The aim of surgical management of all tumors involving the IVC is complete resection of the tumor. In over half of those patients presenting with renal cell carcinoma and associated IVC tumor thrombus, the thrombus likely invades the caval wall if it is adherent to it [10]. The optimal surgical approach is dictated by the level of tumor thrombus. Midline abdominal, subcostal, or chevron incisions generally offer adequate exposure for resection and reconstruction of level I–II tumor thrombus. In cases involving level III tumor thrombus, a thoracoabdominal incision through the eighth or ninth interspace may be preferable as it allows superior exposure of the suprahepatic IVC. Cases involving level IV tumor thrombus may be approached through a midline laparotomy which can be extended to a median sternotomy to facilitate cardiopulmonary bypass. Alternatively, a thoracoabdominal incision through the sixth or seventh interspace allows sufficient exposure for cardiopulmonary bypass in the case of IV tumor thrombi. Intra-abdominal exploration is performed upon entry into the peritoneum to assess for involvement of regional lymph nodes or metastatic disease. Intraoperative ultrasonography may be a useful adjunct to assess the tumor, particularly in cases with higher-level thrombi [32]. Put simply, the operation then consists of three basic steps: renal artery ligation, thrombectomy, and nephrectomy . Ligation of the renal artery allows for retraction of the tumor thrombus and decreases bleeding from venous collaterals that have formed due to obstruction of the IVC by the thrombus [33]. Vascular isolation with thrombectomy can be performed prior to kidney mobilization to decrease the likelihood of pulmonary embolism. One study showed zero occasions of intraoperative embolism as compared to the average of 1–4% when employing this strategy [34]. Vessel loops or umbilical tapes are applied to achieve vascular control proximal and distal to the tumor. When tumor involvement is limited to the infrahepatic portion of the IVC, it is sufficient to obtain control of the renal veins, suprarenal IVC, and infrarenal IVC. When there is more extensive involvement of the IVC, additional control of the suprahepatic IVC and porta hepatis are required in order to facilitate the Pringle maneuver and achieve total hepatic vascular isolation. This necessitates mobilization of the hepatic suspensory ligaments . Obtaining control of large lumbar veins is also imperative as these may contribute to extensive back-bleeding upon creation of the IVC venotomy. Valsalva maneuvers with flushing of the inferior vena cava upon completion of the IVC reconstruction can be helpful. Systemic anticoagulation is administered in the form of intravenous heparin (100 U/kg) prior to cross-clamping of vasculature with dosing targeted to maintain an activated clotting time >250 s until venous flow is restored [2, 35].

The anesthesiology team plays an integral role in IVC resection and reconstruction. Clamping of the IVC causes a profound decrease in venous return that some patients may not be able to tolerate. Patients should be adequately resuscitated prior to IVC clamping and may require additional intravenous fluids or blood products to ensure adequate preload. Temporary occlusion of the IVC with a test clamp should be performed to assess each patient’s ability to tolerate this extreme cardiovascular change. If measures such as intravenous fluid administration, inotropic support, and Trendelenburg positioning are not adequate to facilitate successful IVC clamping, the patient will require extracorporeal support with veno-venous or cardiopulmonary bypass or temporary aortic cross-clamping. Aortic cross-clamping is not a maneuver to be utilized during extensive reconstruction as end-organ ischemia may result when clamp time exceeds 30 min [2, 36].

When IVC reconstruction is undertaken, there are several approaches that may be utilized based on the extent of resection and repair required, including primary repair, patch angioplasty, and interposition grafting [35] (Fig. 41.2). Primary repair is an acceptable choice when partial resection of the caval wall is sufficient for tumor removal, and the subsequent repair results in less than 50% narrowing of the IVC [1, 18, 19, 35, 37]. When resection is more extensive and primary repair would result in narrowing of the IVC by greater than 50%, patch angioplasty with bovine pericardium, PTFE, or Dacron patches is indicated [35]. Finally, if there is circumferential involvement of the IVC necessitating segmental vessel resection, reconstruction with interposition grafting is performed. Conduits described for interposition reconstruction include prosthetic grafts, such as polytetrafluoroethylene (PTFE) or polyester (Dacron) , or may be autogenous, such as the superficial femoral vein [15, 35, 38, 39]. Ring-reinforced PTFE is most commonly used as the external support provided by the rings prevents collapse in the low-pressure venous system and thus has superior patency and low thrombogenic potential [15, 39]. Notably, cryopreserved graft conduits have demonstrated poor outcomes with regard to graft patency in IVC reconstruction and are therefore not a recommended choice of conduit here [40]. In our experience, we use cryopreserved conduits only in cases where there is likely contamination from concomitant bowel or biliary surgery as well.

Renal vein reimplantation is sometimes necessary in patients undergoing reconstruction by interposition grafting. Ligation of the left renal vein without reimplantation is generally tolerated due to the venous collateral system of adrenal, ovarian, and lumbar veins, which empty into the hemiazygos system, whereas collateral flow is less well developed for the right renal vein. Sufficient collateral flow can be determined intraoperatively by measuring left renal vein stump pressure. A measurement of less than 40 mm Hg is considered acceptable for simple ligation of the vein [36].

IVC ligation without reconstruction is another option in patients presenting with complete chronic occlusion of the IVC. Patients presenting with chronic IVC occlusion develop an extensive venous collateral system . Proponents of this approach argue that careful dissection makes it possible to ligate the IVC entirely and preserve this collateral system with low postoperative morbidity [12, 41]. However, it is extremely difficult to preserve these collateral vessels, and they are typically interrupted during the extensive dissection involved with tumor removal, and several institutions, including our own, report significant postoperative morbidity with severe lower extremity edema when reconstruction is not performed; we therefore routinely perform IVC reconstruction following resection [2, 42].

Veno-venous bypass (VVB) is rarely necessary during IVC resection and reconstruction. The decision to use VVB is dependent on whether the patient is able to tolerate IVC clamping. If VVB is necessary, the infrarenal IVC may be cannulated directly with a 24-French angled cannula, or the femoral vein may be percutaneously cannulated with insertion of a straight cannula placed just below the IVC clamp site. The cannula is then connected to the bypass circuit, which consists of a Biomedicus perfusion pump. Venous return is accomplished by connecting it to a cordis placed into the right internal jugular (IJ) vein . VVB is then initiated and performed in a normothermic fashion with flow rates maintained at a mean arterial perfusion pressure of 60–80 mmHg. At cessation of bypass, the inflow cannula is removed with venous repair as appropriate and the outflow tubing is disconnected from the IJ cordis cannulae.

Occasionally, when the IVC tumor thrombus extends above the hepatic veins and into the right atrium, cardiopulmonary bypass (CPB) or deep hypothermic circulatory arrest (DHCA) may be necessary [43].

The use of adjunctive bypass support, including VVB, CPD, and DHCA, involves greater surgical complexity and therefore is associated with an increased rate of perioperative morbidity. While utilization of bypass support is associated with an overall increased risk of perioperative complications , its use does not have an effect on long-term outcomes or survival [2].

Following IVC reconstruction, patients are at risk for thromboembolic events and acute kidney injury or renal failure. Kidney injury occurs approximately 10% of the time and can be decreased or avoided using renal vein reimplantation strategies as described above [2]. In addition, some institutes advocate for administration of sodium bicarbonate and furosemide upon restoration of normal blood flow intraoperatively to provide added protection to the remaining kidney [44]. Preoperative anticoagulation strategies to avoid thromboembolic events were discussed previously. Thromboembolic events are also a notable complication in the postoperative period. Patients with larger tumor sizes, renal vein reimplantation, and increased administration of blood products intraoperatively are at increased risk of deep venous thrombosis (DVT), graft thrombosis, or pulmonary embolism. Reconstruction with prosthetic graft material, level of IVC thrombus, and history of venous thromboembolism (VTE) are not associated with postoperative VTE. Reports vary for incidence of DVT in the postoperative period and range from 0 to 22%, while graft thrombosis when using PTFE is 7%. Postoperative anticoagulation regimens vary greatly among institutions. At our institution 22% of patients were found to experience DVT or PE postoperatively, but only half of these were symptomatic, and there were no mortalities. We do not advocate for routine postoperative anticoagulation following IVC reconstruction [35]. Others recommend indefinite anticoagulation beginning 48 h postoperatively for those patients with incomplete tumor resection or metastatic disease, as well as those who are to receive systemic adjuvant therapy or who presented with a PE [28].

The overall survival of patients undergoing IVC resection and reconstruction differs depending on the primary malignancy resected. Median survival ranges from 14 to 37 months among all malignancies invading the IVC [45]. In renal cell carcinoma, there is much debate regarding tumor thrombus level as a predictor of overall survival. Some studies indicate tumor thrombus level is an independent factor predictive of survival [17, 34, 39, 46–48]. Others show no correlation between thrombus level and overall survival [13, 18, 23, 30, 33, 49–53]. It does appear, however, that thrombus involving the IVC at any level is associated with lower overall survival than that which involves only the renal vein [23, 33, 50].

Graft patency after reconstruction with prosthetic interposition grafts is excellent with 80–100% patency rates at 9 months to 5 years reported in several small series [54–57]. Large, multi-institutional series similarly demonstrate excellent patency rates of 95 and 92% at 1 and 5 years, respectively [58]. Graft thrombosis is associated with tumor recurrence and graft infection [54].

Portal vein (PV) and superior mesenteric vein (SMV) reconstruction due to tumor involvement may be necessary in pancreatic malignancies. Tumor invasion involving the superior mesenteric-portal vein confluence often occurs in patients with pancreatic adenocarcinoma due to the anatomical relationship of these structures posterior to the head of the pancreas, where most of these tumors arise. Most patients undergoing pancreatectomy with simultaneous PV/SMV reconstruction are those in which pathology demonstrates pancreatic ductal adenocarcinoma [59]. Between 75 and 90% of patients with pancreatic adenocarcinoma are at an advanced stage upon presentation such that surgical resection is not possible or indicated [60, 61]. Surgical resection, however, is the only curative treatment option for this disease process. Therefore, aggressive surgical management is becoming increasingly accepted as the standard of care, even in those tumors manifesting with venous infiltration.