The Use of Natural Veno-Venous Bypass during Surgical Treatment of Renal Cell Carcinoma with Inferior Vena Cava Thrombus

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Abstract
Renal cell carcinoma associated with inferior vena cava thrombus complicates radical nephrectomy. Various approaches have been used to deal with this problem including veno-venous and cardiopulmonary bypass. Using natural veno-venous bypass may prevent the use of another type of bypass. A total of 16 patients underwent removal of renal cell carcinoma and an intracaval tumor thrombus without using veno-venous bypass. One of the natural veno-venous bypasses consisted in the mobilization of the liver off the retrohepatic inferior vena cava to allow enhanced access, vascular control, and hepatic venous drainage. The other natural bypass involved the preservation and use of collateral veins created by the longstanding obstruction of the inferior vena cava. In all 16 patients surgery was successful. Inferior vena cava clamping above and below the tumor thrombus did not result in systemic hypotension. There was no intraoperative mortality. There were no other complications. Mobilization of the liver off the retrohepatic inferior vena cava and preservation of collateral drainage (right testicular or ovarian veins and/or lumbar veins) were useful techniques in dealing with renal cell carcinoma with intracaval thrombus. These natural veno-venous bypasses allow vascular isolation of the inferior vena cava without disturbing the venous return to the heart and thereby help to prevent hemodynamic instability.