Resection of an Adrenocortical Carcinoma Invading the Inferior Vena Cava Extending into the Right Ventricle
Miguel R. Abalo, M.D., John Carey, M.D., Oscar Aljure, M.D., Yiliam F. Rodriguez Blanco, M.D.
A
B
S
IES
0
0
180
P
RA
ACC
RA
RY
1
R
RV
IVC
17.0C 38.8℃
Tricuspid Annulus
A drenocortical carcinoma (ACC) is an uncommon and aggressive tumor with the potential to invade the infe- rior vena cava (IVC) and spread to the right atrium (RA) and right ventricle (RV) (image A).
Perioperative evaluation of a patient with a tumor invad- ing the inferior vena cava includes a comprehensive analysis of the preoperative imaging studies (echocardiogram, com- puter tomography, or magnetic resonance) to assess for tumor extension and structures affected. Ultimately, tumor exten- sion will determine the anesthetic management. Tumors occluding the inferior vena cava require large-bore central venous access above the diaphragm. Pulmonary artery cath- eter placement may not be recommended if the tumor is spreading into the right atrium because of the risk of tumor embolism.1 Hepatic vein invasion may affect drug metab- olism and coagulation. Increased collateral circulation will also potentiate the risk of intraoperative bleeding. Significant ascites places the patient at a higher risk for aspiration.
Mechanical obstruction may compromise preload sig- nificantly. The induction agents should be chosen to mini- mize cardiovascular depression, and the anesthesiologist may
consider maintaining spontaneous ventilation to preserve preload to the heart. Cardiac surgery and perfusion teams should be on standby for emergency cardiopulmonary bypass.
Tumor pulmonary embolism is a feared intraoperative complication that can result in right ventricular failure, shock, and death.2 Intraoperative transesophageal echocardiogram (image B; transesophageal echocardiogram exposing adreno- cortical carcinoma protruding through the tricuspid annulus) provides instantaneous information about heart function and monitoring for embolic phenomenon during tumor manip- ulation.3 Early detection of tumor embolism using transe- sophageal echocardiogram may lead to inferior vena cava clamping and the addition of cardiopulmonary bypass with or without deep hypothermic circulatory arrest.2
Competing Interests
The authors declare no competing interests.
Correspondence
Address correspondence to Dr. Abalo: miguel.abalo@ jhsmiami.org
References
1. Fukazawa K, Gologorsky E, Naguit K, Pretto EA Jr, Salerno TA, Arianayagam M, Silverman R, Barron ME, Ciancio G: Invasive renal cell carcinoma with inferior vena cava tumor thrombus: Cardiac anesthesia in liver transplant settings. J Cardiothorac Vasc Anesth 2014; 28:640-6
2. Spelde A, Steinberg T, Patel PA, Garcia H, Kukafka JD, Mackay E, Gutsche JT, Frogel J, Fabbro M, Raiten JM,
Augoustides JGT: Successful team-based management of renal cell carcinoma with caval extension of tumor thrombus above the diaphragm. J Cardiothorac Vasc Anesth 2017; 31:1883-93
3. Cywinski JB, O’Hara JF Jr: Transesophageal echo- cardiography to redirect the intraoperative surgical approach for vena cava tumor resection. Anesth Analg 2009; 109:1413-5