Anesthetic Management of Emergency Cardiopulmonary Bypass during Radical Nephrectomy for Renal Cell Carcinoma with Level IV Right Atrial Tumor Thrombus: A Case Report

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Renal cell carcinoma (cT3N0M0) with Mayo level IV right atrial tumor thrombus (n=1). Intervention: Continuous transesophageal echocardiography-guided anesthetic management and emergency conversion to cardiopulmonary bypass. Primary outcome: Successful intraoperative rescue from acute right ventricular inflow obstruction and postoperative neurological-free survival to discharge.

Q: What does this research mean for the field?

Continuous transesophageal echocardiography surveillance combined with a rehearsed emergency cardiopulmonary bypass conversion protocol enables rapid identification and successful rescue of acute right ventricular inflow obstruction during radical nephrectomy for renal cell carcinoma with Mayo level IV tumor thrombus. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Muhammad Iqbal; Aldy Heriwardito

doi:10.58344/locus.v5i10.6276

October 13, 2026Jurnal Locus Penelitian dan PengabdianOpen Access

Anesthetic Management of Emergency Cardiopulmonary Bypass during Radical Nephrectomy for Renal Cell Carcinoma with Level IV Right Atrial Tumor Thrombus: A Case Report

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Key result

Continuous TEE and emergency CPB enable rapid intraoperative rescue after acute tumor thrombus prolapse.

n=1

Why the study?

Renal cell carcinoma extends into the venous system in 4-10% of cases, and in approximately 1% of cases, the tumor thrombus reaches the right atrium (Mayo level IV), posing a risk of potentially fatal intraoperative right ventricular inflow obstruction during surgery.

Key Points

To describe the anesthetic management and rapid rescue utilizing emergency cardiopulmonary bypass in a patient undergoing radical nephrectomy complicated by a mobile Mayo level IV cavoatrial tumor thrombus.
Case report of a 40-year-old male (53 kg, ASA physical status III) with cT3N0M0 right renal cell carcinoma and a mobile cavoatrial tumor thrombus intermittently obstructing the tricuspid valve, scheduled for open radical nephrectomy and thrombectomy with cardiopulmonary bypass on standby.
Anesthetic management included invasive radial arterial pressure monitoring, ultrasound-guided internal jugular central venous catheterization confirmed on imaging, and continuous multiplane transesophageal echocardiography surveillance throughout the abdominal phase.
During retrohepatic inferior vena cava mobilization, mean arterial pressure fell from 67–95 mmHg to 43 mmHg (blood pressure 63/35 mmHg) with central venous pressure sustained at 9 mmHg, and transesophageal echocardiography immediately identified prolapse of the tumor thrombus obstructing right ventricular inflow.
Emergency median sternotomy and cardiopulmonary bypass were initiated with cooling to a nadir of 31.5 °C, allowing complete direct extraction of the thrombus; the patient was weaned from bypass on dopamine at 10 µg/kg/min, heparin reversed to an activated clotting time of 160 seconds, and discharged on postoperative day 5 without neurological deficits.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

1 40-year-old male with cT3N0M0 right renal cell carcinoma and a mobile Mayo level IV right atrial tumor thrombus undergoing radical nephrectomy and thrombectomy, followed until hospital discharge on postoperative day 5.

I

Intervention

Combined open radical nephrectomy and emergency median sternotomy with cardiopulmonary bypass (CPB) and right atrial tumor thrombectomy. Anesthetic management included pre-induction single-shot spinal injection (bupivacaine 0.25% 10 mg and preservative-free morphine 500 µg), titrated general anesthesia induction (midazolam 0.03 mg/kg, propofol 1 mg/kg, sufentanil 2 µg/kg, rocuronium 1.2 mg/kg), maintenance with sevoflurane and continuous IV morphine, ultrasound-guided high superior vena cava central venous catheterization, continuous intraoperative transesophageal echocardiography (TEE), systemic heparinization for CPB with mild-to-moderate hypothermia (nadir 31.5 °C), weaning with dopamine 10 µg/kg/min, and heparin reversal with protamine.

O

Outcome

Successful intraoperative rescue from acute right ventricular inflow obstruction via emergency CPB and tumor thrombectomy, followed by postoperative survival and neurological recovery at hospital discharge (postoperative day 5).hard clinical

In patients undergoing radical nephrectomy for renal cell carcinoma with a mobile Mayo level IV right atrial tumor thrombus, continuous intraoperative TEE surveillance, a pre-assembled cardiac surgical team, and a rehearsed emergency CPB conversion protocol enable rapid diagnosis and life-saving rescue during acute tricuspid valve inflow obstruction.

Limitations

Single case report with limited generalizability
Cerebral oximetry and objective neurocognitive testing were not performed
Post-thrombectomy transesophageal echocardiography images confirming complete clearance were not archived
Long-term oncological outcome and histological confirmation of the suspected synchronous hepatic lesion were not assessed
Strategy requires a tertiary center with in-house cardiothoracic surgical and perfusion services and is not directly transferable to resource-limited settings
Intraoperative TEE re-examination images confirming clearance of the right atrium and inferior vena cava were not archived
Single-patient case report design

Implication

May guide rescue in rare tumor thrombus events; hypothesis-generating and requires prospective validation before broader adoption.

Abstract

Renal cell carcinoma (RCC) extends into the venous system in 4–10% of cases, and in approximately 1% of cases, the tumor thrombus reaches the right atrium (Mayo level IV). We describe the anesthetic management of a 40-year-old man (53 kg, American Society of Anesthesiologists [ASA] physical status III) with cT3N0M0 right-sided RCC and a mobile cavoatrial tumor thrombus that intermittently obstructed the tricuspid valve. He was scheduled to undergo combined open radical nephrectomy and tumor thrombectomy, with cardiopulmonary bypass (CPB) on standby. Relevant comorbidities included anemia, hypoalbuminemia, hypokalemia, prolonged activated partial thromboplastin time, grade III right hydronephrosis, bilateral pleural effusions, and chronic hypertension. Intraoperative monitoring included invasive arterial blood pressure monitoring, internal jugular central venous access, and continuous transesophageal echocardiography (TEE). Midway through the nephrectomy, the patient's condition deteriorated abruptly; TEE demonstrated prolapse of the tumor thrombus into the right atrium, causing obstruction of right ventricular inflow. Emergency median sternotomy was performed, CPB was initiated, and the thrombus was removed. The patient was successfully weaned from CPB with dopamine at 10 µg/kg/min, heparin was reversed until the activated clotting time reached 160 seconds, and the nephrectomy was subsequently completed. He was extubated on the first postoperative day, transferred to the ward on postoperative day 2, and discharged on postoperative day 5 without neurological deficits. This case illustrates that, in patients with Mayo level IV RCC-associated tumor thrombus, continuous TEE surveillance, a rehearsed emergency conversion protocol to CPB, and a coordinated multidisciplinary team can facilitate the rapid recognition and treatment of a potentially fatal intraoperative event.

Discussion

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Cite This Study

Iqbal et al. (2026) conducted a case report in Renal cell carcinoma (cT3N0M0) with Mayo level IV right atrial tumor thrombus (n=1). Continuous transesophageal echocardiography-guided anesthetic management and emergency conversion to cardiopulmonary bypass was evaluated on Successful intraoperative rescue from acute right ventricular inflow obstruction and postoperative neurological-free survival to discharge. Continuous transesophageal echocardiography and emergency cardiopulmonary bypass enabled rapid rescue after acute tumor thrombus prolapse, permitting extubation on day 1 and discharge on day 5.

synapsesocial.com/papers/6ae28e56cbadf70daf6c41cc https://doi.org/10.58344/locus.v5i10.6276

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Anesthetic Management of Emergency Cardiopulmonary Bypass during Radical Nephrectomy for Renal Cell Carcinoma with Level IV Right Atrial Tumor Thrombus: A Case Report

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Anesthetic Management of Emergency Cardiopulmonary Bypass during Radical Nephrectomy for Renal Cell Carcinoma with Level IV Right Atrial Tumor Thrombus: A Case Report

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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