Anesthetic Management of Renal Tumor with Level 3 Inferior Vena Cava Extension at a University Hospital in Vietnam: A Case Report

Extension of tumor into the inferior vena cava (IVC) and venous thrombus formation are typical characteristics of malignant renal tumors with variable prevalence. Detection of these problems depends on diagnostic imaging. The prevalence varies from 4 to 10% [1]. In patients with renal tumor extension to the IVC, the rate of invading to right atrium is 2–16% [1]. Radical nephrectomy with opening the IVC to remove invasive tumors or thrombosis has a 30-day mortality rate of 1–10%, and a severe complication rate of 18–47%. Depending on the degree of invasion of the IVC, the 5-year survival rate is 40–60% [2‒4].

Anesthetic management for radical nephrectomy with involvement of the IVC has many challenges, difficulties, and high mortality during the perioperative period. Based on the classification of cavoatrial invasion and the nature of the invasion (tumor or thrombus), an anesthetic plan is developed to minimize these obstacles and improve the quality of recovery after surgery (shown in Table 1) [5]. Gard et al. [6] reported a decrease of 22.5% in cardiac index, an increase of 47.1% in stroke volume variation, and a blood loss of 1,150 mL in this type of surgery.

In 2023, a case study of anesthetic management for renal tumor with level 3 IVC extension was published by Gashler et al. [7]. In 2024, a more severe case with level 4 IVC extension that reached the pulmonary artery was published by Chen et al. [8]. In Vietnam, surgery and anesthesia management of renal tumor with level 3 IVC extension are challenging due to lack of experience with this type of surgery and lack of publications or research on anesthesia and resuscitation for this type of surgery. Here, we report a clinical case of anesthesia and resuscitation for radical nephrectomy and opening of the vena cava to remove tumor to treat a kidney tumor with level 3 IVC extension.

Written informed consent was obtained from the patient for publication of the details of their medical case and any accompanying images. This case report adheres to the CARE Checklist guidelines, which have been completed by the authors and are provided as online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000542962).

A 55-year-old female with no abnormal past medical history was admitted in the hospital with the complaint of dull left flank pain. Computerized tomography scans demonstrated left renal cancer measuring 6.6 × 7.4 × 8.5 cm with level 3 cavoatrial invasion. This caused complete obstruction of left renal vein and almost complete obstruction of the IVC from the drainage site of left renal vein to the confluence of hepatic veins. There was extreme dilation of these veins (differential diagnosis included tumor vs. thrombus) (shown in Fig. 1, 2).

After multidisciplinary discussion with nephrology, anesthesiology, cardiac surgeons, radiology, oncology, hepatobiliary, and pancreatic surgeons, a diagnosis of left renal tumor classified as cT3N1M1 (a metastatic liver nodule in hepatic segment 7 and multiple pulmonary metastases) was made. Planning for radical nephrectomy with opening the IVC to remove the renal extension and atypical resection of hepatic segment 7 were conducted.

The patient was a 55-year-old female that weighed 50 kilograms and was 150 centimeters tall. She had no comorbidities. She previously underwent otolaryngologic surgery. Her medical history and physical examination were negative for any manifestation of IVC syndrome (including sign of tissue anoxia or leg edema). Laboratory results revealed mild anemia (Hb 112 g/dL and Hct 24%) and normal renal function (eGFR 72 mL/min/1.73 m²). In addition, liver function, coagulation cascades, and electrolytes were in the normal range. Thoracic cardiac ultrasound demonstrated a normal ejection fraction (of 74%) and no sign of intracardiac thrombus. Consequently, the patient was given an ASA score of III.

The anesthesia plan included general anesthesia with endotracheal intubation, left radial artery catheterization, and two right internal jugular vein catheters (7F, three lumens, and one large 9F lumen) to allow management of potential massive blood loss and transfusions. Six units of packed red blood cells and four units of fresh frozen plasma were prepared, with standby of Belmont rapid infuser for intraoperative use. The patient was kept warm during surgery with a warming blanket and blood and fluid warming systems.

Induction of anesthesia with fentanyl, lidocaine, propofol, and rocuronium was followed by tracheal intubation and volume-controlled mechanical ventilation (VC A/C) with a tidal volume of 7 mL/kg ideal body weight, a respiratory rate of 12–14 breaths per minute, FiO₂ of 40%, PEEP of 5 cm H₂O, Tpause of 20%, and an I:E ratio of 1:2 to maintain end-tidal carbon dioxide between 35 and 40 mm Hg. After induction of anesthesia, a left radial artery catheter (20G) was inserted to monitor invasive blood pressure and blood gasses. The right internal jugular vein catheters were placed under ultrasound guidance. A nasogastric tube and urinary catheter were also inserted, the latter for urine output monitoring. Her temperature was continuously monitored by an esophageal temperature probe. Continuous intraoperative monitoring included heart rate, blood pressure, body temperature, SpO₂, ECG, PPV, central venous pressure (CVP), end-tidal carbon dioxide, and urine output. Intraoperative fluids included Ringer’s lactate and 20% albumin.

The surgery comprised four stages: dissection, radical nephrectomy, opening the IVC for tumor removal and thrombectomy, and atypical resection of hepatic segment 7. The patient was placed in supine position with arms tucked at her sides. The surgical team performed an open procedure using a Mercedes incision (shown in Fig. 3) and bilateral rib retractors. The dissection time, including mobilization of the kidney and liver and preparation for clamping the IVC between the hepatic veins and the left renal vein, was 2 h and 45 min, with a blood loss of 400 mL. During this time, the patient received 3,000 mL of Ringer’s lactate to maintain normal hemodynamic parameters and maintain the CVP at the baseline level in preparation for clamping the IVC. Norepinephrine was administered at a rate of 0.01–0.03 μg/kg/min to maintain mean arterial pressure at 65–70 mm Hg. When the IVC was clamped below the hepatic veins, the CVP decreased from 5 to 2 mm Hg. Fluid resuscitation and norepinephrine (0.05–0.1 μg/kg/min) were used to maintain the mean arterial pressure at 60–65 mm Hg. During this stage, an additional loss of 500 mL of blood occurred (total 900 mL), and the patient received 700 mL of packed red blood cells, an additional 2,500 mL of Ringer’s lactate, and 100 mL of 20% albumin. The total IVC clamp time was 21 min. Arterial blood gas analysis during the period of clamping showed pH 7.41, PaCO₂ 33 mm Hg, HCO₃⁻ 23.6 mmol/L, base excess –1.2 mmol/L, lactate 1.4 mmol/L, PaO₂ 218 mm Hg (with FiO₂ 40%), Na⁺ 136 mmol/L, and K⁺ 3.6 mmol/L. Ten minutes before IVC unclamping, the patient was hyperventilated with a tidal volume of 8 mL/kg of ideal body weight and a respiratory rate of 20 breaths per minute. After unclamping, the patient’s hemodynamics remained remarkably unchanged compared to those before unclamping. Arterial blood gas analysis performed 5 min after unclamping revealed a pH of 7.32, PaCO₂ of 44 mm Hg, HCO₃⁻ of 22.7 mmol/L, base excess of −3.2 mmol/L, lactate of 2.9 mmol/L, PaO₂ of 223 mm Hg (with FiO₂ 40%), Na⁺ of 135 mmol/L, and K⁺ of 3.4 mmol/L. The final stage involved atypical resection of hepatic segment 7.

Summarizing fluid management during the surgical procedure, the patient received a total of 4,400 mL of crystalloid fluids, 700 mL of packed red blood cells, and 100 mL of 20% albumin. The total urine output was 1,230 mL over 4.5 h (4 mL/kg/h), with a surgery duration of 5 h and an anesthesia duration of 7 h.

At the end of the surgery, bilateral subcostal transversus abdominis plane blocks (TAP blocks) were performed with catheters placed to allow continuous analgesia using 0.25% ropivacaine boluses of 15 mL per side, followed by automated infusions of 10 mL of 0.2% ropivacaine every 6 h per side for 48 h postoperatively (shown in Fig. 3). Additional analgesia included paracetamol, nefopam, and tramadol. Muscle relaxation was reversed with 2 mg/kg of sugammadex when the train-of-four reached 2/4. The trachea was extubated in the operating room once the train-of-four ratio reached 100%. Postoperatively, the patient was transferred to the recovery room for continued monitoring and care. Laboratory tests in the recovery room were normal. Visual Analogue Scale (VAS) pain scores were 3 at rest and 4 during movement. No additional morphine was required postoperatively. After 12 h of monitoring in the recovery room, the patient was transferred to a urologic department for continued care. The patient was discharged 7 days postoperatively. A timeline summary is shown in Table 2.

Macroscopic imaging of the kidney tumor showed a tumor with dimensions of 13 × 8 × 8 cm. At the hilum of the kidney, there was a protruding mass measuring 8 × 4 × 3 cm having a smooth outer surface (shown in Fig. 4). Upon longitudinal sectioning of the kidney and the protrusion, a firm white cut surface was observed that was consistent with the renal pelvis. The total weight of the specimen was 593.2 g. Histopathology and immunohistochemistry indicate that it was a leiomyosarcoma (shown in Fig. 5, 6).

Renal tumors with invasion or thrombus formation in the IVC are classified into four levels (shown in Table 1) [5]. Radical nephrectomy with IVC thrombectomy for tumors invading up to level IIIc can often be performed without the need for cardiopulmonary bypass or veno-venous bypass [2, 3, 5, 9, 10].

Advances of surgical techniques, monitoring methods, and the use of extracorporeal circulation, as needed, have made radical nephrectomy with IVC thrombectomy safer with a perioperative mortality rate of 1% to 10%. Depending on the extent of IVC invasion, the 5-year survival rate varies from 40% to 60% [2‒4]. In our case, the patient had a renal tumor invading the IVC at level IIIa, with, according to Ciancio et al. [2], a 5-year survival rate of 40%, making the surgical intervention in this patient appropriate.

However, in our institution, due to lack of prior experience with similar cases, managing this case presented unique challenges for our multidisciplinary team. Especially, anesthesia management and resuscitation for radical nephrectomy and IVC thrombectomy carry several risks, including the following: clamping the IVC above the hepatic veins can reduce preload by 40–60% [11]. Clamping the IVC below the hepatic veins preserves about 10% of the blood volume from the portal system, resulting in a 30–50% reduction in preload [12]. These hemodynamic changes can lead to significant cardiovascular complications and occur in 4% of cases according to Kaag et al. [4]. Reduced preload during IVC clamping is less severe in patients who have developed collateral circulation, as our patient did. The computerized tomography scans showed that the tumor almost completely obstructed the IVC. However, the patient had no clinical signs of IVC occlusion, such as hypotension, tachycardia, lower limb edema, or tissue hypoxia [13, 14]. This aligned with the mild hemodynamic changes observed during IVC clamping when the CVP decreased from 5 to 2 mm Hg and responded to fluid resuscitation and low-dose norepinephrine. Tissue hypoxia was not evident during clamping, as indicated by a lactate level of 1.4 mmol/L. Therefore, from our experience, preoperative identification of collateral circulation was crucial to predict hemodynamic responses during IVC clamping. This allowed anesthesiologists to proactively manage fluid resuscitation, set up appropriate monitoring equipment, large IV catheters, and rapid infusion pump if available to prevent severe complications. Such findings emphasize the role of thorough preoperative imaging and hemodynamic assessments in similar cases.

This risk arises from thrombus fragments, tumor emboli, or air emboli during the opening of the IVC and manipulation of the invasive tumor mass. Transesophageal echocardiography is highly valuable for assessing patient hemodynamics and for detecting pulmonary embolism. In this case, the tumor was firm and unlikely to fragment, minimizing the risk of pulmonary embolism [7, 8, 15]. Consequently, transesophageal echocardiography was not used but was prepared for emergency use if life-threatening hemodynamic instability occurred.

Large-bore venous accesses are required for fluid resuscitation and transfusion of blood products. In this patient, a 9F catheter was placed in the right internal jugular vein. The total intraoperative blood loss was 900 mL, and the patient received 3 units of packed red blood cells, which aligned with the findings of Kaag et al. [4].

Severe pain can occur postoperatively due to the extensive upper abdominal incision from the xiphoid process to above the pubic bone and manipulation of intra-abdominal organs. Inadequate pain control increases the risk of perioperative complications, especially respiratory complications. Kaag et al. [4] identified respiratory complications as the leading postoperative complication in this type of surgery, with a rate of 12%. While epidural analgesia is the gold standard for upper abdominal surgery, it was not chosen and used in this case due to potentially significant hemodynamic changes, potential vasopressor use during and after surgery, the possibility of heparin use during surgery, and the risk of substantial blood loss and consequent severe coagulopathy. Instead, multimodal pain management was employed, involving bilateral subcostal TAP blocks with catheter placement and systemic analgesics. This technique effectively controlled the patient’s pain. Gashler et al. [6] also reported the use of TAP block and quadratus lumborum block for pain management in similar surgeries.

With the cooperation of multiple specialties and thorough perioperative preparation, we successfully managed anesthesia and resuscitation for a patient undergoing radical nephrectomy and IVC thrombectomy. The surgery was performed without complications, and the patient was discharged 7 days postoperatively.

Patient characteristics in these studies [4, 6, 7, 9, 15] are similar to our patient’s characteristics. However, our patient had a renal tumor causing nearly complete obstruction of the IVC but did not exhibit symptoms of IVC syndrome. Even when the surgeon clamped the IVC, the patient’s hemodynamic parameters showed minimal changes, and no reperfusion syndrome was observed upon unclamping. This suggests long-term progression of the tumor invasion and the development of collateral circulation above and below the obstruction, allowing the patient to adapt to this chronic condition. Given the unclear nature of the renal protrusion and tumor prior to surgery, differential diagnoses included tumor invasion versus thrombus formation in the IVC. The risk of pulmonary embolism due to thrombus migration was high in this patient, necessitating the preparation of a specialized team to manage potential acute pulmonary artery embolism, with extracorporeal membrane oxygenation ready for immediate use in case of complications. Fortunately, the renal tumor protrusion was solid and was confined within the IVC and no thrombus was detected.

In conclusion, anesthesia management and resuscitation for surgical removal of a renal tumor with IVC invasion or thrombus formation require meticulous preoperative preparation, invasive monitoring, and circulatory support to address potential complications. Hemodynamic changes during surgery can range from minimal to severe, depending on the extent of invasion and the nature of the invading mass. Finally, our case reinforced the significance of multidisciplinary collaboration, particularly in resource-limited settings, as a critical factor in achieving favorable treatment outcomes. The insights gained from this experience will undoubtedly help improve our future management of similar cases.

We would like to thank the patient and her family with their permission for publication. We also would like to thank our colleagues at Department of Anesthesia, University Medical Center HCMC, Vietnam, for their cooperation to manage the patient. We would like to thank George Gregory, MD, Professor Emeritus, UCSF, for his support in English correction in our case report.

Ethical approval is not required for this case report in accordance with University Medical Center HCMC guideline. Written informed consent was obtained from the patient for publication of the details of their medical case and any accompanying images.

The authors have no conflicts of interest to declare.

This case report was not supported by any sponsor or funder.

Conceptualization, methodology, and writing – review and editing: Vu Ton Ngoc Phan and Dao Thi Ngoc Nguyen. Data curation, formal analysis, and investigation: Dao Thi Ngoc Nguyen. Software and writing – original draft: Phat Thanh Tran and Dao Thi Ngoc Nguyen. Validation: Vu Ton Ngoc Phan.

The data that support the findings of this case report are not publicly available due to privacy restrictions but are available from the corresponding author, contingent upon patient confidentiality considerations.