Extraction of atrial tumor thrombus in renal cell carcinoma via a complete transabdominal approach

Introduction

Renal cell carcinoma (RCC) accounts for 3.8% of all adult cancers and 95% of all renal cancers (1). RCC is known for its high degree of intrinsic resistance to chemotherapy. Although randomized clinical trials such as ASSURE and S-TRAC have demonstrated the power of immune modulators and targeted molecular therapies, their role in treatment is limited as adjuvant and neoadjuvant agents. Complete surgical resection is the only treatment with curative potential and offers a 5-year survival rate of 70–80% in patients with localized disease, whereas those with local nodal extension or distant metastases have a 5-year survival rate of 15–25% and 10% respectively. Most patients who present with multiple distant metastases succumb to the disease within 15 months.

The relationship of the tumor thrombus to the liver, hepatic veins, diaphragm, and right atrium determine the level of the tumor (Figure 1). The tendency of a tumor to traverse the renal vein and inferior vena cava (IVC) occurs in up to 10% of cases upon diagnosis and is known to complicate treatment (2-4). An international consortium demonstrated an independent correlation of tumor thrombus with survival (5). The median survival for patients with RCC and inferior vena cava thrombus (IVCTT) who do not undergo treatment is 5 months (6). Furthermore, patients who present with supradiaphragmatic involvement have a significantly worse survival rate, even after controlling for Fuhrman grade (2).

Figure 1 Classification of IVC thrombus based on anatomic landmarks. Level 0: tumor thrombus is limited to the renal vein; Level I: tumor thrombus extends into the IVC, <2 cm above the renal vein; Level II: tumor thrombus extends into the IVC, >2 cm above the renal vein but below the hepatic veins; Level III: tumor thrombus extends above the hepatic veins but below the diaphragm; Level IV: tumor thrombus extends above the diaphragm, including atrial thrombus. IVC, inferior vena cava.

In the absence of lymph nodes or distant metastases, the 5-year survival rate for patients with renal cell carcinoma with level iv inferior vena cava tumor thrombus (RCCIVCTT) following radical surgery is around 60% (7,8). Thus, there is a strong incentive for surgical resection to provide long term cancer control. Unfortunately, RCCIVCTT poses a difficult operative challenge, and most of the techniques are fraught with complications. In addition, the frequency of a fatal pulmonary thrombus, regardless of approach, ranges from 2–3%. As a result the surgical approach is guided by tumor thrombus location.

Cardiopulmonary bypass (CPB) has been the mainstay for level IV thrombectomy since it was first introduced in 1970. While this method has the advantage of providing a bloodless field and reducing the risk of embolization, it is associated with multisystem failure, hypothermia, and coagulopathic complications. Reports in recent years have demonstrated approaches that circumvent the need for extracorporeal circulation and sternotomy. However, there is a relative scarcity of studies in the literature that document level IV thrombectomy using this method. We present our experience with eleven patients who underwent level IV thrombectomy through a complete transabdominal approach using the technique Ciancio et al. outlined. We present this article in accordance with the SUPER reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0485/rc).

Preoperative preparations and requirements

Methods

Eleven patients were identified as having undergone a total transabdominal level IV thrombectomy from January 1, 2016 to present at The University of Oklahoma Health Sciences Center. All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Institutional Review Board of The University of Oklahoma Health Sciences Center (IRB #19533). Written informed consent was obtained from the patients for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Preoperative assessment

An accurate preoperative assessment guides an optimal surgical approach. Correct RCC staging can be achieved with either computed tomography (CT) or magnetic resonance imaging (MRI) along with an arteriogram, see Figures 2,3 (9). Renal ultrasound has been used after initial CT imaging to assess cephalad extension of thrombus into the cava (10). However, we preferred MRI due to its high yield in detecting vena cava tumor thrombi. In case 1, for instance, MRI revealed a 6 cm calcified segment extending from the tumor thrombus directly into the right atrium. In another patient, a renal mass was detected incidentally on an MRI for back pain evaluation.

Figure 2 Coronal CT abdomen pelvis. Tumor thrombus extension of approximately 10 cm through the vena cava with possibly supradiaphragmatic involvement. The presence of enlarged lymph nodes in the upper abdomen posterior to the IVC suggests metastatic disease. CT, computed tomography; IVC, inferior vena cava.

Figure 3 Axial CT abdomen pelvis. 8 cm right renal mass. Typical finding of tumor penetration into perinephric fat. CT, computed tomography.

Certain radiographic features may correlate with IVC wall invasion. For instance, Gohji et al. reported that a vena cava diameter of 40 mm or more on CT probably indicates extensive tumor invasion (11). However, only surgical exploration allows definitive evaluation, and we found it challenging to assess IVC wall invasion preoperatively. In addition, we found CT and MRI to be limited with respect to Mayo Classification of the tumor thrombus level. In these cases, the use of transthoracic echocardiography (TTE) confirmed the location. In case 1, TTE played a vital role in planning the operation, as it demonstrated the calcified segment’s adherence to the IVC wall and chiari network at the atriocaval junction. Transesophageal echocardiography (TEE) also allows correct staging of the thrombus level and is our next step when TTE fails to adequately locate.

Patients with atrial and even ventricular thrombus were evaluated in tandem with cardiac surgery for transdiaphragmatic approach. Thrombus with clear tissue planes on preoperative CT scan were deemed favorable for a transdiaphragmatic approach. Those that appeared adhered to the myocardium were referred for sternotomy-based approach. Despite if selected for transdiaphragmatic approach, all patients with level IV thrombus had cardiac anesthesia and CPB in the room in case of need for conversion to sternotomy and bypass.

Workup for metastatic disease

The presentation of our patients with metastatic disease varied significantly. One patient’s renal mass was detected incidentally due to complaints of irritative voiding and other nonspecific symptoms. Another patient presented with 40 lb unintentional weight loss, night sweats, and anemia. Metastatic evaluation consisted of non-contrast CT chest, MR brain, and bone scan.

The role of systemic therapy in RCC treatment is undoubtedly promising. Phase II studies have demonstrated pre surgical tumor reduction with molecular agents. For example, Karakiewicz et al. showed effective downstaging of a level IV tumor thrombus with neoadjuvant sunitinib therapy (12). Unfortunately, the controversy regarding the correct sequence of management in advanced RCC translates to difficult clinical decisions.

For instance, one of our patients who presented with metastatic disease ultimately underwent nephrectomy and level IV thrombectomy followed by adjuvant therapy with ipilimumab and nivolumab. We decided against cytoreductive nephrectomy based on the initial analysis of the Carmena randomized phase III trial.

Step-by-step description

Surgical approach

All patients were operated on with the help of the liver transplant technique for thrombectomy without extracorporeal circulation, as outlined by Ciancio et al. (13). The patients’ arms were tucked in anticipation of possible sternotomy. Furthermore, patients’ chests were prepped and draped in anticipation of potential need for urgent to emergent transthoracic exposure. As previously discussed, all patients had cardiac surgery on standby and access to CPB in the room. Supine positioning with an extension of the lumbar lordosis ensured correct access to the subdiaphragmatic spaces. Chevron access consisted of a triradiate incision over the upper abdomen extended underneath both costal margins and superiorly up to the xiphoid process.

Surgical success in cases with level IV tumor thrombus relies on good exposure. Therefore, retractors were placed after transecting the falciform ligament, and the entire retroperitoneum was exposed utilizing a right medial visceral rotation and subsequent duodenal Kocherization. The former—the ‘Cattell-Braasch’ maneuver—is usually performed with lymphadenectomy to optimize aortocaval access. The presence of extensive retroperitoneal collateralization made Cattell-Braasch difficult in patient 6, whose IVC had been chronically obstructed.

Exposure to left-sided tumors was optimized by dissecting the spleen off the diaphragm and mobilizing it en bloc with the pancreas towards the midline. The caval surface was traced up to the area of the left renal vein and encircled with a vessel loop. For the right renal vein to maintain blood flow after Rummel tourniquet placement, the vena cava is isolated below the tumor thrombus and left renal vein but above the right renal vein. Right-sided tumors were approached similarly.

Early ligation of renal artery

It is prudent to ligate the renal artery before proceeding with subsequent steps. Reducing blood flow to the tumor thrombus during the initial stage of the procedure will make the “milking maneuver” more feasible, allowing the surgeon to manually displace the tumor thrombus below the level of the suprahepatic veins with relative ease. Though this technique has classically been described for level IIIb/IIIc tumor thrombi, we recommend it for level IV cases as it negates the need for preoperative renal artery embolization. Early ligation resulted in collapsed collateral circulation, decreased bleeding, and easier dissection.

For left sided tumors the takeoff of the renal artery was identified by tracing up the lateral side of the aorta after, after which it is divided with a vascular stapler. For right sided tumors, the renal artery was ligated through the interaorta-caval space with silk ties and clips. Any lumbar veins encountered during dissection are ligated.

In case 3 the patient had two right renal arteries. The first one was located anterior to the cava and was divided between 2-0 silk ties. Two hem-o-lok clips were placed on the stay side of the artery. The other renal artery was located more superiorly and coursed retrocaval. This one was ligated directly above the renal vein as it emerged from the underside of the cava. Case 4 featured two left renal arteries (the main artery and an accessory lower pole renal artery). Both were ligated with silk sutures as well as hem-o-lok clips then divided.

Liver mobilization

Complete liver mobilization is necessary to expose the infra-diaphragmatic IVC fully. First the right coronary and left triangular ligaments are divided to elevate and rotate the liver in ‘piggyback’ fashion (Figure 4). Control of hepatic veins is critical. All venous tributaries draining the liver other than the major hepatic veins are ligated. Next the hepatic hilum is looped with a Rummel tourniquet to occlude the hepatic inflow as needed. Finally, the pringle maneuver is used to control hepatic bleeding once the cavotomy is made. At this point the tumor thrombus contained within the suprahepatic IVC can be palpated as it extends past the diaphragm (Figure 5).

Figure 4 ‘Piggyback’ mobilization.

Figure 5 Retrohepatic exposure of the IVC. IVC, inferior vena cava.

Transdiaphragmatic pericardial window

One of the most important aspects of surgical treatment for renal tumors with IVC extension is control of the apical part of the tumor thrombus. This was complicated by the high localization of the thrombus apex in all our cases. For this reason, we exposed and isolated the intra-pericardial IVC through dissection of the diaphragm and pericardiotomy. Although the IVC could be exposed through dissection of the central tendon alone, this method has the disadvantage of a technically difficult closure due to the proximity of the diaphragmatic hiatus to the IVC. We were also keen on avoiding the arrhythmic complications which resulted in the death of two of the 12 patients in Ciancio’s study who underwent dissection of the central tendon (7).

The pericardial window is located medial to the IVC foramen to avoid phrenic nerve injury in each case. This method had the added benefit of a larger incision, increasing right atrial exposure (Figure 6), which ensures optimal apical control of the atrial tumor thrombus in each case. After dissection through the oblique pericardial sinus is complete, an umbilical tape is passed around this segment of the IVC to create a near-occlusive compression. This is done under TEE guidance to proceed without conversion to sternotomy and CPB safely.

Figure 6 Pericardial window.

After thrombectomy, the pericardial window is closed with a series of figures of eight 1-0 Ethibond sutures. This was supplemented with a second running Ethibond for weaker tissue or requiring a large pericardial window.

Cavotomy and thrombectomy

Circumferential dissection of the supradiaphragmatic and intra-pericardial IVC facilitates caudal displacement of the thrombus below the level of the major hepatic veins. We chose this ‘milking maneuver’ because it avoids hepatic ischemia and preserves liver drainage into the IVC, so long as a vascular clamp is placed below the level of the suprahepatic veins. This technique is often feasible, especially when it has been preceded by early renal artery ligation. The level of the clamp is assessed using TEE to avoid potential dislodgement of the thrombus. Once the IVC has been dissected, vascular control is established before cavotomy. This begins at the hepatic hilum and proceeds sequentially: infra-thrombotic IVC, contralateral renal vein, right adrenal vein for left-sided tumors, and supra-thrombotic IVC.

Although the placement of a Satinsky clamp has classically been used for hemostasis across the right atrial confluence, we chose to loop it with a Rummel tourniquet before gently guiding it caudally. However, we occasionally encountered significant bleeding after thrombus extraction with this method. A vascular clamp above the cavotomy and below the liver can be placed in such situations while releasing the pringle and the cavoatrial snare. Next, the pringle is switched to a nontraumatic vascular clamp, and the cavoatrial Rummel tourniquet is again snared as the clamp below the liver is released.

Cavotomy starts at the level of the affected renal vein with a 15-blade scalpel and is extended proximally as needed. The infrathrombotic Rummel tourniquet is tightened, and the cava is manually compressed above the left renal vein to interrupt blood flow. Complete removal of the thrombus ensues and is confirmed by TEE. Flow is reconstituted by removing the cephalad clamp and then the inferior clamp. Suctioning of bland thrombus is sometimes required to remove as much of a friable tumor thrombus as possible. In case 5, we also had to excise a small portion of the cava that had been infiltrated by tumor thrombus. Fortunately, IVC en bloc resection was not necessary in any of our cases. After flushing the cava with heparinized saline, reconstruction was done with two 4-0 Prolene sutures in a continuous running fashion.

Anesthetic technique

There are no specific anesthetic recommendations for resection for RCC with IVC extension. All patients in our series were monitored using standard American Society of Anesthesiologists’ guidance for intraoperative monitoring. Due to the large thrombus burden in the IVC, all patients were assumed to be preload depleted. In this circumstance, anesthetic induction can result in immediate severe hemodynamic instability. Therefore, our anesthetic induction in all eleven cases included a pre-induction intra-arterial line for beat-to-beat blood pressure monitoring, judicious colloid infusion (250–500 mL albumin bolus) followed by careful titration of IV etomidate, fentanyl, lidocaine, rocuronium, and vasopressor (either phenylephrine or norepinephrine bolus) through a large-bore peripheral IV placed in the arm. Following induction, a 9-Fr multi-lumen central venous catheter was placed in the internal jugular vein and connected to a central venous pressure monitor and a rapid infuser (Belmont Infuser).

Blood loss in RCC with IVC tumor extension can vary both for intra-level and inter-level resections, as shown by Fukazawa et al. in their review of surgical resection of level III and IV RCCIVCTT in 70 patients (14). In their single-center series, estimated blood loss was significantly higher in patients with level IV than those with level III. Therefore, in our level IV case series, we ensured that adequate amounts of blood products [packed red blood cells (PRBC), fresh frozen plasma (FFP), platelets (PLT), cryoprecipitate] were readily available during each case. The average blood loss for the eleven cases was 2,830 mL (range from 300 to 4,000 mL). Intraoperative blood loss and transfusion data are shown in Table 1. All patients had a significant intraoperative vasopressor requirement, especially during the multiple IVC cross-clamping required in this procedure.

Patients were heparinized prior to clamping of the IVC with 100 units per kilogram. Activated clotting times were not routinely checked, nor patients reversed with protamine unless there were bleeding concerns at the end of the case.

Intraoperative TEE

TEE has been used in RCCIVCTT resections since the 1990s (15). Intraoperative TEE allows for real-time surveillance and surgical guidance of tumor thrombus. TEE is essential in evaluating the cranial extent of tumor thrombus in the right atrium, right ventricle, or pulmonary artery in level IV resections. In addition, it is used to monitor intravascular volume, myocardial performance, and propensity to embolize (14,15). Embolization must be carefully watched for and communicated with surgical team as this guides potential conversion to sternotomy and need for CPB. At the end of the procedure, TEE confirms the presence or absence of residual tumor thrombus.

In a retrospective review of 67 cases of intraoperative resection of Level II to Level IV RCCIVCT, Kostibas et al. found that as the level of tumor thrombus increased, the diagnostic yield and surgical impact of TEE also increased (15). In their study, TEE was used in 35% (12 of 34) of level II, 78% (14 of 18) of level III, and 100% (15 of 15) of level IV cases, respectively. Of particular importance, the use of TEE provided new diagnostic information in all fifteen Level IV cases and this information impacted surgical management 100% of the time. Our use of TEE mirrors that of the study above. We use TEEs in most RCCIVCTT resections and all level IV tumor thrombus resections. Intraoperative TEE use is paramount for the success of transabdominal resection of level IV RCCIVCTT without CPB. In addition to providing information about ease of tumor mobility in the intracardiac chamber during resection, TEE allows quick response to the severe hemodynamic perturbations usually associated with resection of an intracardiac tumor thrombus. Admittedly, it is challenging to evaluate tumor invasion into the caval wall using TEE. Nevertheless, it remains the gold standard of intraoperative imaging for level III and IV tumor thrombus cases. For example, in patient 2, for instance, the tumor thrombus briefly traversed the tricuspid valve, but we could extract it without reverting to sternotomy. In conclusion, intraoperative TEE markedly mitigates the morbidity and mortality associated with resection of a level IV RCCIVCTT.

Postoperative considerations and tasks

Eleven patients at our center underwent level IV IVC thrombectomy via the transdiaphragmatic technique described above (Table 2). The majority were male (6/11, 54.5%) with left-sided RCC (7/11, 63.6%). Tumors were relatively large, with a mean greatest dimension of 10.6 cm. Three patients (27.3%) had metastatic disease at the time of surgery, and six (54.5%) had tumor invasion into the IVC wall.

On average the length of surgery was 328 minutes with 11 minutes of pringle clamp time. All patients had successful thrombus displacement with intrapericardial access. Blood loss varied, but on average was 2.8 liters. Patients remained in the hospital anywhere from 4 to 21 days post op. Median follow up was 21.7 months, with two patients lost to follow up. Three patients had recurrence of disease at the time of our review.

Discussion and conclusions

RCCIVCTT is associated with substantial perioperative risk and historically high morbidity and mortality. Traditional management for level IV disease often involves CPB with or without deep hypothermic circulatory arrest (DHCA), particularly when thrombus extends into the right atrium. Outcomes from CPB-assisted series have varied, but larger historical cohorts suggest high perioperative mortality. For example, a multi-institutional review of RCCIVCTT patients treated with CPB reported an overall perioperative mortality of approximately 22%, with especially high risk in patients who did not receive adjunctive DHCA (22.2% overall; DHCA subgroup 8.3% vs. non-DHCA 37.5%) and median survival measured in months despite aggressive surgical therapy (16).

More recent, broader systematic analyses that include CPB and non-CPB approaches in noncardiac tumor thrombus surgery have shown that perioperative mortality rates do not differ significantly between groups when stratified by CPB usage. A 2025 meta-analysis reported an overall perioperative mortality rate of ~9.2%, with pooled mortality for CPB cases of 10.3% compared with 7.8% for non-CPB approaches, a difference that was not statistically significant (17). Notably, CPB was typically reserved for patients with more extensive thrombus burden or intracardiac extension, indicating that higher procedural complexity, rather than CPB itself, may drive worse outcomes.

In contrast to these historical and aggregated outcomes, our case series demonstrated no perioperative mortality and no progression to dialysis-dependent renal failure. All patients had preserved preoperative cardiac function, and despite significant tumor burden and frequent IVC wall invasion, renal function remained acceptable postoperatively. These findings compare favorably to the existing literature and suggest that, in carefully selected patients and experienced centers, level IV thrombectomy without CPB can achieve perioperative outcomes at least on par with traditional CPB-based strategies. This aligns with earlier single-institution reports showing low mortality (approximately 4–7%) using transabdominal approaches with limited CPB use (17).

Another important consideration is blood loss and hemodynamic instability. Studies of CPB-assisted RCCIVCTT resection often report high intraoperative blood loss and extended operative times, which correlate with postoperative complications and prolonged recovery (18). In our series, while estimated blood loss was significant, there were no fatal embolic events or deleterious hemodynamic outcomes attributable to excessive bleeding or caval manipulation. Moreover, the absence of CPB likely contributed to avoiding systemic inflammatory and coagulopathic sequelae commonly associated with bypass circuits, although this was not directly measured in our case series.

Our perioperative outcomes must be interpreted in the context of careful preoperative evaluation, multidisciplinary planning, and stringent patient selection. All patients had preserved left ventricular function, and intraoperative TEE was employed to minimize the risk of embolization and to confirm complete tumor extraction. The favorable outcomes observed, including stable renal function and the absence of perioperative cardiac or embolic complications, highlight the potential utility of non-CPB approaches in select patients.

This study is limited by its retrospective design, small sample size, and lack of long-term survival data. Future studies can be steered toward larger sample size and long term follow up. Due to the variation in follow up, it is imprudent to draw conclusions from oncologic perspective. Furthermore, changes in electronic medical record made tracking follow up challenging. Comparison to CPB outcomes is also constrained by heterogeneity in the literature with respect to patient selection, surgical technique, and reporting standards. Nonetheless, the current findings suggest that for appropriately selected patients with RCCIVCTT, transabdominal thrombectomy without CPB may offer perioperative outcomes that compare favorably with those reported for CPB assisted surgery, particularly with respect to mortality and preservation of renal function. Future prospective, multi-institutional studies with standardized outcome reporting are needed to better define the optimal surgical strategy for this complex and high-risk patient population.

Resection of RCC with level IV IVC tumor thrombus can be achieved with acceptable perioperative and renal outcomes in carefully selected patients. Surgery without CPB remains a viable option at experienced centers despite advanced disease.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0485/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0485/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0485/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Institutional Review Board of The University of Oklahoma Health Sciences Center (IRB #19533). Written informed consent was obtained from the patients for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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