Multimodal Interdisciplinary Management of Level III Renal Cell Carcinoma With Inferior Vena Cava Tumor Thrombus: The Role of Preoperative Embolization, Intracaval Balloon Control, and Radical Nephrectomy With Inferior Vena Cava Thrombectomy

Figure 1. Contrast-enhanced CT images of the abdomen (1a) Coronal CT scan in the venous phase demonstrating a right RCC (yellow arrow) with tumor thrombus extending through the right renal vein to the IVC (green arrow), reaching just at the level of the hepatic veins (red arrow). (1b) Coronal CT scan indicates that the distance between the proximal thrombus and the cavoatrial junction measures 4 cm. (1c) Axial CT scan in the corticomedullary phase reveals a 10.5 x 9.8 cm solid mass in the upper and mid poles of the right kidney. CT: computed tomography, RCC: renal cell carcinoma, IVC: inferior vena cava

Figure 2. MRI of the abdomen demonstrating the right renal lesion (2a) Axial T2WI at the level of the right kidney showing the thrombus in the IVC. (2b) Sagittal MRI (BTFE) showing the right kidney with RCC (red circle) and the tumor thrombus extending to the IVC (red arrows). MRI: magnetic resonance imaging, T2WI: T2-weighted imaging, IVC: inferior vena cava, BTFE: balanced turbo field echo, RCC: renal cell carcinoma

Figure 3. Angiographic and embolization procedure images of the right renal lesion (3a) Selective renal angiogram demonstrating a hypervascular right renal mass (red circle) and tumoral thrombus extending to the IVC (red arrow), with an intense, heterogeneous tumor blush fed by hypertrophied intra-parenchymal branches. (3b) Post-embolization angiogram shows complete devascularization and an absence of the previously noted tumor and thrombus blush. (3c) Post right renal artery occlusion with absence of renal parenchymal vascularity and tumor blush. (3d) Venacavogram from the right jugular vein through the balloon catheter, showing a filling defect representing the tumor-thrombus within the IVC. (3e) Venacavogram from the right jugular vein through the balloon catheter, while the balloon is inflated and with complete occlusion of the IVC, without reflux to the hepatic veins. IVC: inferior vena cava

Figure 4. Intraoperative vascular control and extracted nephrectomy specimen with level III IVC tumor thrombus (4A) Intraoperative photograph demonstrating circumferential vascular control of the IVC prior to cavotomy and tumor thrombectomy. Three vessel loops are visible, encircling: (1) the infrarenal IVC, (2) the contralateral (left) renal vein, and (3) the infrahepatic IVC. An additional suprahepatic IVC control loop was placed above the hepatic veins to permit total hepatic vascular exclusion if required; this loop lies outside the field of view and is not visible in the photograph. This four-point isolation strategy enabled near-complete interruption of venous inflow and outflow within the affected IVC segment, providing optimal hemostatic control and exposure during cavotomy and tumor thrombus extraction. (4B) Corresponding en bloc radical nephrectomy specimen following complete excision, with the tumor thrombus (encircled) extending from the renal vein in a characteristic sausage-like configuration, illustrating the macroscopic extent of intraluminal venous involvement. IVC: inferior vena cava