IVC THROMBECTOMY: OPEN Gennady Bratslavsky, M.D. Professor and - - PowerPoint PPT Presentation

IVC THROMBECTOMY: OPEN

Gennady Bratslavsky, M.D.

Professor and Chairman

Department of Urology SUNY Upstate Medical University Syracuse, NY

Disclosures

 None  I am not an ideal candidate to argue for open IVC

thrombectomy

I have performed minimally-invasive IVC thrombectomies since 2011

 First level 3 IVC thrombectomy with robot (still the

largest one in the literature) with RPLND

 Last month I have done 2 IVC cases with a robot

Direct invasion of the IVC wall in several places requiring

complete replacement with Gor-Tex graft

T4 with liver invasion and IVC thrombus

49 year old women (350 lbs, ECOG 1)

• Patient discharged 36 hours post op
• Path: pT3b, N0, clear cell carcinoma, Grade 3
• 44 lymph nodes negative

Definitions

Suprahepatic Suprarenal Infrarenal

Levels of Tumor Thrombus

I 42% III 12% IV 5% <2 cm into IVC Suprarenal Intracardiac II 22%

Yet, I will argue for OPEN technique today

 For majority, the robotic IVC is still a VERY

selected group

 Level 1 does not count  True level 3 with Pringle and suprahepatic control is

too long and dangerous

 Level 4 is not there yet

Video at the AUA “controlled piece meal removal”

Venous involvement in RCC Patients

Incidence % Authors

Venous invasion

4-36

Skinner, 1972 Novick, 1980 Marshall, 1988 Hatcher, 1991 Pouliot, 2010

IVC extension

3-5

Kearney, 1981 Libertino, 1987

Atrial extension

0.5-1.0

Neves/ Zincke, 1987

Surgical Principles for Tumor Thrombectomy

1. Assemble experienced team

Anesthesia +/- Hepatobiliary, vascular, cardiac surgery

2. Operate on vessels first (preserve collateralized veins if IVC occluded) 3. Ligate renal artery, no need to embolize 4. Isolate venous structures 5. Completely remove thrombus 6. Manage any distal bland thrombus 7. Repair/patch/replace IVC as needed 8. Complete nephrectomy and LND

Exposure is Everything

Location of tumor Body habitus Veins to be isolated Costal flare

Choice of incision

Avoid Preoperative Embolization

 IVC VTT cases 135 with, 90 without embolization  Embolization: blood loss, complications, mortality

MVA revealed 5 fold increased risk of per operative death in patients with embolization

 Several large series against embilozation

Subramanian, Urology 2009

Right Medial Visceral Rotation to Expose Suprarenal IVC

Divide ligaments to fully mobilize liver

Retrohepatic

Tumor Thrombus: Level III Technique

Renal artery ligation Mobilize liver for suprahepatic IVC access Sequence for venous control: 1. Contralateral renal vein 2. Distal IVC, incl. 2nd lumbar vein 3. Hepatic inflow (Pringle maneuver) 4. Suprahepatic IVC (above thrombus) Remove thrombus or get it below the hepatic

veins

Occlude IVC below hepatic inflow Release suprahepatic IVC & Pringle Repair vena cava leisurely Complete nephrectomy

1 2 3 4

 Veno-veno bypass  Cardiopulmonary bypass  Cardiopulmonary bypass with hypothermic (16ºC) circulatory

arrest

 Advantages: bloodless field, ~60 minutes of ischemia time

 Hypothermic arrest is associated with longer OS and

significant reduction in perioperative mortality

 Disadvantages: need for anticoagulation and reversal

Tumor Thrombus: Level IV Technique

Inferior Vena Cava Reconstruction

 Critical to achieve complete removal of intraluminal

thrombus as well as tumor infiltrating into vein wall

 Vein wall invasion may be difficult to recognize grossly –

frozen section margins useful

 Patch preferred over graft, if possible  Infrarenal IVC resection without replacement if vein

chronically occluded

  Replacement of para- and supra-renal IVC with low

threshold to re-implant renal veins

55 y/o man with renal cell carcinoma and level IV tumor thrombus: Avoided sternotomy: Foley (level IV to level III)

Outcomes of Nephrectomy and IVC Tumor Thrombectomy (pre targeted therapy) ALL levels

Median Survival (mos.) 5-yr. DSS(%) Follow- up Author Yr n No mets Mets No mets Mets

Haferkamp

2007 111* 52 11 46 6.5 16

Karnes/Blute

2008 614**

• 55

13

• Klatte

2007 321 116 16 65 19 25

Lambert

2007 118

• 61
• 18

Sweeney

2003 96 38 20 40 28 25

Modified from Pouliot, et al. J Urol. 2010

• 162 patients
• Level 3: 69
• Level 4: 93
• Major complications: 34%
• 90 day mortality: 10.4%
• ECOG>1 and low albumin

predicted mortality

Eur Urol, 2013

Changing the paradigm:

• Prof. Vsevolod Matveev

Blokhin Cancer Center, Moscow Russia)

Conclusions

 OPEN surgery can provide durable survival and remains

preferred approach for most cases in most centers

 Meticulous attention to management of vascular anatomy

is mandatory: Vessels first approach!

 Experienced multidisciplinary teams can assure low

morbidity/mortality

 Potential for minimally invasive surgery and sternotomy-

free approach

SUNY Upstate Department of Urology