RENAL CELL CARCINOMA INVADING THE INFERIOR VENACAVA: USE OF A “TEMPORARY” VENA CAVA FILTER TO

PREVENT TUMOR EMBOLI DURING NEPHRECTOMY

ERIC WELLONS, DAVID ROSENTHAL, THOMAS SCHOBORG, FREDRICK SHULER, AND

ADAM LEVITT

ABSTRACTRenal cell carcinoma with tumor thrombus extension into the inferior vena cava (IVC) remains a difficultoperative challenge. Placement of a suprarenal “temporary” IVC filter, with its ease of insertion and removal,makes it the ideal treatment to prevent pulmonary embolism in these difficult cases. We report the first 2cases of temporary suprarenal IVC filters placed at the time of radical nephrectomy to eliminate thepossibility of perioperative pulmonary embolus and avoid the potential long-term sequelae of a permanentsuprarenal IVC filter. UROLOGY 63: 380xiii–380xv, 2004. © 2004 Elsevier Inc.

One of the most challenging presentations ofrenal cell carcinoma is tumor thrombus ex-

tension into the inferior vena cava (IVC), whichhas been reported to occur in 4% to 25% of pa-tients.1–4 Despite tumor invasion of the IVC, anaggressive surgical approach for these neoplasms isrecommended, because survival approaches 30%to 72% at 5 years of follow-up.5–8 Prevention of atumor thrombus pulmonary embolus during sur-gery is a major concern, and placement of a supra-renal IVC filter has been advocated.9 Hypercoagu-lable cancer patients, however, are at an increasedrisk of developing recurrent renal vein or IVCthrombosis around a permanent IVC filter, whichmay result in profound lower extremity edema andrenal failure. Placement of a temporary suprarenalIVC filter using a jugular vein approach with itsease of insertion, retrieval, and minimal morbiditymakes it a simple and safe adjunctive procedure,allowing for immediate and perioperative pulmo-nary embolus protection without the potentiallong-term complications of a suprarenal IVC filter.

CASE REPORTS

CASE 1A 44-year-old woman presented with acute onset

of shortness of breath after a long plane flight. Thepatient was admitted and administered heparinwith a presumptive diagnosis of pulmonary embo-lus despite a negative lower extremity duplex. Aventilation-perfusion lung scan was consistentwith the diagnosis of pulmonary embolus. The pa-tient developed hematuria while receiving heparin;diagnostic magnetic resonance imaging revealedan 8-cm, left lower pole renal tumor with exten-sion of tumor thrombus into the left renal vein andIVC. An extensive metastatic workup was negative.

On diagnosis of the tumor thrombus pulmonaryembolus, a superior venacavograph was performedthat identified the level of the tumor thrombus ex-tension. A Gunther Tulip Vena Cava MReye Filter(Cook Group, Bloomington, Ind) was uneventfullydeployed above the thrombus. The left renal arterywas coil embolized immediately before surgery.Through a bilateral subcostal approach, the leftkidney was exposed, the renal artery divided, andthe suprarenal vena cava clamped below the IVCfilter, yet above the tumor thrombus. Vena-cavotomy at the level of the left renal vein allowedthe removal of a 4-cm tumor thrombus. Radicalnephrectomy was completed without complica-tions, and the patient was administered low-molec-ular-weight heparin until discharge. The patient’spostoperative course was uneventful.

From the Department of Vascular Surgery, Atlanta Medical Cen-ter, Atlanta, Georgia

Address for correspondence: Eric Wellons, M.D., Departmentof Vascular Surgery, Atlanta Medical Center, 315 BoulevardNortheast, Suite 412, Atlanta, GA 30312

Submitted: July 16, 2003, accepted (with revisions): October 2,2003

CASE REPORT

© 2004 ELSEVIER INC. 0090-4295/04/$30.00ALL RIGHTS RESERVED doi:10.1016/j.urology.2003.10.010 380xiii

Two weeks after surgery, outpatient, uncompli-cated retrieval of the temporary IVC filter using atransjugular approach was performed.

CASE 2A morbidly obese, 49-year-old woman with

progressive symptoms of malaise, left-sided ab-dominal pain, and malignant hypertension wasevaluated for acute onset of shortness of breath.Her color-flow Doppler ultrasound of the lowerextremity veins was negative. Helical computed to-mography demonstrated multiple left pulmonaryemboli, a 10-cm left renal mass with extension oftumor thrombus into the vena cava, and possiblemetastatic foci in the liver. She was treated withheparin and transferred to our facility. On admis-sion, diagnostic venacavography from the femoralapproach identified the renal veins and tumorthrombus (Fig. 1). An OptEase Vena Cava Filter(Cordis, Miami Lakes, Fla) was placed in the su-prarenal position, allowing room to clamp the venacava above the tumor thrombus during surgery.The left renal artery was coil embolized on the dayof surgery, and the nephrectomy was performedusing a flank incision. The patient tolerated theprocedure well and was discharged on postopera-tive day 4. During the immediate postoperative pe-riod, the patient was administered low-molecular-weight heparin.

Two weeks after implantation, the OptEase filterwas removed using a right femoral approach(Fig. 2). She was undergoing chemotherapy andremained well 6 months after surgery.

In both patients, the need for a suprarenal IVCfilter was explained before insertion. Furthermore,it was emphasized that the need existed only untilthe tumor thrombus had been excised. With this inmind, the option for removal was proposed. Thatthis is not a Food and Drug Administration-ap-

proved indication was explained, and both patientsdecided to have the filters removed.

COMMENT

Up to 25% of patients undergoing radical ne-phrectomy for renal cell carcinoma will have vas-cular invasion of the IVC.1–4 Reports of tumor em-boli during mobilization of the renal vein, venacava, or kidney are anecdotal but, when they occur,are catastrophic. Many methods of suprarenal IVCcontrol have been used, including suprarenal IVCclips, vascular clamping guided by transesophagealechocardiography, and sternotomy with directclamping. Some reports have advocated placementof a suprarenal IVC filter before nephrectomy;however, the potential for recurring IVC or renalvein thrombosis, resulting in massive lower ex-tremity edema and renal failure in hypercoagulablecancer patients is a serious concern.9

The placement of a temporary IVC filter in thesuprarenal vena cava is innocuous, safe, and sim-ple. Venography at the time of filter placementprovides excellent preoperative assessment ofthe extent of tumor thrombus and allows for accu-rate placement with room for operative vascularcontrol. Once the tumor and tumor thrombushas been removed, traditional methods of deepvenous thrombosis prophylaxis can be used, thusdecreasing the risk of any venous thrombosiswhile still protecting the patient from pulmonaryembolus. Subsequent removal of the suprarenal fil-ter can then be safely done up to 2 weeks afterplacement using a transjugular approach or trans-femoral approach, depending on the type of filterdeployed.

Placement of a temporary suprarenal IVC filter atthe time of radical nephrectomy for renal cell car-

FIGURE 1. Venacavogram demonstrating renal tumorthrombus (arrow).

FIGURE 2. EnSnare (Medical Technologies, Gaines-ville, Fla) retrieval of OptEase IVC Filter.

380xiv UROLOGY 63 (2), 2004

cinoma with extension into the vena cava elimi-nates the possibility of pulmonary embolus whileavoiding any potential long-term sequelae of a per-manent IVC filter.

REFERENCES

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6. Neves RJ, and Zincke H: Surgical treatment of renal can-cer with vena cava extension. Br J Urol 59: 390–395, 1987.

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9. Rosenthal D, Gershon CR, and Rudder R: Renal cell car-cinoma invading the inferior vena cava: the use of the Green-field filter to prevent tumor emboli during nephrectomy.J Urol 134: 126–127, 1985.

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