Surgery of left kidney cancer with tumour thrombus formation in the inferior vena cava and the right heart
A 66-year-old male was admitted with the diagnosis: «Tumour of the left kidney T3bNxM0. Tumour thrombus of the left renal vein, inferior vena cava (IVC), right atrium (RA), right ventricle (RV). Subsegmental pulmonary embolism (PE).» He underwent surgical intervention: IVC, rA, RV thrombectomy. Left nephrectomy and adrenalectomy with D1 lymph node dissection. Due to extension of the thrombus into the right parts of the heart cavatomy was performed on two levels: from RA to the diaphragm, and after thrombus removal - from the level of renal veins to the left renal vein orifice. This permitted to significantly reduce the time of assisted blood circulation (AC), creation of a primary suture on IVC and blood loss at the stage of thrombectomy. Also, two-level cavatomy significantly reduces the time of hepatic ischaemia. The hepatoduodenal ligament was clamped only to perform thrombectomy in the right heart and the supradiaphragmatic segment of IVC. Nephradenectomy was performed after protamine injection, which also permitted to reduce blood loss volume during kidney removal together with paranephric body. Cardioplegia was not used, AC was performed in the parallel normothermic mode. The post-operative period was smooth. On the 3rd day the patient was transferred from the resuscitation to vascular surgery unit, discharged from hospital on the 11th day after surgery in a satisfactory state for local oncologist follow-up. The chosen tactics for this patient (two-level cavatomy and nephrectomy with adrenalectomy after protamine injection) permitted not only to reduce blood loss but also the decrease the time of hepatic ischaemia.