Presentation Authors: Scott Lundy*, Mohamed Eltemamy, Molly DeWitt-Foy, Ahmed Elshafei, Venkatesh Krishnamurthi, Cleveland, OH
Introduction: Renal cell carcinoma is unique in its propensity for vascular propagation via inferior vena cava (IVC) tumor thrombus. This is typically managed with radical nephrectomy and IVC thrombectomy. Caval resection and/or ligation of the IVC may be indicated in patients with large defects or significant residual bland thrombus burden with adequate collateralization. We examined our institutional experience to describe the effect of IVC ligation on perioperative outcomes and survival.
Methods: We performed a retrospective chart review of patients who underwent nephrectomy with IVC thrombectomy at a large tertiary referral institution between 1990 and 2018. Baseline demographics, perioperative details, pathology reports, and long-term follow up data were reviewed. The data was analyzed using chi-square and Fisher's exact tests, Kaplan-Meier curves, and Wilcoxon tests.
Results: 360 patients with a median age of 63 underwent nephrectomy with IVC thrombectomy were included in the analysis. 69% of these were men and 71% of tumors were right-sided. 85% of tumors in this cohort were level 2 or higher. Cavectomy was performed in 64(18%) of patients with 56% managed via primary reconstruction and 24% via graft reconstruction. The IVC was ligated in a total of 20 patients (5.5% of cohort). When comparing patients who underwent IVC ligation to those who underwent reconstruction, univariate analysis demonstrated no difference in age, gender, preoperative creatinine, thrombus level, sternotomy or cardiac bypass rate, intraoperative complication rate, postoperative transfusions, pathological margin status, or postoperative complication rates (aside from deep venous thrombosis as expected). Patients undergoing IVC ligation did, however, demonstrate lower preoperative hemoglobin (10.6 vs. 11.5, p=0.048), longer operative time (420 vs 350 min, p=0.02), higher rate of cavectomy (60% vs 40%, p < 0.0001), higher intraoperative transfusion rate (6.5 vs. 4 units, p=0.02), and higher rate of sarcomatoid features on final pathology (p=0.02). There was no difference in 30-day survival (p=0.81), 90-day survival (p=0.71), or 2-year survival (p=0.48) in patients who required IVC ligation compared to those who did not.
Conclusions: Despite a lower preoperative hemoglobin, longer operating time, and higher rate of adverse pathology, patients who underwent IVC ligation do not demonstrate worse perioperative outcomes or intermediate-term survival. This data suggests that if clinically indicated at the time of surgery, IVC ligation is safe in patients undergoing nephrectomy with IVC thrombectomy.