Anesth Analg 2005;101:332
© 2005 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000158467.63965.AF
CARDIOVASCULAR ANESTHESIA
Chasing the Tumor Thrombus
Eric E. C. de Waal, MD*,
Peter Bruins, MD, PhD*,
Jaap R. Lahpor, MD, PhD ,
Jaap J. F. Steijling, MD ,
Laetitia M. O. de Kort, MD, PhD , and
Tom A. Boon, MD, PhD
Departments of *Anesthesiology, Cardiothoracic Surgery, Vascular Surgery and Urology, University Medical Center Utrecht, The Netherlands
Address correspondence and reprint requests to Eric E. C. de Waal, MD, Anesthesiologist-Intensivist, University Medical Center, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands. Address e-mail to e.e.c.dewaal{at}azu.nl.
A 65-yr-old woman (height, 152 cm; weight, 90 kg) underwent right radical nephrectomy and tumor thrombectomy without cardiopulmonary bypass for renal cell carcinoma with an intrahepatic inferior vena cava tumor thrombus. Her history revealed recent pulmonary embolism, diabetes, rheumatoid arthritis, vasculitis, obesity, and hypertension. After a midline laparotomy, a large tumorous right kidney was exposed. The inferior vena cava was distended and a large tumor thrombus was located. During ligation of the right renal artery, venous blood loss from a lumbar vein was difficult to control. Suddenly, her hemodynamic condition deteriorated. Her pulmonary artery (PA) and central venous pressures increased, whereas mixed venous oxygen saturation, end-tidal carbon dioxide, arterial blood pressure, and arterial oxygen saturation all decreased. However, continuous cardiac output remained stable. At that very moment, a large tumor embolus was seen floating in the right atrium (Figure 1). The right atrium was seen shifted to the left, indicating increased right atrial pressures, and the right ventricle was enlarged. While viewing this transesophageal echocardiography image, the intracardiac mass was seen to move from the right atrium to the right ventricle and the PA (see video loop available at anesthesia-analgesia.org). An emergent midline sternotomy was performed. After heparinization, the aorta, the right femoral vein, and the superior vena cava were cannulated and hypothermic cardiopulmonary bypass was instituted at 27°C. Right atriotomy was performed, but it failed to reveal an intracardiac mass. Further inspection revealed a tumor embolus in the right ventricle. Moreover, several emboli were extracted from the main PA and its bifurcation. After closure of the cardiac and PA incisions, the remaining intraabdominal portion of the procedure was completed and the patient was weaned from cardiopulmonary bypass. After the operation the patient was transported to the intensive care unit. The postoperative period was complicated by a wound infection. She was tracheally extubated 4 days after the operation and left the hospital in good condition 18 days after the operation. This case demonstrates that accurate preoperative staging and a well-planned surgical approach complemented by invasive hemodynamic monitoring and transesophageal echocardiography contributed to the timely diagnosis and treatment of tumor-thrombus pulmonary embolism.
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Figure 1. This two-dimensional image shows a tumor embolus in the right atrium and some secondary signs of increased right heart pressures: an enlarged right ventricle and bowing of the intraatrial septum to the left.
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Footnotes
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Supplemental data available at www.anesthesia-analgesia.org.
Accepted for publication January 21, 2005.
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