Tumor Thrombus & Budd Chiari Syndrome in Kidney Cancer

[Dr. Vitaly Margulis]
Yeah, so again how big is the primary? So I started thinking, okay. I mean, obviously if we start talking about tumor thrombus, that patient, obviously the level of the thrombus, degree of obstruction, degree of colorization, I almost think about my thrombus patients completely differently when I plan my surgical approach, almost every single one of these cases will be done in an open fashion.

And some of the things to understand is, as we said, what team do I need with me? And so when you, when you do these thrombus cases, I think you need to have a well oiled team. This has to be... you don't want to experiment, you want to have a well assembled partner in crime, whether it be a cardiovascular thoracic surgeon, vascular surgeon, liver transplant surgeon, I actually utilize probably all of them, depending on where the thrombus is for your retro hepatic thrombi, the thrombi did want to extend above the diaphragm. I've recently shifted to partnering with a liver transplant colleague, and these surgeons are very useful to help you mobilize the liver, get all the hepatic branches controlled, get the liver out of the way, control the cava just below the diaphragm. And so the tumor thrombi that radiographically are above the diaphragm, obviously this is where you have to have a good partnership with their cardiovascular and thoracic team which we do here, and those cases probably are best done in collaboration with them in case of bypass or circ arrest will be needed.

So, again, the level of thrombus is critical. Is there a blunt thrombus? Do we need to resect the cava? Is there enough colorization to allow for safe resection of cava up without reconstruction? Those are all the technical things that go through my mind. But these specific to the thrombus cases. Now, when you start looking at other cases-

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[Dr. Aditya Bagrodia]
So you'd mentioned bland thrombus, caval resection, broad strokes, when you start these operations, do you typically work on the vascular structures first? If it's a right sided tumor, early control of the artery, for instance in the intra caval space, gaining access to your contralateral renal vein, your infrahepatic IVC, super thrombus IVC. Can you just talk a little bit about how you think about that and approach that?

[Dr. Vitaly Margulis]
There'll be some differences in technique among different institutions. So what I've done over the years is have good control of the primary without unnecessarily disturbing the thrombus. And the idea here is we don't want the thrombus to embolize. So the primaries control the arterial flow to the primaries control and in some cases, this results in shrinking at the thrombus, perhaps making the thrombectomy portion easier. Once the primary and the arterial inflow is controlled then we go through our routine steps to isolate the tumor thrombus within the venous system.

So it's generally isolating the super thrombus cava, isolating that portal system if necessary, certainly infra thrombus cava. So once you have the cava isolated, then thrombectomy ensues and the rest of the primary is removed once the cava is closed. Some of the nuances you mentioned in some cases the cava has been obstructed for a long time, and it's probably even safer to resect the thrombus with the cava. And if that is your clinical judgment, then it's very important to preserve that colors, collaterals that have formed over the years, the patient has proper venous return.

[Dr. Aditya Bagrodia]
Excellent points. I think it's very obvious to me that each one of these cases is unique. You've really got to study the imaging. You've got to have a plan going into it. And I think you've also got to be ready for some various things that can happen intra-operatively. I recall as a resident doing a case with Vitaly. It was a relatively low level two thrombus, for no reason, with no manipulation of the cava, there was an embolization event, rapidly mobilized, performed thoracotomy embolectomy and the patient had a wonderful post-operative course, but you can imagine that if you don't take these cases seriously, you could have a very different outcome.

I think again, Vitaly's really stressed the need to prepare, to plan, to be ready, intra-operatively. I think you routinely use intraoperative echo in close collaboration with the cardiovascular anesthesiologists, but any other things that you'd like to mention specifically about obviously thrombus cases?

[Dr. Vitaly Margulis]
Again, if I have to mention one thing is to have a well-oiled team put together and it can be your choice, but you want to work with people that you're comfortable working. You want to have a good anesthesia, anesthesiologists that generally understands all of the nuances are there applicable to the cases where it could be high volume blood loss. You want to have an anesthesiology team with cardiac echo capabilities. And as you know, I do. Essentially every one of these cases in a situation where access to a quick pump, if we need to crash on pump during some of the situations you've just described is available.

That would be the most critical aspect you have to have... then you have to think about how am I going to reconstruct my cava. So you have to have access to things like catheters to embolize bland thrombus or de-embolize bland thrombus. If necessary, you have to have access to your Dacron grafts. You have to have access to your patches that they were given needs to be patched. It's a highly nuanced surgery, but the key here is it cannot overstress this, to have a team in place that is familiar with those cases.