How I Do It: A Two-Stage Nephrectomy and Caval Thrombectomy for Renal Cell Carcinoma With Level IV Thrombus Complicated by Budd–Chiari Syndrome

We aim to visually present our two-stage approach to nephrectomy and caval thrombectomy for patients with renal cell carcinoma complicated by Level IV tumour thrombus (TT) and Budd–Chiari syndrome (BCS) [1, 2] (Video S1). Additionally, we discuss the anatomical and pathophysiological considerations needed for safe and satisfactory performance of this technique.

Supra-diaphragmatic TT extension is associated with significant perioperative risks including major haemorrhage from coagulopathy and potential for massive pulmonary embolism (PE) [3, 4]. This risk is exacerbated in patients with BCS. Our technique aims to mitigate these risks, thereby improving perioperative morbidity and mortality.

High-level IVC thrombus can cause secondary BCS and acute liver failure due to hepatic venous outflow obstruction [5]. A thorough preoperative evaluation for BCS is essential and should include clinical assessment, liver function tests, computed tomography (CT), and Doppler ultrasonography.

Congestive hepatopathy in BCS can complicate intraoperative liver mobilisation and, when combined with cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) for supra-diaphragmatic thrombectomy, predisposes to severe hepatic coagulopathy and bleeding [3]. By staging the procedures, our transthoracic approach minimises liver mobilisation while debulking TT from the hepatic veins and retro-hepatic IVC restores hepatic venous outflow. This facilitates liver function recovery, preventing hepatic decompensation. The second stage, which involves significant bleeding risk due to liver mobilisation, nephrectomy, and IVC resection and reconstruction, is then performed under improved coagulation conditions without the additional impact of CPB and DHCA.

Although perioperative PE is uncommon, it can carry substantial mortality risk, particularly during liver mobilisation and IVC manipulation [6]. To mitigate risk between stages, we utilise an occlusive endoluminal IVC purse-string suture just below the hepatic vein ostia during the first stage (Figure 1B). This is made feasible by the development of a well-formed collateral circulation due to chronic IVC occlusion, which is routinely assessed preoperatively on CT. Importantly, the suture must not impede hepatic venous outflow.

The second stage is performed within 2 weeks and aims to achieve complete abdominal tumour clearance. The procedure is performed via a Makuuchi incision, utilising the Cattell–Braasch manoeuvre for optimal retroperitoneal and IVC exposure. Vascular control is achieved through early ligation of the renal artery and accessory veins (lumbar, renal and para-renal), minimising blood loss by collapsing the collateral circulation [7]. Diaphragmatic attachments to the liver are dissected, fully exposing the abdominal IVC for vascular control through clamping [8]. The liver is then completely detached from the IVC with meticulous ligation and suturing of caudate veins, facilitating en bloc resection to achieve clear oncological margins. By avoiding severe coagulopathy with this two-stage approach, we reduce the need to compromise oncological clearance due to bleeding risk.

In cases where tumour invades the hepatic vein ostia, hepatic vein reconstruction and total vascular exclusion of the liver may be necessary, potentially with cold perfusion [1]. Caval resection is performed to achieve clear margins. Depending on the extent of caval invasion, reconstruction may necessitate bovine pericardial patch, or interposition prosthetic graft (Figure 1C). When interposition bypass is performed, the contralateral renal vein is anastomosed directly to the graft. In patients undergoing reconstruction, anticoagulation (e.g., heparin or enoxaparin) is typically initiated 24 h postoperatively, provided there are no signs of active bleeding. The dose is then gradually up-titrated to a therapeutic level. This approach is especially important in patients with a history of PE, with the duration of therapy often guided by haematology input. After 30 days, anticoagulation is generally transitioned to aspirin, as clinically appropriate.

Following caval repair or reconstruction, the abdomen is closed.

Our technique has been safely implemented at our institution, demonstrating no 30-day (from first-stage) postoperative mortality in a patient cohort with historically poor short-term survival [1, 5]. Given perioperative complexity, we recommend this procedure be performed in high-volume centres with multidisciplinary involvement, including uro-oncologists, hepatobiliary, cardiothoracic and vascular surgeons.

Georgi Atanasov and Samith M. Alwis are co-first authors and were involved in data curation, investigation, software, visualisation, and writing and reviewing of the manuscript for submission. Dixon Woon, Joseph Ischia, Sara Qi, Graham Starkey and Siven Seevanayagam participated in data curation and investigation. Marcos V. Perini is the senior corresponding author and participated in conceptualisation, supervision, data curation, visualisation and writing and review of the manuscript.

The authors declare no conflicts of interest.

This “How I Do It” study provides a step-by-step video demonstration and discussion of relevant anatomical and pathophysiological considerations to safely replicate our novel two-stage technique for nephrectomy and caval thrombectomy for level IV renal cell carcinoma complicated by Budd-Chiari Syndrome.