Resection of inferior vena cava carcinoma with vena cava filter protection for renal cancer
Feng Xiang1 Jing Zaiping1 Hou Jianguo2 Gao Xu2
In patients with renal cancer combined with inferior vena cava thrombosis, resection of the inferior vena cava thrombosis along with radical resection of renal cancer can still result in a good prognosis, but unfortunately many patients give up surgical treatment due to the high risk of surgery. The main intraoperative risk comes from pulmonary embolism caused by dislodgement of the cancer embolus due to compression of the inferior vena cava during tumor separation, which is usually fatal. Since 2006, the author has used Tempofilter II inferior vena cava temporary filter to protect the inferior vena cava cancer thrombectomy for kidney cancer, and achieved good treatment results, the surgical method and results are reported as follows: Feng Xiang, Department of Vascular Surgery, Shanghai Changhai Hospital
1 Data and methods
1.1 Clinical data From October 2006 to May 2008, a total of 8 cases of Tempofilter II inferior vena cava cancer thrombectomy under the protection of temporary inferior vena cava filter were performed, including 7 cases of renal cell carcinoma and 1 case of nephroblastoma. The clinical data of all patients are shown in Table 1. No distant metastasis was found in the preoperative examination. The main clinical manifestations of the patients were painless hematuria or lumbar pain, and the right lumbar mass could be palpated on physical examination. 4 cases had bilateral lower limb edema in their medical history, but the lower limb edema had subsided at the time of admission, 1 case had left spermatic varices on physical examination, and 2 cases had dilated superficial veins in the abdominal wall. Table 1.
Table 1. Clinical data of patients
Serial number
Sex
Age (years)
Preoperative diagnosis
Maximum diameter of tumor (cm)
Inferior vena cava cancer thrombus site
Distance between proximal end of cancer thrombus and right atrium (cm)
1
Female
43
right kidney cancer
8.5
intrahepatic segment
3.0
2
Male
47
Right kidney cancer
9.0
Intrahepatic segment
2.5
3
Female
37
Right kidney cancer
10.5
intrahepatic segment
2.5
4
Male
7
Right nephroblastoma
10.0
Intrahepatic segment
2.0
5
male
55
right kidney cancer
11.0
Intrahepatic segment
2.5
6
Female
42
Right kidney cancer
7.5
Lower hepatic segment
6.0
7
Female
72
Right kidney cancer
13.0
intrahepatic segment
2.0
8
Male
49
Right kidney cancer
9.0
Lower hepatic segment
6.0
1.2 Inferior vena cava carcinoma thrombus typing[1] Clinically, based on the anatomical position of the proximal end of the carcinoma thrombus in the inferior vena cava, the inferior vena cava carcinoma thrombus can be divided into 4 types: (1) renal vein type (type I): the carcinoma thrombus is not more than 2 cm above the opening of the renal vein; (2) subhepatic type (type II): the carcinoma thrombus is more than 2 cm from the opening of the renal vein but does not exceed the level of the hepatic portal; (3) intrahepatic type (type III): the carcinoma thrombus exceeds the level of the hepatic portal but is below the diaphragm; (4) supraphrenic type (type IV): the carcinoma thrombus exceeds the level of the diaphragm and can reach the right atrium. (3) intrahepatic type (type III): the cancer thrombus exceeded the level of the hepatic portal but was below the diaphragm; (4) supra-diaphragmatic type (type IV): the cancer thrombus exceeded the level of the diaphragm and could reach the right atrium. Among the 8 cases in this group, there were 2 cases of type II (case 6 and case 8) and 6 cases of type III.
1.3 Temporary inferior vena cava filter implantation method The temporary inferior vena cava filter Tempofilter II from Beltran was used in all 8 patients. The filters were implanted 1 day before surgery or on the morning of the day of surgery. The implantation was done in the DSA room with the patient lying flat on the DSA examination table, with the head tilted to the left, and the right internal jugular vein was punctured under local anesthesia, and a 5F pigtail catheter was introduced to the proximal end of the cancer thrombus in the inferior vena cava. If the guidewire passed smoothly through the gap between the cancer thrombus and the wall of inferior vena cava into the inferior segment of inferior vena cava, the lateral hole catheter at the 5F end was exchanged and the image was taken again to fully understand the location and morphology of the cancer thrombus. After marking the location of the cancer thrombus, the dilator and delivery sheath of Tempofilter II temporary inferior vena cava filter are introduced along the guidewire, and the dilator is withdrawn and the filter is released, and the olive head of the delivery rod is fixed under the skin of the neck.
1.4 Cancer embolus resection method In all 8 patients, general anesthesia was used, and an incision was made in the middle of the upper abdomen or through the right rectus abdominis muscle. After entering the abdominal cavity, the hepatic colonic ligament and the lateral peritoneum were incised to push the colon and its ligament to the midline, and the duodenum was reversed to the left by the Kocher maneuver to expose the ventral side of the kidney and the front of the vena cava.
Patients with type III carcinoma embolism first kidney tumor until only the right renal vein is connected with the inferior vena cava, free the free inferior hepatic vena cava, inferior renal vena cava, left renal vein, then pull down the hepatic round ligament, free the hepatic lianic ligament and left triangular ligament, reverse the left lobe of the liver to the right side, free the posterior inferior hepatic vena cava about 2 cm under the diaphragm, at this time the implanted filter can be palpated in the posterior hepatic vena cava, free the hepatic duodenal ligament. The left renal vein, inferior renal vena cava, posterior inferior hepatic vein and hepatoportal were blocked in turn, the inferior hepatic vena cava was incised longitudinally, the cancer embolus and right renal tumor were removed under direct vision, the inferior vena cava was flushed with heparin saline, and the filter was probed with fingers for no residual cancer embolus, the inferior vena cava was closed with CV-5 suture, and the blocking band of the hepatoportal was released first, then the left renal vein, inferior renal vena cava and inferior hepatic vena cava blocking forceps were released in turn. After closing the abdomen, the filter was removed directly through the right internal jugular vein without further imaging.
In type II cancer embolus, the implanted inferior vena cava filter can be palpated under the liver when the inferior vena cava is explored, and the inferior hepatic vena cava, inferior renal vena cava and left renal vein are freed. When the renal tumor is freed until only the renal vein is connected to the inferior vena cava, each vein is blocked in turn in the above order, the inferior hepatic vena cava is incised under direct vision, the cancer embolus is removed along with the right renal tumor, the inferior vena cava is flushed with heparin saline, and the CV-5 suture is closed The inferior vena cava was flushed with heparin saline, and the inferior vena cava was closed with CV-5 suture.
2 Results
All 8 procedures were successful and no intraoperative pulmonary embolism occurred.
The proximal end of the cancer embolus in the inferior vena cava was 2.0-6.0 cm away from the right atrial opening, 6 cases of type III and 2 cases of type II, which was consistent with the preoperative CT results.
In seven cases, the cancer thrombus was not obviously adherent to the wall of inferior vena cava and the whole thrombus was removed. In one case (case 7), the cancer thrombus was densely adherent to the wall of inferior vena cava and the opening of the right renal vein of inferior vena cava was infiltrated by tumor.
In the six cases of type III, the intraoperative hepatic portal block time was 10-17 minutes, and there was no significant change in postoperative liver function. The systolic blood pressure decreased by 20-40 mmHg during posthepatic inferior vena cava block, and all 6 cases underwent abdominal aortic block. There was no significant fluctuation in blood pressure during intraoperative infrahepatic inferior vena cava block in two cases of type II.
Tempofilter II temporary inferior vena cava filter implantation time ranged from 0.5 to 1.0 h, operative time ranged from 2.0 to 3.5 h, intraoperative blood transfusion ranged from 800 to 4000 ml, and postoperative hospital stay ranged from 12 to 17 d, with an average of 14 d. There were no surgical complications or perioperative deaths.
3 DISCUSSION
Renal cell carcinoma is a common malignant tumor in the urological system, and about 4%-10% of the patients with renal cancer can develop renal vein and inferior vena cava tumor in the same period. In 1972, Skinner et al. reported a 5-year survival rate of 55% for radical kidney cancer surgery with complete removal of the thrombus [2]. It is now generally accepted that if no local or distant metastases are found, the prognosis is still good with radical resection of renal cancer along with resection of renal vein cancer thrombus and removal of inferior vena cava cancer thrombus [3].
The most critical issue in surgery is to prevent pulmonary embolism caused by dislodgement of the cancer thrombus due to compression of the inferior vena cava during tumor freeing. In the available literature, intraoperative control of the proximal inferior vena cava or extracorporeal circulation and deep hypothermic stopping circulation have been used to prevent cancer thrombus dislodgement [4,5]. The choice of specific surgical approach depends on the level of cancer thrombus extension into the inferior vena cava and whether there is invasion of the inferior vena cava wall. For type IV (suprahepatic) inferior vena cava thrombus, it is generally accepted that extracorporeal circulation (with or without deep hypothermic stopping circulation) is the safest and most effective method to remove the thrombus. type I (renal vein type) and type II (infrahepatic type), due to the low location of the thrombus, standard radical nephrectomy and infrahepatic inferior vena cava block are used, but intraoperative freeing of the larger tumor cannot avoid moving the tumor and compressing the inferior vena cava. Dislodgement of the cancer thrombus cannot be completely avoided. For type III (intrahepatic) inferior vena cava thrombosis, some scholars advocate surgery in extracorporeal circulation, which has the advantage that the surgeon can remove the thrombus comfortably in a bloodless environment and can carefully observe it to prevent part of the thrombus from adhering to the vessel wall and not being removed, and the procedure is safe [6]. However, coagulation dysfunction, local ischemic injury, and neurological sequelae may occur after extracorporeal circulation and deep cryopause circulation. Therefore, some scholars also advocate intraoperative blockade of the inferior vena cava behind the subdiaphragmatic liver to prevent dislodgement of the cancer embolus and to effectively control bleeding without establishing extracorporeal circulation [7]. This makes it impossible to avoid moving the liver and squeezing the cancer thrombus in the inferior vena cava of the intrahepatic segment when freeing the posterior hepatic inferior vena cava.
Therefore, if a protective device that prevents dislodgement of the cancer thrombus in the proximal end of the inferior vena cava is placed before freeing the tumor, there is no need to worry about dislodgement of the cancer thrombus during intraoperative freeing of the tumor, and the inferior vena cava filter capture used to prevent dislodgement of deep vein thrombus can be used exactly to capture the cancer thrombus in the inferior vena cava that is larger than the volume of the inferior deep vein thrombus. However, unlike the prevention of lower extremity DVT dislodgement, the filter for the prevention of cancer thrombus dislodgement has the following requirements: 1) the filter can be easily removed after surgery to avoid patients taking anticoagulant drugs for a long time after surgery; 2) the filter can be properly fixed in the limited space from the proximal end of the cancer thrombus to the right atrium opening to prevent the filter from dislodging into the right atrium. Among the existing tethered vena cava filters, the Tempofilter II temporary inferior vena cava filter can meet this requirement. This filter can be implanted through the right internal jugular vein and fixed to the inferior vena cava by a delivery rod. As long as the proximal end of the cancer embolus is more than 2 cm away from the right atrial opening, the filter can be fixed securely.
Because the Tempofilter II temporary inferior vena cava filter requires at least 2 cm of inferior vena cava fixation, this method can be used for types I, II, and III but not for type IV cancer emboli.
Another problem in inferior vena cava thrombectomy is the control of bleeding, for type I and II cancer thrombosis inferior vena cava control is easier, while for type III cancer thrombosis our group used the whole liver blood flow block method, due to the opening of a large number of lateral branches of lumbar vein, there is still more bleeding during the operation, the most bleeding is 4000 ml of blood transfusion during the operation, the longest time of hepatic portal block is 17 minutes, and the postoperative liver function is not significantly affected. However, the patient’s blood pressure fluctuated greatly during the block of the posterior inferior hepatic vena cava, so the anesthesiologist is needed to cooperate with the rapid expansion via the upper limb vein before the block, and if the blood pressure is still unstable, the assistant can be instructed to press the abdominal aorta toward the spine in the plane of the renal artery, which can make the blood pressure rise significantly.