Off-Pump Pulmonary Thrombectomy During Radical Nephrectomy For RCC: TEE Value

Proposal Number:

MCC-7156 

Proposal Type:

Scientific Poster 

Author:

Gabriel Mena  
MD Anderson Cancer Center

Co-Author(s):

Jessica Brown  
MD Anderson Cancer Center
Javier Lasala  
MD Anderson Cancer Center
Shital Vachhani  
The University of Texas MD Anderson Cancer Center
Piotr Kwater  
The University of Texas MD Anderson Cancer Center
Salameh Obeidat  
MD Anderson Cancer Center
Jeffrey Lim  
MD Anderson Cancer Center

Introduction:

Renal cell carcinoma (RCC) is the most common primary kidney malignancy. RCC presents several challenges for the anesthesiologist during the intraoperative phase as tumor thrombus can extend through the lumen of the renal vein and the inferior vena cava (IVC) into the cardiac chambers. TEE allows for immediate recognition, diagnosis and treatment.

Methods:

65-year-old male Dx with right RCC 9.0 x 7.7 cm and level II tumor thrombus for right radical nephrectomy. Standby CPB machine not planned. TEE inserted to evaluate for overall global ventricular function prior to incision. No evidence of RWMA, intracavitary thrombus or evidence of tumor in the intrahepatic IVC. After palpatory examination of the right kidney by the surgeon, large tumor thrombus suddenly noted in RA. Immediately consulted CV surgeons for on-pump thrombectomy. Ongoing TEE examination revealed passage of the tumor thrombus into RV, rapidly lodging into the right PA. Patient remained hemodynamically stable with no changes in ETCO2 or peak airway pressures. 7.0 Arndt bronchial blocker introduced for lung isolation. While waiting for the CBP machine thrombus migrated to the right PA. Surgeons decided to perform median Sternotomy and off-pump pulmonary thromboembolectomy. Patient transported hemodynamically stable to ICU, extubated next day. TEE lead to positive outcome.
Supporting Image: InfrahepaticRCCThrombus.jpg
RA-RVThrombus.pptx
RightPAthrombus.pptx
 

Results:

Tumor thrombus invading the IVC has an incidence of 4% to 15% in patients with RCC (1-2). Tumor embolization occurring in a patient undergoing nephrectomy for renal cell carcinoma secondary to tumor thrombus in the infra-hepatic IVC is very rare (1.5%). However, if it occurs, it carries a 75% mortality (3). Currently, there are no guidelines for the use of intraoperative TEE during the resection of renal cell carcinomas. TEE offers some valuable benefits such as monitoring the level of tumor thrombus, clinical implications, and presence of thromboembolism for surgical accessibility (4-5). TEE has also been useful in the localization and removal of pulmonary thromboembolism, continuous monitoring for ventricular function after pulmonary thrombectomy, and to guide fluid management and inotropic support (6).

Conclusion:

Our experience demonstrates the diagnostic power and crucial role of continuous TEE monitoring during surgical manipulation for renal cell carcinoma allowing for immediate identification of intraoperative pulmonary thromboembolism, rapid resource mobilization and a significant impact in the patient's positive outcome.

Professional Category:

Attending Physician

Keywords:

Cardiothoracic
Educational

Enter up to three (3) references.

  Reference
1. Chan F. Kee WD, Low JM. Anesthetic management of renal cell carcinoma with inferior vena cava extension. J Clin Anesth 2001; 13:585-7.
2. Shuch B, Larochelle JC, Onyia T, Vallera C, et al. Intraoperative thrombus embolization during nephrectomy and tumor thrombectomy: critical analysis of the University of California-Los Angeles experience. J Urol 2009; 181:492-8
3. 2. Koide Y, Mizoguchi T, Ishii K, Okumura F. Intraoperative management for removal of tumor thrombus in the inferior vena cava or the right atrium with multiple transeophageal echocardiography. J Cardiovasc Surg 1998; 39:641-7.