SESSION TITLE: Cardiothoracic Surgery Cases - Student/Resident
SESSION TYPE: Student/Resident Case Report Slide
PRESENTED ON: Sunday, October 25, 2015 at 03:15 PM - 04:15 PM
INTRODUCTION: Renal cell carcinoma invades the IVC in approximately 10% of patients with further tumor extension into the RA occurring in only 1%. Survival after tumor embolization into the PA is unusual, but successful surgical resection of RCC tumor emboli has been occasionally reported. We describe our management of large bilateral pulmonary tumor emboli after nephrectomy for RCC.
CASE PRESENTATION: A 66 year-old, previously healthy man, presented with gross hematuria. CT revealed a 4.8x4.0x4.6 cm mass in the inferior pole of the right kidney with tumor extension into the right renal vein and intrahepatic IVC. While the patient was undergoing nephrectomy two large pieces of tumor were dislodged, embolizing to the RA and RV (noted on TEE). CT surgery was consulted intraoperatively, but the fragments embolized through the right heart and could no longer be visualized. The patient remained stable, thus the surgery was completed as planned. The patient was extubated in the OR and his immediate postoperative course was uneventful. A postoperative CT scan demonstrated large bilateral tumor emboli in the distal right and left main PA. TEE estimated peak PA systolic pressure at 71 mmHg and showed a mildly enlarged RV with preserved systolic function. The large burden of tumor emboli causing severe pulmonary hypertension prompted us to return the patient to the operating room on POD#2 for PA tumor embolectomy. TEE performed after intubation revealed that the patient’s RV was now severely dilated and its contractile function was profoundly reduced. Median sternotomy was performed and the left and right PA were isolated using blunt dissection during cardiopulmonary bypass. Bilateral arteriotomies were made and the PAs were directly visualized and the tumor extracted. The patient was transferred to the ICU in a stable condition and extubated later that day. The remainder of his hospital course was unremarkable being discharged POD#7.
DISCUSSION: Embolization of RCC to the pulmonary circulation is a rare, often fatal complication (mortality of 60-75%), but successful resection of pulmonary tumor emboli have been reported using either simultaneous or staged approaches with advocates for both. In our patient we observed real-time embolism of two tumor fragments through the right heart during nephrectomy, however he remained hemodynamically stable allowing a CT and ECHO to be obtained to define anatomy and pursue a staged approach in a more elective manner.
CONCLUSIONS: This case illustrates that pulmonary embolectomy can be performed safely as a staged approach following nephrectomy for RCC. However, one must take into account the strain being put on the right heart during this waiting period as evidenced by our patient’s relatively rapid decrease in right heart function.
Reference #1: Shuch B et al. Intraoperative thrombus embolization during nephrectomy and tumor thrombectomy: critical analysis of the University of California-Los Angeles experience. J Urol 2009;181:492-9.
DISCLOSURE: The following authors have nothing to disclose: Elizabeth Colwell, Sweeta Gandhi, Zafar Iqbal, Zahir Rashid, Paul Pagel
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