Transdiaphragmatic-intrapericardiac Approach to Supradiaphragmatic Vena Cava Invasion Secondary to Renal Cell Carcinoma: a Novel Surgical Approach

Introduction: A combined abdominal and thoracic surgical approach is the treatment of choice for renal cell carcinoma with secondary thrombus extending to the supradiaphragmatic vena cava and initially into the right atrium. This procedure usually requires a median sternotomy with cardiopulmonary bypass and deep hypothermic circulation arrest or, alternatively, venovenous bypass. In this report, we present a transdiaphragmatic-intrapericardiac approach to supradiaphragmatic thrombus extending to the atrium that avoids the disadvantages, mortality, and morbidity related to cardiopulmonary bypass and deep hypothermic circulatory arrest or venovenous bypass.

Technique: We describe a combined abdominal and transdiaphragmatic-intrapericardiac approach that was performed in 3 patients with renal cell carcinoma with secondary thrombus extending to the atrium. The estimated blood loss of the patients ranged from 1.1 to 2.8 L (mean 1.5). The total operative time ranged from 3 hours, 20 minutes to 4 hours. No postoperative complications were observed in any patient.

Conclusions: This technique allows excellent exposure of the supradiaphragmatic inferior vena cava through a 10-cm incision and optimal control of the distal thrombus edge when it reaches the right atrium. This approach is safer, faster, easier, and minimally invasive and avoids cardiopulmonary bypass with deep hypothermic cardiac arrest or venovenous bypass.