Anesthetic and perioperative management during nephrectomy with thrombectomy from the inferior vena cava in patients with renal cell carcinoma

Renal cell carcinoma (RCC) is one of the most common oncourological diseases (90% of all malignant neoplasms of the kidney) accompanied by high mortality in the world and the Russian Federation. About 120,000 new cases of RCC are detected in the world anually, which is about 2% in the structure of oncological morbidity, 65% of patients are detected in developed countries. Nephrectomy is the main method of radical treatment of patients with RCC. Tumor thrombosis (TT) of the inferior vena cava (IVC) develops in 25-30% of cases of RCC and is a fatal complication of this disease due to fragmentation of thrombotic masses and development of pulmonary embolism. Nephrectomy with thrombectomy (NE TE) is indicated for all the patients with RCC complicated by TT of the IVC (TT IVC).Mayo Clinic Classification:level 0 – thrombus is limited to the renal vein;level I - the thrombus extends into the IVC no more than 2 cm above the level of the renal vein;level II - the thrombus extends into the IVC more than 2 cm above the level of the renal vein, but does not reach the level of the hepatic veins;level III - the thrombus is at or above the level of the hepatic veins, but below the diaphragm;level IV - thrombus extends into the supradiaphragmatic IVC or right atrium.Surgical strategy in patients with levels III and IV of the TT IVC is accompanied by significant "traumatic" manipulations on the liver, suprahepatic section of the IVC, as well as on the heart chambers, suggesting parallel cardiac surgery. Surgical interventions in patients with levels III and IV of the TT IVC are accompanied by complete or parallel methods of extracorporeal circulation.The initially complicated condition of the patient (cancer intoxication, anemia, hyperazotemia, and in some cases thrombosis of the venous system of the lower extremities, along with concomitant pathologies) and the volume of surgical intervention determine the high risk of complications (up to 93%) and hospital mortality (up to 10%). Preoperative assessment of the risks of the operation, determination of the most favorable tactics for the patient, thorough preoperative preparation are necessary for the safest performance of the operation and early rehabilitation of the patient.Currently, the developed publicly available algorithms for managing patients with high surgical and anesthetic risk, as well as with a high risk of perioperative cardiovascular complications, are of a general nature and do not reflect the essence and characteristics of patients with TT IVC in patients with RCC.This review attempts to compile the features of anesthetic management of NE TE in patients with RCC, to describe the main pathophysiological features of TT IVC, perioperative complications, methods of their prevention and treatment. The main directions of complex diagnostics and treatment are presented, special attention is paid to the multidisciplinary team (urologists, oncologists, cardiovascular and cardiac surgeons, anesthesiologists and resuscitators) approach to the perioperative management of patients with TT IVC.