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Defining the Role of Intraoperative Transesophageal Echocardiography During Radical Nephrectomy With Inferior Vena Cava Tumor Thrombectomy for Renal Cell Carcinoma

  • Megan P. Kostibas
    Correspondence
    Address correspondence to: Megan P. Kostibas, M.D., Cardiac Anesthesia Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Sheikh Zayed Tower, 6208, 1800 Orleans Street, Baltimore, MD 21287.
    Affiliations
    Cardiac Anesthesia Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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  • Vivek Arora
    Affiliations
    Cardiothoracic Anesthesiology Division, Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA
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  • Michael A. Gorin
    Affiliations
    The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
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  • Mark W. Ball
    Affiliations
    The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
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  • Phillip M. Pierorazio
    Affiliations
    The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
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  • Mohamad E. Allaf
    Affiliations
    The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD
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  • Daniel Nyhan
    Affiliations
    Cardiac Anesthesia Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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  • Mary Beth Brady
    Affiliations
    Cardiac Anesthesia Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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      Objective

      To determine the impact of transesophageal echocardiography on the surgical management of patients undergoing nephrectomy and inferior vena cava tumor thrombectomy for renal cell carcinoma.

      Materials and Methods

      We retrospectively analyzed intraoperative records of 67 patients with renal cell carcinoma and level II-IV invasion of the inferior vena cava who underwent nephrectomy with tumor thrombectomy between 2007 and 2015. Based on preoperative imaging, patients were categorized according to vena cava thrombus level. Diagnostic utility and impact on surgical management were extracted from the operative note, anesthesia record, and intraoperative echocardiography report.

      Results

      Twelve of 34 patients (35%) with level II thrombus, 14 of 18 (78%) with level III thrombus, and 15 of 15 (100%) with level IV thrombus had intraoperative transesophageal echocardiography. With increasing level of tumor thrombus, the diagnostic yield and surgical impact increased. Echocardiography provided new diagnostic information in 7 of 12 (58%) patients with level II thrombus and altered surgical management in 16%. Among level III thrombus patients, echocardiography provided new diagnostic information in 12 of 14 (86%) and altered surgical management in 21%. Echocardiography provided new diagnostic information and impacted surgical management in all 15 (100%) patients with a level IV thrombus.

      Conclusion

      The diagnostic yield of intraoperative transesophageal echocardiography increases in patients with greater vena caval tumor thrombus extension. This information has a significant influence on surgical decision-making.
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