Anesthesia for Nephrectomy with Vena Cava Thrombectomy

Up to 10% of renal cell carcinoma (RCC) tumors extend intravascularly from the kidney into the inferior vena cava (IVC) via the renal vein. Radical nephrectomy and vena cava thrombectomy is the therapy of choice for these patients. Surgical complexity and morbidity increases with cephalad extension of the tumor thrombus; Level I thrombus extends minimally into the IVC (≤2 cm) while Level IV extends into the IVC above the diaphragm. Anesthetic management varies based on extension of tumor and is often challenging due to IVC clamping, hemodynamic instability, potential for massive hemorrhage, and risk of intraoperative tumor embolization. Patients with high-level tumors should be managed in experienced centers with expertise in advanced techniques including transesophageal echocardiography (TEE), venovenous bypass, and cardiopulmonary bypass. A multidisciplinary team approach is important in the management of these patients.