1905 INTRAPERICARDIAL CONTROL DURING INFERIOR VENA CAVAL THROMBECTOMY WITHOUT CARDIOPULMONARY BYPASS

Vol. 189, No. 4S, Supplement, Tuesday, May 7, 2013

1905 INTRAPERICARDIAL CONTROL DURING INFERIOR VENA CAVAL THROMBECTOMY WITHOUT CARDIOPULMONARY BYPASS Mukul Patil*, Jeremy Montez, Jeffrey Loh-Doyle, Los Angeles, CA; Eila Skinner, Stanford, CA; Donald Skinner, Anne Schuckman, Siamak Daneshmand, Los Angeles, CA INTRODUCTION AND OBJECTIVES: Inferior vena cava (IVC) tumor thrombectomy is an advanced procedure requiring experienced urologic & anesthesia teams due to complex hemodynamic considerations. Cardiopulmonary bypass is often used by a second surgical team, but introduces additional risk. Control of the IVC within the pericardium obviates the need for CP bypass for intrahepatic (Level II), supradiaphragmatic (Level III) & selected intra-atrial (Level IV) cases. We present our experience with intrapericardial control during IVC tumor thrombectomy. METHODS: From 1978 to 2012, 101 patients underwent extirpative surgery with intrapericardial IVC control. This technique was performed in all cases of Level II (n⫽38) and III (n⫽37) thrombi, and in select cases of Level I (infrahepatic, n⫽7) & Level IV (n⫽17). Surgical approach was through a right thoracoabdominal incision, allowing access to the pleural cavity & pericardium. Intrapericardial control was obtained with a Rumel tourniquet with test occlusion to confirm hemodynamic stability. Splanchnic arteries, contralateral renal vein, and infrarenal IVC were controlled prior to occlusion of the porta hepatis. IVC tumor thrombectomy was then completed, followed by additional procedures when indicated (ie, IVC resection/partial interruption, filter placement, cavoscopy). RESULTS: Of 101 patients, 98 underwent successful extirpation (97%). Intraoperative mortality occurred in three patients (massive pulmonary embolism, n⫽2, uncontrollable hemorrhage, n⫽1). Median Pringle maneuver time was 14 min (3-30). Additional procedures included IVC resection or partial interruption (n⫽41), IVC filter placement (n⫽9) and vena cavoscopy (n⫽16). Cavoscopy permitted visualization of residual tumor thrombus in 3 patients. Median length ventilator dependence was 1 day, median ICU stay was 5 days, and median length of stay was 11 days. Pathology revealed renal cell carcinoma (n⫽92), adrenocortical carcinoma (n⫽1), urothelial carcinoma (n⫽1), and nephroblastoma (n⫽1). Extensive lymphadenectomy was performed in 96 patients, revealing nodal metastasis in 35 patients (38%). Thirty-two patients with RCC were alive at an average of 35.7 months after surgery (0.3-198). Of those deceased, mean overall survival after surgery was 24.2 months (0.03-117). CONCLUSIONS: Intrapericardial control of the IVC allows a single surgical team to safely perform tumor thrombectomy for intrahepatic and supradiaphragmatic thrombi. This approach obviates the need for cardiopulmonary bypass and eliminates associated morbidity. Source of Funding: None

1906 PREOPERATIVE PULMONARY EMBOLISM DOES NOT PREDICT POOR POSTSURGICAL OUTCOMES IN RCC PATIENTS WITH VENOUS THROMBUS E. Jason Abel*, Madison, WI; Christopher G. Wood, Houston, TX; Nathan Eickstaedt, Madison, WI; Justin E. Fang, Patrick Kenney, Houston, TX; Aditya Bagrodia, Daniel Ramirez, Bishoy A. Gayed, Dallas, TX; Tracy M. Downs, Madison, WI; Ramy F Youssef, Christopher Odom, Arthur Sagalowsky, Vitaly Margulis, Dallas, TX INTRODUCTION AND OBJECTIVES: Renal cell carcinoma (RCC) patients who present with pulmonary embolism (PE) and venous thrombus may not be offered surgery because of concerns with anticoagulation and presumed poor post-surgical outcomes. The objective of this study was to evaluate post- surgical recurrence and cancer specific survival in RCC patients with venous thrombus who had PE diagnosed at initial presentation. METHODS: After IRB approval, we reviewed the records from 2000-2011 at 3 tertiary hospitals (UW, UTMDACC, UTSW) for all

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consecutive RCC patients who had nephrectomy with thrombectomy. Clinical and pathologic predictive factors for recurrence and survival were collected for each patient. Univariate and multivariate analysis was used to evaluate whether PE at presentation was associated with RCC recurrence or survival after nephrectomy with thrombectomy. RESULTS: Preoperative PE was diagnosed in 35/782 (4.4%) RCC patients undergoing nephrectomy with thrombectomy with a median follow-up time of 22 months. Patients with PE at initial diagnosis were more likely to have higher level thrombus (p⬍0.01) but no differences were found between groups for age, gender, race, tumor diameter, Fuhrman grade, sarcomatoid de-differentiation, peri-nephric fat invasion or histologic subtype. In N0M0 patients, there was no difference (p⫽0.36) in the rate of RCC recurrence for 395/782(50%) or 7/17(41%) patients without PE or with PE respectively. On multivariate analysis, peri-nephric fat invasion, Fuhrman grade, and thrombus height, but not preoperative PE status, were predictive of recurrence risk. Similarly, there was no difference in the rates of lung metastases for 67/123 (53%) N0M0 patients without PE or 3/7 (43%) patients with PE (p⫽0.71). Preoperative PE diagnosis was not predictive of death from RCC (p⫽0.58). On multivariate analysis, presence of metastatic disease, peri-nephric fat invasion, sarcomatoid de-differentiation, Fuhrman grade 4, and tumor diameter were independently predictive of risk of death from RCC. CONCLUSIONS: PE at initial diagnosis is not associated with worse post-surgical recurrence or survival in RCC patients with tumor thrombus.

Source of Funding: None