Presentation Authors: Molly DeWitt-Foy*, Scott Lundy, Mohamed Eltemamy, Ahmed Elshafei, Venkatesh Krishnamurthi, Cleveland, OH
Introduction: Given the rarity and complexity of inferior vena cava (IVC) thrombi, single center series describing surgical outcomes are typically small. Alternatively, large multicenter studies may lack granularity to change management approaches. Here we present our single center experience with radical nephrectomy and IVC thrombectomy.
Methods: Retrospective chart review was conducted of all patients who underwent nephrectomy and IVC thrombectomy at a single institution between 1990 and 2018. Demographic information, laboratory results, intra- and postoperative details, and overall survival were captured from the electronic medical record (EMR). Social security death index was queried when mortality data was not available in the EMR. Descriptive statistics, chi-square and Fisher's exact tests, Kaplan-Meier curves and Wilcoxon tests were employed for data analysis.
Results: From April 1990 to July 2018 409 patients underwent nephrectomy with IVC thrombectomy, of whom 281 were men (68.7%) and 128 were women (31.3%). Average age at time of surgery was 62 years. Intraoperative thrombus level was I in 59 patients (14.4%), II in 134 patients (32.8%), III in 115 (28.15%) and IV in 101 (24.6%). Most (94%) of surgeries were performed via a chevron incision, a thoracoabdominal approach was used in 10, and a robotic approach was used in 3. The IVC was repaired primarily in the majority of cases, 6 were closed with the aid of a bovine graft, 10 with Goretex, 2 with native pericardium, and in 20 cases the IVC was managed with ligation. 131 cases were done on cardiac bypass. Mean primary tumor size was 10cm (range 1.4 to 30 cm) and 289 (71%) of tumors were right sided. On final pathology 27% were node positive and 20% had metastatic disease. Ipsilateral adrenal invasion was identified in 18% of patients. Post-operative complications occurred in 149 (36.7%) of cases and reoperation and perioperative death each occurred in < 5%. 30 day, 90 day, and 5 year mortality occurred in 6.3%, 12.0%, and 60.3% of patients, respectively. Level IV thrombus, as compared to levels I-III, conferred a higher risk of postoperative complication (55.0% v 30.4%, p < 0.0001), intraoperative complication (14.0 v 6.7%), and perioperative death (14% v 2.93%, p=0.0001).
Conclusions: Renal neoplasm with associated IVC thrombus is a complex condition with high long term and perioperative morbidity and mortality. In this large single center series, level IV thrombus was associated with higher risk of short-term complications and mortality.