Managing kidney tumors with level IV thrombus typically requires cardiopulmonary bypass for safe vena caval thrombectomy, though this method may involve significant risks. This study explores an alternative approach using a transdiaphragmatic technique to control the proximal inferior vena cava (IVC) without cardiopulmonary bypass. Two patients with kidney tumors and level IV thrombus underwent radical nephrectomy and IVC thrombectomy using this method. The procedure involved a rooftop incision with xiphoid extension and right-to-left visceral rotation for optimal exposure of the IVC, as well as isolation of the left renal vein, IVC, and right renal vein. The right renal artery was then managed at the aortocaval junction, and the liver was mobilized to expose the retro-hepatic IVC. Next, a small incision was made in the diaphragm’s central tendon and pericardium, allowing direct access to the supra-diaphragmatic IVC, which could then be clamped to facilitate safe removal of the thrombus.
The operative times for the two cases were 515 and 267 minutes, respectively. In one patient, the IVC had to be transected due to thrombus spread into the common iliac veins, leading to hospital stays of 31 and 12 days. Pathology results indicated T3c Grade 2 clear cell renal cell carcinoma in one patient and epithelioid angiomyolipoma in the other. Both patients remained recurrence-free at follow-ups of three years and five months. This study shows that a transdiaphragmatic approach may allow safe proximal control of the IVC in patients with advanced thrombus, eliminating the need for cardiopulmonary bypass and potentially minimizing postoperative complications. Further research is encouraged to validate the broad applicability of this technique for managing level IV thrombus in kidney cancer patients.
