CLINICAL CARE
Residual Inferior Vena Cava Thrombus Detected by Transesophageal Echocardiography After Resection of a Malignant Adrenal Mass
Nelson H. Burbano, MD, Claudene Vlah, MD, and Maged Argalious, MD, MBA, MEd
A 43-year-old woman with a history of the Cushing syndrome secondary to adrenocortical carci- noma presented to the operating room for right adrenalectomy, hepatectomy, nephrectomy, and inferior vena cava (IVC) thrombectomy. Initial intraoperative transesophageal echocardiogram (TEE) confirmed the presence of an IVC tumor below the hepatic veins. Total vascular exclusion of the liver was necessary to perform the operation. A repeat TEE showed a residual thrombus within the IVC prompting an additional cavotomy to successfully remove the entire mass. The remainder of the procedure finalized uneventfully. The case highlights the importance of TEE monitoring for noncardiac surgery with thrombotic involvement of the IVC. (A&A Case Reports. 2015;5:143-5.)
A drenocortical carcinoma is a rare malignant endo- crine neoplasm with a poor prognosis. At the time of diagnosis, the disease is typically locally advanced or has produced systemic metastasis.1 Although the rate of recurrence after surgical intervention is high, surgical exci- sion is the only curative treatment, making the complete resection of the tumor of paramount importance. Inferior vena cava (IVC) thrombus is a well-known complication of renal cell carcinoma, with an incidence of 5% to 15%. The association of IVC thrombus with adrenocortical carcinoma is not well established (approximately 3%).1 However, given the high intrinsic metabolic activity of the adrenal glands and their rich vascular supply, it is not surprising that some of these malignancies can migrate into the IVC.
Transesophageal echocardiography (TEE) has been found useful in cases of renal cell carcinoma complicated by malignant infiltration of the IVC and is used routinely in some institutions.2 We report a case of a large adrenocorti- cal carcinoma with advanced regional disease including the IVC, in which the use of intraoperative TEE was crucial to direct the complete resection of the tumor.
At the time of writing this case report, the patient had died. We made multiple attempts to contact the patient’s fam- ily but were not successful. We thus sought approval from our local IRB who determined that approval is not required.
CASE DESCRIPTION
A 43-year-old woman with history of the Cushing syn- drome secondary to adrenocortical carcinoma presented
From the Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
Accepted for publication March 5, 2015.
Funding: None.
The authors declare no conflicts of interest.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.cases-anesthesia-analgesia.org).
Address correspondence to Maged Argalious, MD, MBA, MEd, Anesthe- siology Institute, Cleveland Clinic Foundation, 9500 Euclid Ave., E3-41, Cleveland, OH 44195. Address e-mail to argalim@ccf.org.
Copyright @ 2015 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000194
to the operating room for right adrenalectomy, right hep- atectomy, right nephrectomy, and IVC thrombectomy. A preoperative magnetic resonance imaging showed an ill-defined heterogeneous 9 x9 x 8 cm mass located in the right suprarenal region, locally invading the right hepatic lobe and IVC (Fig. 1). The level of cephalad extension of the mass within the IVC extended up to 3.5cm from the right atrium (RA) but was still below the major hepatic veins, precluding preoperative placement of an IVC fil- ter. Preoperative transthoracic and TEE examinations were unable to confirm the presence of thrombotic dis- ease within the IVC. A TEE done after induction of anes- thesia confirmed the presence of a 0.8-cm echogenic level IIIa tumor within the IVC (retrohepatic IVC but below the ostia of the hepatic veins; Fig. 2; Supplemental Digital Content, Video 1, http://links.lww.com/AACR/A25). An en bloc resection of the right adrenal mass, right hepatic lobe, and adjacent retroperitoneal tumor plus cholecystec- tomy and IVC thrombectomy was performed. A transverse cavotomy at the level of the insertion of the right adrenal vein with total vascular occlusion of the liver (clamping of the suprahepatic and infrahepatic IVC with clamping of the hepatic hilum) were required for the surgical resection of the mass. Test clamping of the IVC was performed, and norepinephrine and vasopressin infusions were required during the IVC thrombectomy. A second TEE done after the resection was completed and showed a small residual tumor thrombus within the IVC above the point of the pre- vious transverse cavotomy (Fig. 3; Supplemental Digital Content, Video 2, http://links.lww.com/AACR/A26). Suprahepatic, infrahepatic, and hilar clamps were applied again, and a second more superior transverse cavotomy was performed to complete the resection of the residual mass. Upon completion of the second cavotomy, a new TEE examination did not show evidence of residual dis- ease in the infrahepatic IVC. However, the examination demonstrated a long linear thrombus, approximately 10×2mm, located at the junction of the IVC and RA. After discussing the treatment options for this new finding with the cardiothoracic surgery service and given the location and size of the thrombus, the risk/benefit of attempting a surgical resection was considered unacceptably high, and
VIDEO+
VIDEO+
IVC thrombus
Adrenocortical carcinoma
<41°℃
51
IVC
RHV
Thrombus
130
VIDEO+
it was decided to treat expectantly (Fig. 4; Supplemental Digital Content, Video 3, http://links.lww.com/AACR/ A27). The remainder of the procedure concluded unevent- fully. The patient was started on prophylactic unfraction- ated heparin on postoperative day 2, discharged home on low-molecular-weight heparin on postoperative day 7, scaled up to full anticoagulation on postoperative day 14, and finally transitioned to Coumadin for a total of 3 months. Mitotane was started on the second postoperative week because of persistently elevated cortisol levels sug- gesting residual disease. Extensive metastatic progression to the lungs and brain was confirmed 3 months after the surgery. The patient died 6 months later.
DISCUSSION
There are important anesthetic challenges in the periopera- tive management of patients with functional adrenocorti- cal carcinomas, especially when they extend into the IVC. Endocrine syndromes, mainly hypercortisolism (less fre- quently hyperaldosteronism), have been associated with high catabolic states, protein depletion, poor nutritional state, potential difficult airway, difficult IV access, and a high risk of perioperative thromboembolic disease.3 The intravascular
CT
<41°℃
46
IVC
Residual thrombus
120
CT
>=41°℃
LA
109
IAS
RA
SVC
4.
Thrombus
120
location or extension of the tumor increases the risk of intra- operative bleeding, incomplete resection of the tumor, and massive intraoperative pulmonary embolism.1,4
The surgical technique for resection of the tumor clot from the IVC depends almost exclusively on the level of cephalad extension of the thrombus (Table 1).4 Level I and II caval tumor thrombi can be resected with a single IVC clamp applied below the junction of the hepatic veins. Level III tumors typically require mobilization and total vascular exclusion of the liver (IVC clamp superior and inferior to the hepatic veins and clamp of the hepatic hilum). Level IV tumors usually require the use of cardiopulmonary bypass. Intraoperative monitoring with TEE during resection of IVC tumor thrombus presents several advantages. It is useful to confirm the presence and extension of the tumor, guide the correct placement of clamps on the IVC, diagnose embolic events during the manipulation of the tumor, assess the preload during clamping of the IVC, and avoid incomplete resection of the mass.
Imaging of the IVC from the midesophageal bica- val view (90°-110°) as indicated in the American Society of Echocardiography/Society of Cardiovascular Anesthesiologists guidelines for performing a comprehensive
| Level | Extension of the thrombus |
|---|---|
| I | Limited to the renal vein |
| II | Within the IVC but below the inferior liver margin |
| IIIA | Retrohepatic IVC but below the major hepatic veins |
| IIIB | Retrohepatic IVC up to the major hepatic veins |
| IIIC | Retrohepatic IVC above the hepatic veins but below the diaphragm |
| IIID | IVC above the diaphragm but below the right atrium |
| IV | Intracardiac |
IVC = inferior vena cava.
TEE examination is limited.5 Nonetheless, longitudinal visualization of the IVC can be obtained through 2 differ- ent approaches not included in the guidelines. Beginning from the midesophageal bicaval view, the probe is advanced deeper into the esophagus to bring the IVC to the center of the display, which is followed by multiplane rotation back to 40° to 70°. On this view, the posterior and anterior walls of the IVC are observed on the top and the bottom of the display, respectively. The right hepatic vein is usually seen joining the anterior wall of the IVC.2 The second option to view the IVC starts at the level of the aortic valve at 0°. From this point, the probe is advanced and turned to the right until the tricuspid valve and the coronary sinus come into view. Further advanc- ing and turning to the right will show the IVC and bring it to the center of the display. From here, the probe is further advanced and the multiplane rotated to 40° to 60° to view the right hepatic vein. The middle and left hepatic veins can also be visualized by turning the probe to the left at the same time the multiplane is rotated to from 90° to 120°.6 In addition to important anatomic information derived from imaging the IVC, crucial hemodynamic data regarding preload (collaps- ibility of IVC) and right ventricular diastolic function (pulse- wave Doppler of hepatic vein flow) can be obtained.7
Although the use of intraoperative TEE in noncardiac surgery continues to increase, its impact on the operative plan is unknown. This contrasts with the use of TEE in car- diac surgery where intraoperative TEE changes the surgi- cal plan in up to 10% of cases.8 This case highlights how intraoperative TEE detected residual thrombotic disease in the IVC, modifying the surgical plan by prompting a sec- ond cavotomy to complete the resection of the tumor. This second incision in the IVC was also guided by the TEE, given the more superior location of the residual thrombus.
In addition, the new finding of a thrombus at the junction of the IVC and RA after the second cavotomy introduced new treatment challenges requiring intraoperative consultation with the cardiothoracic surgery service to determine the final plan for the management of this thrombus.
In cases of adrenal carcinoma with extension in the IVC, intraoperative TEE is helpful for confirming tumor exten- sion within the IVC, guiding placement of the IVC clamp, assessing completeness of tumor resection from the IVC, and identifying new thrombi formation and/or embolic events. Adequate imaging of the IVC at the level of the hepatic veins with TEE is usually achievable from the trans- gastric depth with the probe turned to the right and the multiplane rotated between 40° and 120°.
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