Xeno-pericardial patch repair of the inferior vena cava for radical resection of renal cell carcinoma with tumor thrombus

A Predictive Model for Tumor Invasion of the Inferior Vena Cava Wall Using Multimodal Imaging in Patients with Renal Cell Carcinoma and Inferior Vena Cava Tumor Thrombus

Purpose

Developed a preoperative prediction model based on multimodality imaging to evaluate the probability of inferior vena cava (IVC) vascular wall invasion due to tumor infiltration.

Materials and Methods

We retrospectively analyzed the clinical data of 110 patients with renal cell carcinoma (RCC) with level I-IV tumor thrombus who underwent radical nephrectomy and IVC thrombectomy between January 2014 and April 2019. The patients were categorized into two groups: 86 patients were used to establish the imaging model, and the data validation was conducted in 24 patients. We measured the imaging parameters and used logistic regression to evaluate the uni- and multivariable associations of the clinical and radiographic features of IVC resection and established an image prediction model to assess the probability of IVC vascular wall invasion.

Results

In all of the patients, 46.5% (40/86) had IVC vascular wall invasion. The residual IVC blood flow (OR 0.170 [0.047-0.611]; P = 0.007), maximum coronal IVC diameter in mm (OR 1.203 [1.065-1.360]; P = 0.003), and presence of bland thrombus (OR 3.216 [0.870-11.887]; P = 0.080) were independent risk factors of IVC vascular wall invasion. We predicted vascular wall invasion if the probability was >42% as calculated by: {Ln [Pre/(1 - pre)] = 0.185 × maximum cornal IVC diameter + 1.168 × bland thrombus-1.770 × residual IVC blood flow-5.857}. To predict IVC vascular wall invasion, a rate of 76/86 (88.4%) was consistent with the actual treatment, and in the validation patients, 21/26 (80.8%) was consistent with the actual treatment.

Conclusions

Our model of multimodal imaging associated with IVC vascular wall invasion may be used for preoperative evaluation and prediction of the probability of partial or segmental IVC resection.

Inferior Vena Cava Resection and Reconstruction with Bovine Pericardium for Renal Cell Carcinoma: Complications and Outcomes

OBJECTIVES

To assess the postoperative complication rate and overall survival when bovine pericardium is used as graft material for inferior vena cava (IVC) reconstructions in patients with renal cell carcinoma (RCC). The ideal graft material is yet to be established, with synthetic grafts widely studied and used in the current literature.

METHODS

We performed a retrospective cohort analysis of consecutive patients who underwent IVC reconstructions as part of resection for RCC, using bovine pericardium as either a patch repair or tubular interposition graft.

RESULTS

A total of 15 patients underwent resection with IVC reconstruction between 2010 and 2018. Nine patients had tubular interposition grafts and 6 had patch repairs. Three patients had Clavien-Dindo grade 3 or higher short-term complications. There was no difference in Comprehensive Complications Index between those who had interposition grafts and patch repairs. Two patients had a long-term graft-associated thrombus requiring temporary anticoagulation. Overall survival was 46.5 months (95% confidence interval [CI] 36.9-56.1). There were no perioperative deaths. All long-term deaths were due to disease progression.

CONCLUSION

Reconstruction of the IVC with a bovine pericardium graft is safe in experienced centers. Bovine pericardium could be considered as the material of choice, given its safety in the immediate postoperative period, ease of use, and patency without routine long-term anticoagulation. Advanced surgical management leads to good overall survival in this cohort with high tumor burden.

Xeno-pericardial patch repair of the inferior vena cava for radical resection of renal cell carcinoma with tumor thrombus

Background and Objectives

For tumor thrombus in the inferior vena cava (IVC) complicated with kidney cancer, we built a surgical team to achieve (1) en bloc tumor resection; (2) xeno‐pericardial patch IVC repair; and (3) minimum organ damages. We reviewed outcome of the case series to verify rationale of this approach.

Methods

A consecutive series of 12 patients having the IVC tumor thrombus by renal cell carcinoma in the last 3 years was enrolled. Minimum kidney ischemia was induced in five cases (Procedure I), whereas liver and kidney ischemia was induced in five cases (Procedure II). Mild hypothermic extracorporeal circulation was used in two cases (Procedure III).

Results

There was no mortality or severe morbidities related to the surgery. Postoperative recovery was most prompt by the Procedure I. Liver and kidney ischemic time was longer in the Procedure III than the Procedure II, whereas organ function was not substantially impaired in either series. The resected IVC margin was free from the cancer in all cases, while local recurrence was not seen in any cases.

Conclusions

En bloc resection with xeno‐pericardial patch repair of the IVC was successfully performed in the tumor thrombus complicated with kidney cancer with minimum organ damage.