Service de Chirurgie Cardiaque et Vasculaire, Hôpital Européen Georges Pompidou, AP-HP, Faculté de Médecine René Descartes, Université Paris 5, Paris, France
Abdominal tumors with involvement of the inferior vena cava (IVC) are most frequently of renal origin or sarcomas . Ten percent of renal tumors invade the IVC, and 1 % extend up to the right atrium [2, 3]. Nevertheless, extensive caval infiltration or extension to the heart is uncommon. This latter situation is challenging as surgical difficulties and postoperative complications rise along with the level of extension of the thrombus in the IVC and the involvement of surrounding structures [4, 5]. Even in the presence of local invasion or metastasis, surgical resection is the only treatment shown to improve survival in these patients [5, 6]. The use of cardiopulmonary bypass (CPB), for tumors extending to the level of the hepatic veins or into the atrium, is highly recommended [5, 7]. Several series report the use of CPB with deep hypothermia and circulatory arrest (DHCA) [3, 7], but these procedures are associated with significant mortality. For renal cell carcinoma with cavoatrial extension, a recent multi-institutional study reported an 8.3 % operative mortality with the use of DHCA . Despite the fact that deep hypothermia provides organ protection, circulatory arrest is associated with a higher risk of neurologic complications and ischemia—reperfusion injury . We reported our experience with the use of CPB and deep hypothermia without circulatory arrest in the surgical treatment of abdominal tumors with IVC and right atrial involvement .
9.2 Preoperative Staging
The staging should include thoracoabdominal computed tomography scan and magnetic resonance angiography to assess tumor extension and rule out metastasis. The upper extent of the tumor thrombus is defined in accordance with the classification of Neves and Zincke , which encompasses four stages. Stage 1 includes tumors with thrombus extension less than 2 cm in the IVC. Stage 2 is for thrombus extension below the hepatic veins. Intrahepatic IVC thrombus extension that remains below the diaphragm corresponds to stage 3. Thrombus extension above the diaphragm is stage 4. In case of cardiac extension of the tumoral thrombus, the tumor may cross the tricuspid valve. Acute Budd-Chiari syndrome can be seen preoperatively in case of severe hepatic vein obstruction.
9.3 Surgical Technique
Under general anesthesia, the right common femoral vein is exposed through a groin incision and prepared for cannulation. A complete median sternotomy is performed. Depending on the location of the primary tumor, the sternotomy should be extended through a right subcostal incision for right renal, hepatic, and primary IVC tumors. Bilateral subcostal incision or median laparotomy should be used for left renal and left adrenal primary tumors. The pericardium is opened, and the ascending aorta is cannulated. The superior vena cava and common femoral vein are cannulated to ensure venous drainage of the upper half and lower half of the body. Mobilization of the right colon is followed by a Kocher maneuver to expose the IVC and the renal veins. The falciform ligament and the right triangular ligament are incised to allow a right hepatic lobe mobilization and exposure of the suprarenal and retrohepatic vena cava. An anteroposterior phrenotomy is achieved, widely exposing the hepatic veins and the cavoatrial junction.
Concomitant to the beginning of tumor resection and vena cava dissection, CPB is started and systemic cooling initiated until cessation of all electrical brain activity. This would usually be achieved at an esophageal temperature of 18–20 °C. The decrease and then cessation of electrical brain activity is assessed by electroencephalography. Once the electroencephalogram is flat, CPB flow is decreased from 1 to 1.5 L/min. This would decrease the venous return through hepatic, lumbar, phrenic, and adrenal veins, facilitating dissection, tumoral resection, and atriohepatic confluent reconstruction.
In case of renal or adrenal cancer, the primary tumor would be first removed. Then, under deep hypothermia and low CPB flow, the IVC and right atrium are opened to assess thrombus extension (Figs. 9.1 and 9.2) and to consider the patency of the hepatic veins (Fig. 9.3). The right atrium is incised parallel to the right atrioventricular sulcus. When the IVC is invaded, an en bloc resection of the infiltrated part with removal of the tumoral thrombus should be carried out, respecting carcinoid margins. In the case of preoperative Budd-Chiari syndrome, the hepatic veins are thrombectomized. Small secondary veins are ligated, and the major hepatic veins are reimplanted directly into the right atrium, using a bovine pericardial patch to offset tissue loss (Fig. 9.4), as initially described by Pasic and associates . If IVC is occluded preoperatively (confirmed by preoperative imaging and by operative findings), no vena cava reconstruction (bypass) should be performed. The IVC is usually interrupted just distal to the remaining renal veins. The venous drainage of the lower part of the body and of the renal veins will be achieved through the cavoazygos collateral system.
Longitudinal opening of right atrium and inferior vena cava allowing exposure of the thrombus and the origin of the hepatic veins
Extraction of the tumoral thrombus from the hepatic veins and the right heart, and resection of the infrahepatic inferior vena cava (IVC)
Surgical field after thrombus removal, with verification of the patency of the hepatic veins
Atriohepatic confluent reconstruction with direct anastomosis of the hepatic veins in the right atrium, using a pericardium patch
After completion of hepatic vein reconstruction and anastomosis to the right atrium, CPB normal flow can be restored and rewarming started up to a central temperature (bladder or rectal temperature) of 36.5 °C. Then CPB is stopped, cannulas removed, heparin neutralized, and careful hemostasis performed in the thoracic and abdominal cavities.
9.4 Postoperative Management
Postoperatively, patients are placed in light Trendelenburg position to improve venous drainage of the inferior part of the body after interruption of the IVC. Compression stockings can be used to avoid lower limb edema. Patients are also started on intravenous anticoagulation as soon as bleeding is controlled and then switched to oral anticoagulation for at least a year, to prevent extensive thrombosis of the iliac and lower limb venous system. A control computed tomography angiography scan is recommended before hospital discharge, to control the patency of the atriohepatic reconstruction.