Decision making and strategies in inferior vena cava transection during robotic venous thrombectomy: a feasibility study based on venography
To introduce our experience on inferior vena cava (IVC) transection during robotic venous thrombectomy.
Nine patients underwent IVC transection from July 2016 to September 2017. Primary tumor type was renal cell carcinoma in 8 patients and retroperitoneal malignancy in 1. Venography was performed both preoperatively and postoperatively. Indications for IVC transection include complete IVC occlusion, venous wall invasion, dense adherence of the tumor to the endothelium, the presence of bland thrombus in distal IVC and establishment of potent collateral circulation. Intraoperative ultrasound was used to identify the thrombus limit and major collateral vessels. For right cases with Mayo level 1 - 2 thrombus, the caudal IVC, left renal vein, and cephalic IVC was ligated and transected with Endo-GIA. The tumor and IVC, which included the thrombus, were en bloc resected. In cases of Mayo level 3 - 4 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.
There were 8 right cases and 1 left case. Median blood loss was 1700ml. Median blood transfusion was 1000ml. Median intensive care unit stay was 4d. Median preoperative serum creatinine was 94.9µmol/L. Median serum creatinine at 1 to 3-month follow up was 102.7µmol/L. Four patients occurred mild transient lower extremity edema and recovered within one month. No severe hemodynamic disorder was observed. Distant metastasis occurred in 3 patients postoperatively, resulting in 2 deaths. One died from hepatic metastasis 5.5 months after surgery and the other died from multiple organ metastasis. Median follow-up time was 5 months.
IVC transection is safe and feasible during robotic venous thrombectomy. Venography is essential to identify the collateral vessels and helping 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.