Multiplane Transesophageal Echocardiographic Guidance During Resection of Renal Cell Carcinoma Extending into the Inferior Vena Cava

It has been reported previously that biplane transesophageal echocardiography (TEE) is useful to ascertain the extent of invasion of renal cell carcinoma in the inferior vena cava (IVC) and the right atrium [1-3]. In this report, we describe anesthetic management using TEE with multiplane imaging to guide manipulation of a vena caval balloon for occlusion of the IVC just above the tumor, while permitting maintenance of flow from the hepatic vein into the atrium and facilitating removal of renal cell carcinoma extending into the IVC. Case Report The patient was a 59-yr-old female with renal cell carcinoma extending into the IVC. Preoperative magnetic resonance imaging Figure 1A revealed that the right kidney was almost replaced by the tumor, which filled and dilated the suprarenal IVC. The cranial portion of the tumor extended to the level of the diaphragm without direct invasion to the IVC. Preoperative inferior venacavography Figure 1B demonstrated that the tumor was mobile, although it almost occluded the IVC and considerable venous collateral flow was observed from the infrarenal IVC to the superior vena cava through the azygos and the lumbar veins.Figure 1: A, Preoperative magnetic resonance imaging. The cranial portion of the tumor extended to the level of the diaphragm. B, Preoperative inferior venacavography. The right atrium (RA) was outlined by the considerable venous collateral flow. IVC = inferior vena cava.After induction of anesthesia, a multiplane TEE probe (Model 21364 OmniPlane; Hewlett-Packard, Palo Alto, CA) was inserted in the esophagus and advanced until the entrance of the IVC could be seen. In this case, the suprahepatic IVC, the top of the tumor, and the hepatic vein were best seen in a direction approximately 45-80 degrees from the horizontal plane Figure 2. Intraoperative TEE imaging showed that the cephalad extent of the tumor was near the atriocaval junction and its rock and roll motion was synchronized with the heart beat.Figure 2: Transesophageal echocardiography shows the tumor extending into the inferior vena cava (IVC) above the junction of the hepatic vein.During the operation, test cross-clampings were performed on the infrarenal IVC and the left renal vein to observe hemodynamic effects, but there was no remarkable change. Therefore a balloon catheter (17-206 large occlusion balloon catheter, outer diameter 40 mm; Meditech; Boston Scientific) was inserted into the IVC at the junction of the left renal vein and advanced up to the right atrium under TEE guidance. The balloon was inflated with saline in the right atrium Figure 3A, however it was too large to pull down to the IVC. The balloon volume was therefore adjusted under TEE observation to a size large enough to permit occlusion of the IVC. Initially, the IVC was occluded above the junction of the hepatic veins. This procedure resulted in a decrease in systolic blood pressure from 121 mm Hg to 89 mm Hg and an increase in IVC pressure from 13 mm Hg to 30 mm Hg. Therefore, under TEE guidance, the balloon was positioned inferior to the hepatic veins to allow flow from the hepatic vein into the atrium to continue Figure 3B. After this procedure, systolic blood pressure increased to 120 mm Hg and IVC pressure decreased to 18 mm Hg. The IVC was incised infrahepatically and the right kidney and the IVC tumor were removed in continuity. Total blood loss was approximately 800 mL and total transfusion was 800 mL with 2600 mL of fluid infusion.Figure 3: A, Transesophageal echocardiography (TEE) shows the balloon inflated in the right atrium (RA). B, TEE shows the balloon positioned inferior to the hepatic vein in the inferior vena cava (IVC).Discussion Resection of renal cell carcinoma with vena cava involvement is associated with a high incidence of morbidity and mortality [4]. The surgical techniques used to remove the tumor thrombus are dependent on the extent of the tumor [5], and in cases such as this, with the tumor extending into the suprahepatic IVC, cardiopulmonary bypass is generally required [5-7]. We were able to avoid cardiopulmonary bypass by using TEE imaging to guide the manipulation of a vena caval balloon to occlude the IVC just above the tumor, while allowing flow to continue from the hepatic vein into the atrium. Although the balloon occlusion and tumor extraction have been reported [8,9] previously, Montie et al. [5] described the disadvantages of balloon occlusion and extraction, including tears of the IVC and incomplete extraction of the tumor thrombus, leading to poorly controlled hemorrhage. Therefore, they recommended use of hypothermia with cardiac arrest to facilitate surgical excision. They also recommended that the hepatic circulation be controlled prior to tumor extraction. The balloon occlusion technique, which we describe, with extraction inferior to the hepatic vein overcomes previously encountered disadvantages of the balloon method, including difficulties related to control of the hepatic circulation. Using the guidance of TEE, the necessary volume of the balloon was adjusted to avoid tearing the IVC, and the position of the balloon was adjusted to allow continuation of flow from the hepatic vein into the atrium. We assessed the optimal placement of the balloon and the adequacy of occlusion by hemodynamic improvements, visualization of the hepatic venous flow by Doppler measurements of TEE, absence of significant hemorrhage in the operative field during occlusion, and no visualized air or tumor inflow to the suprahepatic IVC. The tumor in the intrahepatic IVC could be visualized on the standard horizontal Figure 4A and the orthogonal Figure 4B images of TEE, but a single longitudinal view demonstrating the relationship of the IVC, tumor, and the complete suprahepatic IVC, including the hepatic veins and the right atrium, could be obtained only in a nonorthogonal plane approximately 45-80 degrees from the horizontal plane Figure 2 and Figure 3. Intraoperative TEE is being used widely, and it allows visualization of major vessels in and around the liver [10-13] with optimal simultaneous visualization of the suprahepatic IVC with the hepatic vein and the right atrium in a plane approximately 30-45 degrees from the horizontal plane [13]. Generally, as our case illustrates, a multiplane probe is therefore more likely to be useful to visualize major vessels in and around the liver than a biplane probe, due to the obliquity of the structures involved.Figure 4: The standard horizontal (A) and orthogonal (B) planes of transesophageal echocardiography show the tumor in the intrahepatic inferior vena cava (IVC), but neither of them demonstrate the relationship of the hepatic vein, tumor, and suprahepatic IVC in the same view.In conclusion, intraoperative multiplane TEE guidance for removal of renal cell carcinoma in the IVC is useful to assess cardiac function and manage embolism of tumor and/or air. Multiplane TEE is especially more useful than biplane TEE in diagnosing the extent of the tumor in the IVC and guiding the necessary volume and position of the IVC balloon occluder to minimize systemic and hepatic circulatory effects of IVC occlusion.