Journal of Perioperative Echocardiography

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VOLUME 7 , ISSUE 1 ( January-June, 2019 ) > List of Articles


Role of Intraoperative Transesophageal Echocardiography in the Management of Renal Cell Carcinoma with Cavoatrial Extension

Ganesh K Munirathinam, Vamsi Dar

Keywords : Cardiac extension, Renal cell carcinoma, Transesophageal echocardiography

Citation Information : Munirathinam GK, Dar V. Role of Intraoperative Transesophageal Echocardiography in the Management of Renal Cell Carcinoma with Cavoatrial Extension. J Perioper Echocardiogr 2019; 7 (1):2-5.

DOI: 10.5005/jp-journals-10034-1099

License: CC BY-NC 4.0

Published Online: 31-07-2020

Copyright Statement:  Copyright © 2019; The Author(s).


In all, 4–10% of tumor thrombus in renal cell carcinoma (RCC) extends into the inferior vena cava (IVC). When the thrombus extends into the right atrium (RA), it becomes surgically challenging; and depending on its extension and adherence to the underlying structure, it may need cardiopulmonary bypass (CPB). The utility of transesophageal echocardiography (TEE) is reviewed for the management of RCC with cavoatrial extension. Intraoperative TEE is an essential modality in cases of RCC with level IV tumor thrombus, and in cases that require CPB with or without deep hypothermic circulatory arrest (DHCA). Intraoperative TEE provides us real-time information about thrombus staging in addition to the properties of the thrombus, such as adherence and fragility. Intraoperative TEE can also be used to assess cardiac function, fluid status, real-time monitoring of thrombus including embolization while manipulation and to ensure no residual thrombus. We therefore recommend the use of intraoperative TEE in RCC with level IV tumor thrombus. In the future, more research is needed to demonstrate the impact of intraoperative TEE on morbidity, mortality, and complication rate of the procedures.

  1. Siegel RL, Miller KD, Jemal A. Cancer statistics. 2015. CA Cancer J Clin 2015;65(1):5–29. DOI: 10.3322/caac.21254.
  2. Marshall VF, Middleton RG, Holswade GR, et al. Surgery for renal cell carcinoma in the vena cava. J Urol 1970;103(4):414–420. DOI: 10.1016/s0022-5347(17)61970-0.
  3. Pouliot F, Shuch B, Larochelle JC, et al. Contemporary management of renal tumors with venous tumor thrombus. J Urol 2010;184(3): 833–841. DOI: 10.1016/j.juro.2010.04.071.
  4. Abreu SC, Gill IS. Renal cell carcinoma: modern surgical approach. Curr Opin Urol 2003;13(6):439–444. DOI: 10.1097/00042307-200311000-00003.
  5. Vogt PR, Ensner R, Prêtre R, et al. Less invasive surgical treatment of renal cell carcinomas extending into the right heart and pulmonary arteries: surgery for renal cell carcinoma. J Card Surg 1999;14(5): 330–333. DOI: 10.1111/j.1540-8191.1999.tb01004.x.
  6. Blute ML, Leibovich BC, Lohse CM, et al. The mayo clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumour thrombus. BJU Int 2004;94(1):33–41. DOI: 10.1111/j.1464-410X.2004.04897.x.
  7. Neves RJ, Zincke H. Surgical treatment of renal cancer with vena cava extension. Br J Urol 1987;59(5):390–395. DOI: 10.1111/j.1464-410x.1987.tb04832.x.
  8. Dominik J, Moravek P, Zacek P, et al. Long-term survival after radical surgery for renal cell carcinoma with tumour thrombus extension into the right atrium. BJU Int 2013;111(3 Pt B):E59–E64. DOI: 10.1111/j.1464-410X.2012.11515.x.
  9. Novick AC, Kaye MC, Cosgrove DM, et al. Experience with cardiopulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi. Ann Surg 1990;212(4):472–476. DOI: 10.1097/00000658-199010000-00010.
  10. Shuch B, Larochelle JC, Onyia T, et al. Intraoperative thrombus embolization during nephrectomy and tumor thrombectomy: critical analysis of the University of California-Los Angeles experience. J Urol 2009;181(2):492–498. DOI: 10.1016/j.juro.2008.10.036.
  11. Raj V, Alpendurada F, Christmas T, et al. Cardiovascular magnetic resonance imaging in assessment of intracaval and intracardiac extension of renal cell carcinoma. J Thorac Cardiovasc Surg 2012;144(4):845–851. DOI: 10.1016/j.jtcvs.2011.11.035.
  12. Kandpal H, Sharma R, Gamangatti S, et al. Imaging the inferior vena cava: a road less traveled. Radiographics 2008;28(3):669–689. DOI: 10.1148/rg.283075101.
  13. Lawrentschuk N, Gani J, Riordan R, et al. Multidetector computed tomography vs magnetic resonance imaging for defining the upper limit of tumour thrombus in renal cell carcinoma: A study and review. BJU Int 2005;96(3):291–295. DOI: 10.1111/j.1464-410X.2005.05617.x.
  14. Woodruff DY, Van Veldhuizen P, Muehlebach G, et al. The perioperative management of an inferior vena caval tumor thrombus in patients with renal cell carcinoma. Urol Oncol 2013;31(5):517–521. DOI: 10.1016/j.urolonc.2011.03.006.
  15. Blute ML, Boorjian SA, Leibovich BC, et al. Results of inferior vena caval interruption by greenfield filter, ligation or resection during radical nephrectomy and tumor thrombectomy. J Urol 2007;178(2):440–445. DOI: 10.1016/j.juro.2007.03.121.
  16. OIkawa T, Shimazui T, Johraku A, et al. Intraoperative transesophageal echocardiography for inferior vena caval tumor thrombus in renal cell carcinoma. Int J Urol 2004;11(4):189–192. DOI: 10.1111/j.1442-2042.2003.00780.x.
  17. Glazer A, Novick AC. Preoperative transesophageal echocardiography for assessment of vena caval tumor thrombi: a comparative study with venacavography and magnetic resonance imaging. Urology 1997;49(1):32–34. DOI: 10.1016/S0090-4295(96)00374-3.
  18. Sigman DB, Hasnain JU, Del Pizzo JJ, et al. Real-time transesophageal echocardiography for intraoperative surveillance of patients with renal cell carcinoma and vena caval extension undergoing radical nephrectomy. J Urol 1999;161(1):36–38. DOI: 10.1016/S0022-5347(01)62054-8.
  19. Wax DB, Torres A, Scher C, et al. Transesophageal echocardiography utilization in high-volume liver transplantation centers in the United States. J Cardiothorac Vasc Anesth 2008;22(6):811–813. DOI: 10.1053/j.jvca.2008.07.007.
  20. Shine T, Feinglass NG, Leone BJ, et al. Transesophageal echocardiography for detection of propagating, massive emboli during prosthetic hip fracture surgery. Iowa Orthop J 2010;30:211–214.
  21. Walker P, Bali K, Van der Wall H, et al. Evaluation of echogenic emboli during total knee arthroplasty using transthoracic echocardiography. Knee Surg Sports Traumatol Arthrosc 2012;20(12):2480–2486. DOI: 10.1007/s00167-012-1927-4.
  22. Feigl GC, Decker K, Wurms M, et al. Neurosurgical procedures in the semisitting position: evaluation of the risk of paradoxical venous air embolism in patients with a patent foramen ovale. World Neurosurg 2014;81(1):159–164. DOI: 10.1016/j.wneu.2013.01.003.
  23. Porter TR, Shillcutt SK, Adams MS, et al. Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: a report from the American society of echocardiography. J Am Soc Echocardiogr 2015;28(1):40–56. DOI: 10.1016/j.echo.2014.09.009.
  24. Fukazawa K, Gologorsky E, Naguit K, et al. Invasive renal cell carcinoma with inferior vena cava tumor thrombus: Cardiac anesthesia in liver transplant settings. J Cardiothorac Vasc Anesth 2014;28(3):640–646. DOI: 10.1053/j.jvca.2013.04.002.
  25. Spelde A, Steinberg T, Patel PA, et al. Successful team-based management of renal cell carcinoma with caval extension of tumor thrombus above the diaphragm. J Cardiothorac Vasc Anesth 2017;31(5):1883–1893. DOI: 10.1053/j.jvca.2017.02.036.
  26. Parissis H, Young V. A stepwise algorithm for the surgical resection of a hyper-nephroma involving the inferior vena cava. Hellenic J Cardiol 2011;52(3):204–210.
  27. Gerstein NS, Zhang R, Davis MS, et al. Lessons still being learned: acute pulmonary tumor embolus during renal cell carcinoma resection. A & A Case Rep 2016;7(8):172–176. DOI: 10.1213/XAA.0000000000000378.
  28. Ciancio G, Gonzàlez J, Shirodkar SP, et al. Liver transplantation techniques for the surgical management of renal cell carcinoma with tumor thrombus in the inferior vena cava: step-by-step description. Eur Urol 2011;59(3):401–406. DOI: 10.1016/j.eururo.2010.07.028.
  29. Nesbitt JC, Soltero ER, Dinney CPN, et al. Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus. Ann Thorac Surg 1997;63(6):1592–1600. DOI: 10.1016/s0003-4975(97)00329-9.
  30. Schimmer C, Hillig F, Riedmiller H, et al. Surgical treatment of renal cell carcinoma with intravascular extension. Interact Cardiovasc Thorac Surg 2004;3(2):395–397. DOI: 10.1016/j.icvts.2004.02.014.
  31. Ciccone MM, Cortese F, Corbo F, et al. Bemiparin, an effective and safe low molecular weight heparin: a review. Vascul Pharmacol 2014;62(1):32–37. DOI: 10.1016/j.vph.2014.03.001.
  32. Sharma V, Cusimano RJ, McNama P, et al. Intraoperative migration of an inferior vena cava tumour detected by transesophageal echocardiography. Can J Anesth 2011;58(5):468–470. DOI: 10.1007/s12630-011-9480-z.
  33. Martinelli SM, Mitchell JD, McCann RL, et al. Intraoperative transesophagealechocardiography diagnosis of residual tumor fragment after surgical removal of renal cell carcinoma. Anest Analg 2008;106(6):1633–1635. DOI: 10.1213/ane.0b013e3181734147.
  34. Colwell EM, Gandhi SD, Iqbal Z, et al. Use of multimodal imaging in the management of tumor embolism from the inferior vena cava through the right heart in a patient with renal cell carcinoma. J Cardiothorac Vasc Anesth 2014;28(5):1421–1424. DOI: 10.1053/j.jvca.2014. 04.033.
  35. Negi SL, Dutta V, Puri GD. Role of transesophageal echocardiography in detection of residual tumor in renal cell carcinoma extending in to right atrium. J Perioperat Echocardiog 2015;3(1):35–38. DOI: 10.5005/jp-journals-10034-1034.
  36. Chen H, Ng V, Kane CJ, et al. The role of transesophageal echocardiography in rapid diagnosis and treatment of migratory tumor embolus. Anest Analg 2004;99(2):357–359. DOI: 10.1213/01.ANE.0000133001.42742.49.
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