inferior vena cava tumor thrombectomy in renal cell carcinoma patients is a challenging procedure , frequently requiring the vascular bypass technique for high - level thrombi with additional complications . adopting a technique such as intrapericardial control in selected cases will circumvent these problems . here , we present the results of our intrapericardial control technique during supradiaphragmatic inferior vena caval tumor thrombectomy . the records of six patients with supradiaphragmatic tumor thrombi , who underwent radical nephrectomy and thrombectomy at our center with intrapericardial control between the years 2008 and 2015 , were retrospectively reviewed . the patients characteristics , intra- and postoperative data , histology , and follow - up records were gathered and compared . there were no immediate or 30-day postoperative deaths . the mean age of the patients was 61.3 years ( range 46 - 75 ) . the total mean duration of surgery was 315 minutes and the mean amount of transfused red blood cells was 4.33 units during surgery and 0.8 units in the postoperative period . tumor stage was t3 in four patients and t4 in two , due to ipsilateral adrenal involvement . only one of the patients developed recurrences , first in the tumor bed and then at the site of the skin incision ; these were excised with no apparent complications . radical nephrectomy and tumor thrombectomy by intrapericardial control without cardiopulmonary bypass and hypothermic circulatory arrest is a safe and effective procedure that can avoid serious intra- and postoperative complications while providing acceptable cancer - control and mortality results . renal cell carcinoma ( rcc ) is unique among urologic tumors because of its potential for tumor thrombus formation and migration into the venous system ( 1 ) . this develops in approximately 4% - 10% of cases ( 2 ) and some ( 2% - 10% ) may extend up to the right atrium ( 3 ) . rccs are chemo- and radio - resistant , and due to the impending catastrophic nature of these tumors and also to recent advances in targeted therapy , an aggressive surgical approach has been advocated ( 4 ) . managing these situations is not only a surgical challenge but also has prognostic implications , ( 5 ) with an overall 5-year survival rate of 30 to 60% ( 6 ) . extensive tumor thrombi can be approached by either thoracoabdominal or abdominal ( with midsternotomy ) incisions . both approaches will provide excellent exposure to the diseased kidney , inferior vena cava ( ivc ) , liver , and heart , and will facilitate the use of cardiopulmonary bypass ( cpb ) ( 2 , 7 ) . cpb with or without deep hypothermic circulatory arrest ( dhca ) is recommended by many groups for high - level ivc tumor thrombectomy ; however , some opposing views have advocated its use only for level iv thrombi ( 2 , 7 , 8) . most importantly , cpb requires expensive and sophisticated equipment , as well as highly trained and experienced staff . in addition , cpb with or without dhca can lead to hematologic ( platelet dysfunction and coagulopathy ) and neurologic complications . also , extensive heparinization in cpb could result in uncontrollable bleeding from raw surgical surfaces ( 9 , 10 ) . hence , avoiding cpb while not compromising the aims of the cancer surgery or the patient s prognosis is a logical approach that should be pursued . different surgical methods for radical nephrectomy with ivc tumor thrombectomy without cpb have been previously reported . however , to the best of our knowledge , we report for the first time intrapericardial control without cpb for radical nephrectomy with ivc tumor thrombectomy . between march 2008 and november 2015 , of the 32 patients in our hospital with rcc and ivc tumor thrombi , six patients with supradiaphragmatic ivc tumor thrombi underwent radical nephrectomy with thrombectomy using the intrapericardial control technique . our department is an educational tertiary uro - oncology center with a uro - oncology fellowship program . all of the patients data , including pre- and intraoperative findings , postoperative complications , pathology reports , and follow - up information , were prospectively recorded . the tumor characteristics and thrombus level were preoperatively evaluated by computed tomography ( ct ) scanning and magnetic resonance imaging ( mri ) . the thrombus level was double - checked with transesophageal echocardiography ( tee ) during surgery . none of the patients had imaging evidence of ivc wall invasion or metastases , and the thrombi were mayo level iv ( 11 ) in all cases , with no intra - atrial components . each patient s performance status was determined according to the eastern cooperative oncology group ( ecog ) criteria . the cardiac , pulmonary , and renal functions of all patients were evaluated prior to surgery . postoperative follow - up evaluations included physical examinations and blood chemistry testing at one , three , and six months , then every six months for the next two years and yearly thereafter . beginning three months postoperatively , abdominopelvic ct scans and chest x - rays were performed at every visit as follow - up imaging modalities . abbreviations : rcc , renal cell carcinoma ; m , male ; f , female ; r , right ; l , left ; t , tumor ; n , lymph node ; m , metastasis ; ecog , eastern cooperative oncology group performance status . this technique was chosen because it allows a single incision to provide good access to the entire ivc , renal pedicle , and contralateral kidney , and it is a convenient approach for a probable cardiopulmonary bypass or an emergent pulmonary emboli evacuation . after confirmation of the infra - atrial position of the tumor thrombus by light touch , the intrapericardial ivc was isolated with a curved pedicle clamp and loosely controlled with a rummel tourniquet . the surgery proceeded by exposing the infrarenal and infrahepatic portions of the ivc , as well as both renal veins and the ipsilateral renal artery ( figure 1 ) . the renal artery was ligated as soon as possible to limit the amount of bleeding and to reduce cephalad extension of the tumor thrombus . rummel tourniquets were loosely placed on the infrarenal part of the ivc and the contralateral renal vein , and the diseased kidney was fully mobilized with only the venous connection left intact . in one patient ( number 3 ) , because of a suspicion of major hepatic vein involvement , liver mobilization with the pringle maneuver was also performed . after fastening all of the tourniquets , a longitudinal cavotomy incision from the renal vein insertion up to the short hepatic veins was made , and the kidney with the tumor thrombus was removed in its entirety by either digital manipulation or a tissue elevator . by establishing the retrograde flow from the infrahepatic ivc before closure , flushing of all tumor debris was ensured . in patient number 3 , the cavotomy incision was extended until the major hepatic veins and tumor thrombus were extracted under direct visualization . in patient number 2 , because of infrahepatic caval wall invasion , that segment was excised and the distal ivc was anastomosed to the left renal vein . after complete resection , the cavotomy was closed with double running sutures ( 5 - 0 prolene ) . removal of intrapericardial tourniquets was performed under tee control to check for the occurrence of any tumor emboli . after meticulous hemostasis , a drain was placed in the pericardial space and the sternum was closed . another drain was placed within the renal bed , and the laparotomy incision was closed in layers . the mean amount of transfused blood was 4.33 units during surgery and 0.8 units in the postoperative period . all patients were monitored in the surgical intensive care unit ( sicu ) for an average of 2.83 days ( range 1 - 5 ) . only one patient ( number 6 ) required prolonged hospitalization , due to of due to fever and a collection at the surgical site ; this patient was managed with percutaneous drainage and antibiotic therapy . the other complication was acute renal failure ( arf ) in patient number 2 , who was managed conservatively and discharged with a serum creatinine level of 1.8 mg / dl . based on the clavien - dindo classification of surgical complications , these patients complications were grade 3 and 2 , respectively . there were no immediate or 30-day postoperative deaths . none of the patients had thrombi fragmentations or pulmonary emboli based on intraoperative tee findings and postsurgical symptoms . pathological examinations showed clear - cell rcc in four patients and papillary type 2 rcc in two , with additional sarcomatoid features in one of the specimens . the tumor stage was t3c in four patients and t4 in two because of ipsilateral adrenal involvement . the mean duration of follow - up was 33.5 months ( range 3 - 94 ) . recurrence was detected in one patient ( number 3 ) at the tumor bed 12 months after surgery , which was resected ( clear - cell rcc , 7  6  3 cm in size ) with no complications . she developed a second recurrence at the surgical incision site 27 months after the operation ( clear - cell rcc , 4.5  3.5  3 cm in size ) which was again resected . figure 2 shows ct images for patient number 4 at the 18-month postoperative follow - up . this technique was chosen because it allows a single incision to provide good access to the entire ivc , renal pedicle , and contralateral kidney , and it is a convenient approach for a probable cardiopulmonary bypass or an emergent pulmonary emboli evacuation . after confirmation of the infra - atrial position of the tumor thrombus by light touch , the intrapericardial ivc was isolated with a curved pedicle clamp and loosely controlled with a rummel tourniquet . the surgery proceeded by exposing the infrarenal and infrahepatic portions of the ivc , as well as both renal veins and the ipsilateral renal artery ( figure 1 ) . the renal artery was ligated as soon as possible to limit the amount of bleeding and to reduce cephalad extension of the tumor thrombus . rummel tourniquets were loosely placed on the infrarenal part of the ivc and the contralateral renal vein , and the diseased kidney was fully mobilized with only the venous connection left intact . in one patient ( number 3 ) , because of a suspicion of major hepatic vein involvement , liver mobilization with the pringle maneuver was also performed . after fastening all of the tourniquets , a longitudinal cavotomy incision from the renal vein insertion up to the short hepatic veins was made , and the kidney with the tumor thrombus was removed in its entirety by either digital manipulation or a tissue elevator . by establishing the retrograde flow from the infrahepatic ivc before closure , flushing of all tumor debris was ensured . in patient number 3 , the cavotomy incision was extended until the major hepatic veins and tumor thrombus were extracted under direct visualization . in patient number 2 , because of infrahepatic caval wall invasion , that segment was excised and the distal ivc was anastomosed to the left renal vein . after complete resection , the cavotomy was closed with double running sutures ( 5 - 0 prolene ) . removal of intrapericardial tourniquets was performed under tee control to check for the occurrence of any tumor emboli . after meticulous hemostasis , a drain was placed in the pericardial space and the sternum was closed . another drain was placed within the renal bed , and the laparotomy incision was closed in layers . the mean amount of transfused blood was 4.33 units during surgery and 0.8 units in the postoperative period . all patients were monitored in the surgical intensive care unit ( sicu ) for an average of 2.83 days ( range 1 - 5 ) . only one patient ( number 6 ) required prolonged hospitalization , due to of due to fever and a collection at the surgical site ; this patient was managed with percutaneous drainage and antibiotic therapy . the other complication was acute renal failure ( arf ) in patient number 2 , who was managed conservatively and discharged with a serum creatinine level of 1.8 mg / dl . based on the clavien - dindo classification of surgical complications , these patients complications were grade 3 and 2 , respectively . none of the patients had thrombi fragmentations or pulmonary emboli based on intraoperative tee findings and postsurgical symptoms . pathological examinations showed clear - cell rcc in four patients and papillary type 2 rcc in two , with additional sarcomatoid features in one of the specimens . the tumor stage was t3c in four patients and t4 in two because of ipsilateral adrenal involvement . the mean duration of follow - up was 33.5 months ( range 3 - 94 ) . recurrence was detected in one patient ( number 3 ) at the tumor bed 12 months after surgery , which was resected ( clear - cell rcc , 7  6  3 cm in size ) with no complications . she developed a second recurrence at the surgical incision site 27 months after the operation ( clear - cell rcc , 4.5  3.5  3 cm in size ) which was again resected . figure 2 shows ct images for patient number 4 at the 18-month postoperative follow - up . rcc with vena caval extension is infrequent , but when it occurs , it necessitates an aggressive approach by a surgical team with extensive experience in urological cancer surgery ( 1 , 12 ) . the standard treatment for advanced tumor thrombi is radical nephrectomy and thrombectomy via laparotomy and midsternotomy incisions with atriotomy . this is possible only using cpb with or without dhca ( 13 , 14 ) . cpb with hypothermia carries a known risk of perioperative bleeding due to platelet dysfunction and systemic heparinization ( 15 ) . other known risks of cpb are sepsis , multi - organ failure , and neurological deficits ( 15 - 17 ) . in addition , specific and expensive equipment and highly trained personnel are required . furthermore , the majority of hospitals lack the facilities for cpb , even in the wealthiest countries . due to these complications and limitations , there are abundant recommendations to limit the use of cpb for only large intra - atrial thrombi , and to manage infra - atrial or small non - adherent atrial thrombi with non - bypass techniques ( 15 ) . there are several recommended non - cpb techniques in the literature with proven efficacy in terms of surgical perfection and overall survival . ciancio and colleagues ( 15 ) described a technique used on 12 patients with supradiaphragmatic tumor thrombi . they performed the surgery through an abdominal incision using a transdiaphragmatic approach to the intrapericardial ivc , entering the right atrium . in their series , there were no complications , operative deaths , or pulmonary emboli related to the surgery . in another series by patil and colleagues , 44 patients with mayo level iv thrombi ( 35 supradiaphragmatic and nine intra - atrial ) underwent radical nephrectomy and thrombectomy via right thoracoabdominal incisions and intra - pericardial control ( 4 ) . patil et al . had only one intraoperative mortality ( in the supradiaphragmatic thrombus group ) , which was before 1990 . using this approach , they avoided complications related to vascular bypass techniques and achieved favorable survival outcomes at two and 10 years of follow - up , even in patients with nodal or distant metastases . sobczynski and colleagues ( 18 ) performed cavoatrial thrombectomies in four patients with an innovative foley catheter - assisted technique , with no extracorporeal circulation or hypothermic arrest . all patients had level iv tumor thrombi with intra - atrial components . there was no intraoperative mortality or any recurrence after at least 12 months of follow - up . their approach resulted in comparable or even better results with regard to blood loss and transfusion requirements compared to conventional or minimally invasive techniques . however , this technique is not suitable for large intra - atrial thrombi ( i.e. those extending over 3 cm into the right atrium ) or ivc wall infiltration . compatible with previous studies , our series also showed favorable results with regard to operation time , duration of hospital stay , and surgery - related complications . our mean operation time was 315 minutes , which was lower than in the series by ciancio et al . the mean number of units of blood required for transfusion during surgery in our study was 4.33 , which is better than with other non - cpb techniques ( 4 , 15 ) . in ciancio and colleagues16 study of the intra - abdominal approach , a mean of nine units of red blood cells were required during surgery . ( 4 ) because of our low number of patients , the complication rate can not be compared with previous studies ; however , we did not encounter any major morbidities or postoperative mortality in our patients . postoperatively , the average length of stay in the icu was 2.83 days ( range 1 - 5 ) , with a mean length of hospitalization of 8 days ( range 5 - 17 ) . in the studies by patil et al . ( 4 ) and ciancio et al.,(15 ) the mean hospital and sicu stays were 8.4 days ( range 2 - 35 ) and 14.5 days ( range 5 - 85 ) , and 7 days ( range 1 - 17 ) and 12 days ( range 7 - 22 ) , respectively . radical nephrectomy and ivc tumor thrombectomy by intrapericardial control without cpb or hypothermic circulatory arrest is a safe and effective procedure for level iv infra - atrial tumor thrombi . this procedure can avoid serious intra- and postoperative complications while providing acceptable cancer - control and mortality results . this technique is also applicable for small non - adherent intra - atrial tumor thrombi that are shrunk into the ivc after diseased renal artery ligation and can be milked downward before intrapericardial tourniquet placement . radical nephrectomy and ivc tumor thrombectomy by intrapericardial control without cpb or hypothermic circulatory arrest is a safe and effective procedure for level iv infra - atrial tumor thrombi . this procedure can avoid serious intra- and postoperative complications while providing acceptable cancer - control and mortality results . this technique is also applicable for small non - adherent intra - atrial tumor thrombi that are shrunk into the ivc after diseased renal artery ligation and can be milked downward before intrapericardial tourniquet placement .
introductioninferior vena cava tumor thrombectomy in renal cell carcinoma patients is a challenging procedure , frequently requiring the vascular bypass technique for high - level thrombi with additional complications . 
 adopting a technique such as intrapericardial control in selected cases will circumvent these problems . here 
 , we present the results of our intrapericardial control technique during supradiaphragmatic inferior vena caval tumor thrombectomy.case presentationthe records of six patients with supradiaphragmatic tumor thrombi , who underwent radical nephrectomy and thrombectomy at our center with intrapericardial control between the years 2008 and 2015 , were retrospectively reviewed . 
 the patients characteristics , intra- and postoperative data , histology , and follow - up records were gathered and compared . there were no immediate or 30-day postoperative deaths . 
 the mean age of the patients was 61.3 years ( range 46 - 75 ) . 
 the total mean duration of surgery was 315 minutes and the mean amount of transfused red blood cells was 4.33 units during surgery and 0.8 units in the postoperative period . 
 the average hospitalization duration was 8 days ( range 5 - 17 ) . 
 tumor stage was t3 in four patients and t4 in two , due to ipsilateral adrenal involvement . 
 the mean duration of follow - up was 33.5 months . 
 only one of the patients developed recurrences , first in the tumor bed and then at the site of the skin incision ; these were excised with no apparent complications.conclusionsradical nephrectomy and tumor thrombectomy by intrapericardial control without cardiopulmonary bypass and hypothermic circulatory arrest is a safe and effective procedure that can avoid serious intra- and postoperative complications while providing acceptable cancer - control and mortality results .