Preoperative decision-making and analysis of influence factors for inferior vena cava transection during inferior vena cava thrombectomy
Du Songliang1, 2, Huang Qingbo1, Shi Taoping1, Gu Liangyou1, Li Hongzhao1, Wang Baojun1, Shen Dan1, Peng Chen1, Liu Fengyong3, Xiong Jiang4, Ma Xin1, Zhang Xu1
1 Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing 100853, China;
2 School of Medicine, Nankai University;
3 Department of Interventional Radiology, Chinese PLA General Hospital;
4 Department of Vascular Surgery, Chinese PLA General Hospital
Abstract：Objective: To explore preoperative decision-making and influencing factors for inferior vena cava (IVC) transection during inferior vena cava thrombectomy. Methods: Eight patients with venous tumor thrombus underwent IVC transection from July 2016 to August 2017. There were 7 cases at right side and 1 case at left side. Primary tumor type was renal cell carcinoma in 7 patients and retroperitoneal malignant solitary fibrous tumor in 1. There were 7 cases of Mayo level Ⅱ and 1 case of level Ⅲ thrombus. Cases of level Ⅱ and level Ⅲ thrombus according to the "301" classification were 7 and 1, respectively. Preoperative imaging study revealed that the IVC was completely occluded in 7 cases and distal bland thrombus in 5 cases. Preoperative venography demonstrated robust collateral veins were established. For right cases with Mayo level Ⅰ-Ⅱ thrombus, the IVC was ligated and transected without reconstruction. For the cases of Mayo level Ⅲ-Ⅳ thrombus, the IVC was ligated and transected below the second porta hepatis; The IVC above the second porta hepatis was cut and then sutured after removal of the thrombus. For left cases, the IVC was ligated and transected at infra-renal vein level; the IVC above the right renal vein was cut and reconstructed after removal of the thrombus. Results: All cases were given the robotic surgery. Median operation time was 290 min. Median blood loss was 1600 mL. Median blood transfusion was 1025 mL. Median intensive care unit stay was 4 days. Median preoperative serum creatinine was 95.8 μmol/L (58.7-174.5). Median serum creatinine at 1st to 3rd month during the follow up period was 99.7 μmol/L (70.0-162.3 μmol/L). The mild transient lower extremity edema occurred in 3 patients and recovered within one month. No perioperative death occurred. Distant metastasis occurred in 4 patients postoperatively, resulting in 2 deaths. Median follow-up time was 11 months. Conclusions: IVC transection is safe and feasible during robotic venous thrombectomy. Venography is essential to ide.pngy the collateral vessels and help in preoperative decision making. According to tumor thrombus extent, primary tumor side, vena cava obstruction, venous wall invasion, establishment of collateral circulation, different strategies could be developed preoperatively.
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