Preoperative Extracorporeal Membrane Oxygenation (ECMO) Cannulation in Inferior Vena Cava Tumor Thrombus: A Case Report

TL;DR

A patient with kidney cancer and a large tumor thrombus underwent preoperative ECMO cannulation to manage embolic risks during surgery.

Contribution

This case report highlights the use of preoperative ECMO cannulation in managing tumor thrombus embolic risks during kidney cancer surgery.

Findings

Preoperative ECMO cannulation was performed to manage embolic risk in a patient with RCC and IVC tumor thrombus.

The patient remained hemodynamically stable despite postoperative pulmonary thromboembolism.

Multidisciplinary team approach was critical in preoperative planning and managing perioperative complications.

Abstract

Intravascular tumor thrombus can occur in different tumor types, but it is most common in renal cell carcinoma (RCC). This can extend into the renal vein and inferior vena cava (IVC), increasing the risk of pulmonary embolism. In cases of massive pulmonary embolism, the use of venoarterial extracorporeal membrane oxygenation (ECMO) is lifesaving, allowing time for hemodynamic stability and definitive treatment.

This case involves a 51-year-old male patient who was scheduled for elective right radical nephrectomy, ipsilateral adrenalectomy, and thrombectomy due to a large RCC. Preoperative abdominopelvic magnetic resonance imaging revealed a tumor thrombus in the right renal vein extending into the IVC. Given the high embolic risk associated with hemodynamic instability, the multidisciplinary team decided to perform preoperative venoarterial ECMO cannulation with vascular access sheaths. During the intraoperative period, the patient experienced hemodynamic instability due to hemorrhagic shock. However, a transesophageal echocardiogram (TEE) demonstrated preserved biventricular function and no evidence of right ventricular dilation, leading to withholding initiation of ECMO. Postoperative thoracoabdominal computed axial tomography scan showed segmental pulmonary thromboembolism of the right lower lobe of the lung, yet the patient remained hemodynamically stable.

In our case, during the preoperative period, we focused on optimizing the patient’s clinical condition and proceeded with ECMO cannulation using introducer sheaths. This case underscores the critical role of a multidisciplinary approach in preoperative assessment and highlights the importance of anticipating potential perioperative complications.

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