Anaesthetic challenges in a rare case of renal cell carcinoma with inferior vena cava tumor thrombus extension into right atrium under cardiopulmonary bypass with deep hypothermic circulatory arrest

Renal cell carcinoma, an epithelial tumour of the kidney, is the ninth most common cancer worldwide. It is uniquely associated with tumour thrombi extending into the renal vein and inferior vena cava, while rarely extending till the right atrium. This poses challenges in intra-operative and post-operative hemodynamic management as well as perioperative cardio and neuroprotection making it a challenging case from anaesthetic point of view. We report a rare case of Right renal cell carcinoma with thrombus extension into right renal vein, inferior vena cava and right atrium. Right radical nephrectomy with en-bloc tumor-thrombus excision under cardiopulmonary bypass with deep hypothermic circulatory arrest was performed. The case was suspected to have a difficult intraoperative and postoperative course with major hemodynamic instability, neuroprotection, and cardioprotection in mind, and was managed appropriately.