2024 FSA Podium and Poster Abstracts

S013: ANESTHETIC MANAGEMENT OF RENAL CELL CARCINOMA WITH STAGE IV TUMOR THROMBOSIS REQUIRING CARDIOPULMONARY BYPASS SURGERY. A CASE REPORT.
Tatsiana Kryvitskaya, MD; Padraic O'Malley, MSc, MD, FRCSC; Eric I Jeng, MD, MBA, FACS, FACC; Thiago Beduschi, MD; Albert Robinson, MD, FASA, FASE; University of Florida

Introduction: Renal cell carcinoma (RCC) is a potentially lethal cancer with aggressive behavior. It is characterized by a propensity to infiltrate the inferior vena cava (IVC) via the renal vein. IVC invasion occurs in 4% to 10% of cases, whereas about 1% to 3% of patients present with thrombus reaching the right atrium (RA). Although an aggressive surgical approach remains the primary treatment for RCC, the intraoperative anesthetic management remains a challenge. There is a paucity in the literature regarding the comprehensive management of RCC especially with RA thrombus extension. The role of transesophageal echocardiography (TEE) is important to assess cardiac morphology, pathology and provide real-time imaging for assisting the surgical team and preventing further embolization. We report the case of a patient with RCC with stage IV tumor thrombus according to the Mayo classification, who underwent surgery under cardiopulmonary bypass (CPB) with the use of TEE to assess and treat the tumor.

Method: 66-year-old, super morbidly obese male with recent pulmonary embolism (PE), lower extremity edema and presumed RCC with IVC tumor thrombus and RA extension presented for radical nephrectomy and cavoatrial thrombectomy under CPB.

Results: Anesthesia induction and maintenance were uneventful. Standard ASA monitors plus invasive blood pressure, central venous/pulmonary artery pressure, and TEE were employed. Pre-CPB TEE exam revealed good biventricular function with a large mass occupying significant part of RA (Fig.A). A multidisciplinary team was established in order to provide care for this complex surgical case. Full laparotomy with right radical nephrectomy was performed followed by IVC incision with tumor burden resection and sternotomy with CPB. After controlled intraoperative cardiac arrest was achieved, the RA was incised transversely toward the IVC and thrombus was resected in its entirety. Total CPB time was 49 minutes. Throughout the operation, continuous monitoring for PE was carried out by TEE. The patient was successfully separated from CPB. Post-CPB TEE showed no residual mass in the RA (Fig.D). The patient was transferred to the ICU on epinephrine and norepinephrine infusions. The total operative time was 7.5 hours. Postoperatively, the patient showed no neurologic dysfunction. However, the postoperative course was notable for adrenal insufficiency, prolonged intubation, pericardial effusion with tamponade requiring evacuation with pericardial window. The patient was discharged on POD39 with complete recovery and no evidence of disease recurrence in 6 months.

Discussion: RCC patients with mass extension into the IVC and RA is a rare occurrence and treatment should be considered with aggressive surgical approach under CPB. Anesthetic management of these patients presents a unique challenge and can be optimized with customized anesthetic plan. These cases require special attention to pre-operative optimization of the patient, peri-operative management of emboli, maintenance of cerebral perfusion and flexibility in response to intraoperative real-time findings. PE is a potentially catastrophic intraoperative complication that can result in right ventricular failure, shock, and mortality. Intraoperative TEE is critical and provides instantaneous information about heart function, guides mass removal and monitoring for embolic phenomenon during tumor manipulation. Furthermore, a multidisciplinary team approach and preoperative preparation positively affect patient outcomes.