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Modified technique of cavoatrial tumor thrombectomy without cardiopulmonary by-pass and hypothermic circulatory arrest: a preliminary report.

Sobczyński R, Golabek T, Przydacz M, Wiatr T, Bukowczan J, Sadowski J, Chłosta P - Cent European J Urol (2015)

Bottom Line: None of the patients developed disease recurrence.All patients were still alive at the time of study completion.Obtained results support the validity of our own, Foley catheter assisted technique, without cardiopulmonary bypass and hypothermic circulatory arrest for the treatment of renal cell carcinoma with tumor thrombus extending into the right atrium.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiovascular Surgery and Transplantology, the John Paul II Hospital, Cracow, Poland.

ABSTRACT

Introduction: Traditionally, tumor thrombi extending into the right atrium have been managed by open surgery with sternotomy, cardiopulmonary bypass circulation and hypothermic circulatory arrest, and are associated with significant morbidity and mortality rates. Here, we evaluate the results of cavoatrial thrombectomy using our own, Foley catheter assisted-technique, obviating the need for thoracotomy, extracorporeal circulation, and/or hypothermic circulatory arrest.

Material and methods: Between June 2013 and January 2015, 4 consecutive patients underwent cavoatrial thrombectomy performed with our own, Foley catheter assisted technique, via Chevron incision, with no need for extracorporeal circulation or hypothermy for renal cell carcinoma with tumor thrombus extending into the right atrium. Analyses of patients' data from a prospectively maintained database with respect to perioperative characteristics, morbidity and mortality were performed.

Results: The total mean duration of surgery was 255 minutes. The mean time of total IVC (inferior vena cava) occlusion was 90 seconds. The average blood loss volume, timed from the beginning of cavotomy incision until its closure, was 1200 ml. The total mean intraoperative blood loss was 3,150 ml. There was no perioperative death. Postoperative complications included one transient acute kidney injury requiring one-off hemodialysis and one re-operation due to bleeding. The follow-up time ranged between 12 to 17 months. None of the patients developed disease recurrence. All patients were still alive at the time of study completion.

Conclusions: Obtained results support the validity of our own, Foley catheter assisted technique, without cardiopulmonary bypass and hypothermic circulatory arrest for the treatment of renal cell carcinoma with tumor thrombus extending into the right atrium.

No MeSH data available.


Related in: MedlinePlus

Schematic view of Foley catheter balloon-assisted cavoatrial thrombectomy. Tumor thrombus being retracted from the right atrium with inflated baloon of Foley catheter. Arrow indicates the direction of the Foley catheter and thrombus withdrawal.
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Figure 0004: Schematic view of Foley catheter balloon-assisted cavoatrial thrombectomy. Tumor thrombus being retracted from the right atrium with inflated baloon of Foley catheter. Arrow indicates the direction of the Foley catheter and thrombus withdrawal.

Mentions: Cavoatrial tumor thrombectomy was performed as described previously [9]. Briefly, after laparotomy via Chevron incision had been carried out, exposing the infra- and suprarenal (up to the level of the heart) parts of the inferior vena cava (IVC) (with liver mobilisation), as well as, both renal veins and the infrarenal aorta, the renal artery, supplying the kidney with the tumor, was ligated. In order to prevent TT fragmentation and subsequent thromboembolic complications, Rummel tourniquets were loosely placed over the infrarenal IVC, the contralateral renal vein, and the hepatic porta, while the diseased kidney was fully mobilized being attached only to the renal vein. A purse string suture was stitched over the IVC where the cavotomy was performed. Next, the intraoperative hemodynamic reserve was assessed by placing the patient in the Trendelenburg position while clamping the IVC for one minute. The aim of this maneuver was to ascertain whether blood transfusion or circulatory support would be required, which, fortunately, was not the case in any of our patients. The infrarenal IVC, the unaffected renal vein and possibly the hepatic porta (only in case of significant hemorrhage), were clamped with tourniquets. A short, 2 cm long, cavotomy incision was performed at the level of the renal vein ostium on the affected side, where a 22F Foley catheter (siliconised 2-way catheter, maximum inflatable volume of the balloon of 30 ml, Unomedical, Sdn. Bhd., Denmark) was carefully introduced and passed through, up to the right atrium under direct TOE guidance (Figures 1 and 2). As soon as the catheter reached the target position (just above the TT), the catheter balloon was inflated with approximately 15 ml of normal saline (Figure 3), and the TT was removed by slowly withdrawing the catheter (constantly adjusting balloon volume to the IVC diameter under continuous TOE guidance) allowing for en bloc TT with the tumorous kidney removal (Figure 4). The cavotomy was closed with a double-running suture (4-0 prolene). After a meticulous haemostasis was achieved, two surgical drains were left in situ (one within the renal bed and the second within the peritoneal cavity), and the laparotomy incision was closed in layers.


Modified technique of cavoatrial tumor thrombectomy without cardiopulmonary by-pass and hypothermic circulatory arrest: a preliminary report.

Sobczyński R, Golabek T, Przydacz M, Wiatr T, Bukowczan J, Sadowski J, Chłosta P - Cent European J Urol (2015)

Schematic view of Foley catheter balloon-assisted cavoatrial thrombectomy. Tumor thrombus being retracted from the right atrium with inflated baloon of Foley catheter. Arrow indicates the direction of the Foley catheter and thrombus withdrawal.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4643704&req=5

Figure 0004: Schematic view of Foley catheter balloon-assisted cavoatrial thrombectomy. Tumor thrombus being retracted from the right atrium with inflated baloon of Foley catheter. Arrow indicates the direction of the Foley catheter and thrombus withdrawal.
Mentions: Cavoatrial tumor thrombectomy was performed as described previously [9]. Briefly, after laparotomy via Chevron incision had been carried out, exposing the infra- and suprarenal (up to the level of the heart) parts of the inferior vena cava (IVC) (with liver mobilisation), as well as, both renal veins and the infrarenal aorta, the renal artery, supplying the kidney with the tumor, was ligated. In order to prevent TT fragmentation and subsequent thromboembolic complications, Rummel tourniquets were loosely placed over the infrarenal IVC, the contralateral renal vein, and the hepatic porta, while the diseased kidney was fully mobilized being attached only to the renal vein. A purse string suture was stitched over the IVC where the cavotomy was performed. Next, the intraoperative hemodynamic reserve was assessed by placing the patient in the Trendelenburg position while clamping the IVC for one minute. The aim of this maneuver was to ascertain whether blood transfusion or circulatory support would be required, which, fortunately, was not the case in any of our patients. The infrarenal IVC, the unaffected renal vein and possibly the hepatic porta (only in case of significant hemorrhage), were clamped with tourniquets. A short, 2 cm long, cavotomy incision was performed at the level of the renal vein ostium on the affected side, where a 22F Foley catheter (siliconised 2-way catheter, maximum inflatable volume of the balloon of 30 ml, Unomedical, Sdn. Bhd., Denmark) was carefully introduced and passed through, up to the right atrium under direct TOE guidance (Figures 1 and 2). As soon as the catheter reached the target position (just above the TT), the catheter balloon was inflated with approximately 15 ml of normal saline (Figure 3), and the TT was removed by slowly withdrawing the catheter (constantly adjusting balloon volume to the IVC diameter under continuous TOE guidance) allowing for en bloc TT with the tumorous kidney removal (Figure 4). The cavotomy was closed with a double-running suture (4-0 prolene). After a meticulous haemostasis was achieved, two surgical drains were left in situ (one within the renal bed and the second within the peritoneal cavity), and the laparotomy incision was closed in layers.

Bottom Line: None of the patients developed disease recurrence.All patients were still alive at the time of study completion.Obtained results support the validity of our own, Foley catheter assisted technique, without cardiopulmonary bypass and hypothermic circulatory arrest for the treatment of renal cell carcinoma with tumor thrombus extending into the right atrium.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiovascular Surgery and Transplantology, the John Paul II Hospital, Cracow, Poland.

ABSTRACT

Introduction: Traditionally, tumor thrombi extending into the right atrium have been managed by open surgery with sternotomy, cardiopulmonary bypass circulation and hypothermic circulatory arrest, and are associated with significant morbidity and mortality rates. Here, we evaluate the results of cavoatrial thrombectomy using our own, Foley catheter assisted-technique, obviating the need for thoracotomy, extracorporeal circulation, and/or hypothermic circulatory arrest.

Material and methods: Between June 2013 and January 2015, 4 consecutive patients underwent cavoatrial thrombectomy performed with our own, Foley catheter assisted technique, via Chevron incision, with no need for extracorporeal circulation or hypothermy for renal cell carcinoma with tumor thrombus extending into the right atrium. Analyses of patients' data from a prospectively maintained database with respect to perioperative characteristics, morbidity and mortality were performed.

Results: The total mean duration of surgery was 255 minutes. The mean time of total IVC (inferior vena cava) occlusion was 90 seconds. The average blood loss volume, timed from the beginning of cavotomy incision until its closure, was 1200 ml. The total mean intraoperative blood loss was 3,150 ml. There was no perioperative death. Postoperative complications included one transient acute kidney injury requiring one-off hemodialysis and one re-operation due to bleeding. The follow-up time ranged between 12 to 17 months. None of the patients developed disease recurrence. All patients were still alive at the time of study completion.

Conclusions: Obtained results support the validity of our own, Foley catheter assisted technique, without cardiopulmonary bypass and hypothermic circulatory arrest for the treatment of renal cell carcinoma with tumor thrombus extending into the right atrium.

No MeSH data available.


Related in: MedlinePlus