngaage and colleagues [5] adds retrograde cerebral perfusion. Other authors prefer moderately hypothermic cardiopulmonary bypass, and clamp either the descending thoracic aorta close to the diaphragm or the abdominal aorta above the celiac trunk for a bloodless surgical field. Our proposal consists in moderately hypothermic (25°C) circulatory arrest associated with both the cerebral and cardiac perfusion achieved either by clamping the aortic arch between the left carotid artery and the subclavian artery or the thoracic aorta immediately after the origin of the subclavian.
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Technique
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The surgical exposure is obtained through a median sternotomy associated with a midline abdominal incision. Once a conventional nephrectomy is prepared, leaving the renal vein connected to the inferior vena cava, the aortic arch and brachiocephalic vessels are mobilized. The ascending aorta (or the axillary artery) is cannulated. Venous drainage is assured by insertion of a right angle cannula into the superior vena cava and cannulation of the right atrial appendage while maintaining a safe distance from the tumor thrombus by transesophageal echocardiography. Cardiopulmonary bypass is established and the patient is cooled until a body temperature of 25°C is reached. The aortic arch is clamped between the left carotid and subclavian artery (to avoid blood steal from the brain, the subclavian artery must be clamped), otherwise the descending aorta can be clamped after the origin of the subclavian artery and the pump flow is adjusted to maintain a right radial pressure between 40 and 70 mm Hg. The right atrial cannula is clamped and the superior vena cava cannula is snared to assure cerebral venous drainage (Fig 1). The kidney and the tumor thrombus can be excised en bloc by incising the right atrium and the anterior wall of the inferior vena cava. Minor blood loss from the coronary sinus or the vena cava is not troubling, but if necessary, once 25°C is reached, circulation may be stopped for brief periods. After the right atrium has been closed and the vena cava is repaired, the circulation in the rest of the body is resumed, and warming is continued until the body temperature reaches 37°C.
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Fig 1. Schematic representation of antegrade cerebral and cardiac perfusion. (A) The aortic clamp is positioned between the left carotid artery and the subclavian artery; in this case the left subclavian artery must be clamped (asterisk). (B) A clamp is positioned on the right atrial cannula (T). The tumor thrombus extends from the right renal vein to the right atrium. The black arrows show the flow of the blood during selective cerebral perfusion.
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The case report of a 50-year-old woman presented with a history of gross hematuria and an abdominal distension. A computer tomographic scan and a magnetic resonance imaging scan showed a right renal tumor involving the inferior vena cava that extended into the right atrium. Preoperative echocardiography confirmed right atrial extension of the tumor thrombus and a normal left ventricular function (Fig 2). The operation was carried out as previously described (the aorta was clamped after the origin of the subclavian artery), the tumor thrombus was free floating into the inferior vena cava, and it was not adherent to the atrial wall so that it could be removed en bloc together with the kidney and the renal vein. The pathologic examination showed a clear renal cell carcinoma extending to the perinephric fat with negative surgical margins and no involvement of the lymph nodes. The postoperative course was uneventful, and 8 months after the operation the patient is in good health without evidence of tumor dissemination.
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Comment
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Prognosis of the renal carcinoma is not affected by its extension into the inferior vena cava or into the right atrial chamber, therefore justifying an aggressive surgical approach in such circumstances [1–3]. Hypothermic cardiopulmonary bypass alone is used to avoid the disadvantages of DHCA, but the exposure and visualization of the tumor thrombus can be compromised by the blood and the risk of hepatic and renal ischemia should be remarked [3]. On the other hand, DHCA gives enough visceral protection while the bloodless surgical field allows optimal visualization of the inferior vena cava and the right atrium for complete resection of the tumor. To reduce the extent of the operation and to ameliorate the patient’s recovery after DHCA, Svensson and colleagues [6] suggest minimal access to the right atrium for resection of this kind of tumor. Ngaage and colleagues [5] propose retrograde cerebral perfusion to prolong safe cerebral ischemia during DHCA for removal of extensive renal cell tumors. Ruel and colleagues [7] suggest reducing venous return from the lower body by clamping the thoracic aorta near to the diaphragm or the abdominal aorta above the celiac trunk. The authors advise performing the procedure when the patient is cooled to 30°C, but if the visualization is not adequate, further cooling to DHCA could be difficult once the inferior vena cava or right atrium are opened. Also clamping of the descending thoracic aorta exposes potential damage of the esophagus and vagi. Antegrade selective cerebral perfusion and moderate hypothermia have proven a safe method of cerebral protection during surgery of the thoracic aorta, while problems due to deep hypothermia are reduced, and ischemic injury of the abdominal viscera and spinal cord are prevented [8]. With the technique of the aortic clamping described in this article, both antegrade selective cerebral and cardiac perfusion in a bloodless surgical field and visceral protection are guaranteed without incurring in the drawback of DHCA.
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References
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- Libertino JA, Zinman L, Watkins Jr E. Long-term results of resection of renal cell cancer with extension into inferior vena cava J Urol 1987;137:21-24.[Medline]
- Nesbitt JC, Soltero ER, Dinney CPN, et al. Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus Ann Thorac Surg 1997;63:1592-1599.[Abstract/Free Full Text]
- Chiappini B, Savini C, Marinelli G, et al. Cavoatrial tumor thrombus: single-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]
- Stewart JR, Carey JA, McDouglas WS, Merrill WH, Brender Jr WH. Cavoatrial tumor thrombectomy using cardiopulmonary bypass without circulatory arrest Ann Thorac Surg 1991;51:717-722.[Abstract]
- Ngaage DL, Sharpe DAC, Prescott S, Kay PH. Safe technique for removal of extensive renal cell tumors Ann Thorac Surg 2001;71:1679-1681.[Abstract/Free Full Text]
- Svensson LG, Libertino J, Sorcini A, Kaushik D, Marinko E. Minimal-access rigth atrial exposure for tumor extensions into the inferior vena cava J Thorac Cardiovasc Surg 2001;121:589-590.[Free Full Text]
- Ruel M, Bedard P, Morash CG, Hynes M, Barber GG. Resection of right atrial tumor thrombi without circulatory arrest Ann Thorac Surg 2001;71:733-734.[Abstract/Free Full Text]
- Di Eusanio M, Schepens MA, Morshuis WJ, et al. Brain protection using antegrade selective cerebral perfusion: a multicentric study Ann Thorac Surg 2003;76:1181-1189.[Abstract/Free Full Text]
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Abstract
Introduction
