Abstract: PD04-05
Sources of Funding: NONE

Introduction

Usually, kidney cancer with cavoatrial extension is managed with cardiopulmonary by-pass (CBP) and deep hypothermia circulatory arrest (DHCA). _x000D_ In this study, we aim to report the feasibility, safety and effectiveness of radical nephrectomy with cavoatrial thrombectomy on normothermic CPB and beating heart._x000D_

Methods

Through a laparotomic median incision, the urological equipe mobilised the colon and exposed the kidney. The renal vascular pedicle was exposed and the radical nephrectomy with adrenalectomy was performed. The right or left renal veins, that were obstructed by neoplastic thrombus (NT), were isolated. The liver was mobilized to allow the exposition of the intra and supra hepatic inferior vena cava (IVC), completely occupied by the NT. Sternotomy and pericardiothomy were performed by the heart surgery equipe. Aortic arch, superior VC and the IVC just above iliac veins were cannulated. On normothermic CBP and beating heart, right atriotomy and a “J� incision on IVC were simultaneously performed. At the same time, the heart surgeons and urologists removed the NT from the right atrium (RA) and pulmonary artery (PA), the left or right renal vein (RV) and the IVC. The IVC wall was resected only if infiltrated by the thrombus. RA and IVC were closed and the patient was weaned from CBP.

Results

We treated 8 patients (pts; range 51-74 yrs) affected by renal tumor with a NT extended from the right (3 pts) or the left (4 pts) RV to all IVC and to the RA. The diagnosis was incidental in 3 pts. One pt had a previously cardio-pulmunar by-pass. In one case the thrombus partially involved the right supra hepatic veins and the left renal vein; in other patient the thrombus jutted out a right branch of PA. Distant metastasis were detected in 3 pts. A significant coronary disease was diagnosed in 1 patient and was contemporarily resolved with CABG._x000D_ Median CPB time: 113 min (range 40-240); Surgical time: 380 min (range 360-440). Estimated blood loss 800 ml (range 300-2000). Autologous blood transfusion: 700 ml (range 500-1000)_x000D_ Intensive care stay: 4 days (range 1-7). Post operative in-hospital stay: 9,5 days (range 7-20). Post operative complications: atrial fibrillation in 1 case; anaemia in 1 case treated with blood transfusion; intestinal ischemia in 1 pt with nodal involvement of mesenteric artery and who died one day after surgery._x000D_ A post-surgical transthoracal echocadiography demonstrated regular parameters without any residual thrombus in RA and normal cardiac function in all pts. The 1-month post operative total body CT showed a regular IVC with no signs of persistent disease._x000D_ The median CSS was 23 months (range 7-38)._x000D_

Conclusions

In our experience, management of T3c kidney cancer with a beating heart normothermic CBP appears a feasible, safe and effective technique. As neither hypothermia nor heart arrest are needed, our technique improves patient recovery and reduces risks for complications. Furthermore, with cannulation of lower IVC, other vascular access for lower venous return are not necessary.

Funding

NONE