Resection of intrahepatic and suprahepatic inferior vena cava (IVC) thrombi associated with renal cell carcinoma (RCC) can be surgically demanding procedures that can involve multidisciplinary surgical teams.
One aspect of the procedure that is approached with trepidation is the actual removal of the vena cava tumor thrombus, which is often done as a "blind" element of the operation. Here, Lowentritt and colleagues describe a very useful surgical adjunct to vena cava thrombectomy, using a flexible cystoscope to perform venacavoscopy, to assist in ensuring complete tumor removal.
The authors report on the use of a 16fr flexible cystoscope to perform intraoperative venacavoscopy during IVC thrombus removal for intrahepatic and suprahepatic RCC thrombi in seven patients. The procedure added on average 5.6 minutes to the operative procedure. Residual tumor in the IVC was identified in 3/7 patients, which was subsequently removed through a combination of endoscopic and manual manipulation. None of the residual tumor thrombi that were identified with this technique were noted using intraoperative transesophageal echocardiography. Average blood loss for the patients in the study was 1.170 liters, which was not added to significantly by the addition of venacavoscopy. With a mean follow-up of 17.6 months, 5/7 patients are still alive after surgery.
In describing their surgical technique, the authors describe extracting the thrombus with the use of a distended foley balloon, much like a vascular Fogarty catheter. They then use Rommel tourniquets to occlude and isolate specific segments of the IVC, which allow venacavoscopy with the use of infused normal saline, without significant blood loss. Using this technique, the IVC, as well as the hepatic veins and right atrium can be inspected for evidence of retained thrombus after thrombectomy.