Presentation Authors: Kevan Iffrig, Dharam Kaushik, Hanzhang Wang, Michael Liss, Ahmed Mansour, Wasim Chowdhury, Ronald Rodriguez, Deepak Pruthi*, San Antonio, TX
Introduction: Radical nephrectomy (RN) with venous tumor thrombectomy (VTT) carries a significant morbidity and mortality risk. Closure of the inferior vena cava (IVC) can be performed with a patch/graft or can be closed primarily. We sought to examine the early outcomes of primary caval closure in this contemporary series.
Methods: We retrospectively reviewed the records of all patients who underwent RN with VTT between January 2013 and October 2017. Patients who had primary closure of the IVC were included. All patients received ASA post-operatively. Patients were followed until death or Jul 30, 2018. Chi-square test, t-test, and Fischerâ€™s exact test were employed.
Results: Sixty-four patients underwent RN with VTT, of these fifty-two people had a Mayo Clinic level II tumor thrombus or higher. Five patients were excluded due to grafts or stapling off the cava. Of the remaining 47 patients the mean age and Charlson co-morbidity score were 60 and 2.6; overall 43% had metastatic disease on presentation. Majority of cases (66%) were right sided, 70% were level 3 or higher, 40% required venovenous/cardiopulmonary bypass, and 78% of patients had clear cell RCC. At a median follow-up 16.1 months, 17% developed caval occlusion. Two patients had IVC tumor recurrence, two patients had fibrosis of their IVC, and four developed thrombosis. The mean time caval occlusion was 13.3 months. IVC tumor recurrence was a poor outcome with both patients dying shortly after diagnosis. No variable predicted caval patency. Twenty one patients (45%) died with a median time of death of 10 months. Those with caval patency were less likely to die than those who developed IVC occlusion (28% vs 75%, p=0.0178). All level 4 thrombi cases were closed primarily, however, there was occlusion in 44% of cases vs 17% for infradiaphragmatic thrombectomy cases (p=0.09).
Conclusions: Complex inferior vena cava reconstruction can be successfully avoided in most cases when managing venous tumor thrombectomy. Thrombosis occurs infrequently however, while not statistically significant, was more frequently encountered in supradiaphragmatic tumor thrombectomies.
Source of Funding: CPRIT Grant Research Training Award (RP170345)