European Journal of Cardiovascular Medicine

Renal cell carcinoma (RCC) accounts for approximately 2–3% of all adult malignancies and is known for its tendency to invade the venous system. Tumor thrombus extension into the IVC occurs in approximately 4–10% of cases and represents an advanced stage of the disease.[1] Radical nephrectomy with inferior vena cava thrombectomy remains the primary treatment option offering potential long-term survival in these patients.[2] However, the procedure is technically demanding and requires extensive surgical dissection and major vascular manipulation. From an anesthetic perspective, these surgeries present unique challenges including large fluid shifts, significant blood loss, potential tumor embolization, and profound hemodynamic instability during IVC clamping.[3]

Interruption of venous return from the lower body during IVC cross-clamping results in sudden reduction in preload and cardiac output. Conversely, restoration of venous return following clamp release may cause abrupt hemodynamic changes requiring vigilant monitoring and timely intervention. Advances in intraoperative monitoring, including cardiac output monitoring and stroke volume variation analysis, have enabled better understanding of hemodynamic changes during complex oncological surgeries. [3,4]

Limited data exist regarding intraoperative hemodynamic trends and perioperative anesthetic implications during radical nephrectomy with IVC thrombectomy, particularly in Indian population. Therefore, the present study was conducted to evaluate the same objectives.

This retrospective observational study was conducted at a tertiary care hospital after obtaining approval from the institutional ethics committee. Data were retrieved for patients who underwent radical nephrectomy with IVC thrombectomy between January 2015 and December 2025 were included. Patients with incomplete intraoperative records or who required cardiopulmonary bypass (CPB) machine were excluded from the study. Categorical data (gender) were reported as frequency while continuous variables (age, weight, hemodynamic, blood loss and operative time) were reported as mean (standard deviation) or median (interquartile range), according to the normality of distribution. Each haemodynamic outcome at various surgical step was compared to baseline values using Shapiro–Wilk test for (checking normality). Analyses was conducted using repeated measures ANOVA (if normally distributed) or Freidman test (if non normal). p value of less than 0.05 was considered significant. The Mayo clinic thrombus classification was used for describing the level of IVC thrombus. Anaesthetic Management All patients received standardized general anaesthesia with endotracheal intubation. Invasive arterial blood pressure monitoring and central venous access were established. Flotrac monitor was attached as minimally invasive cardiac output monitor. Patients were positioned in supine position for open approach and lateral decubitus for laparoscopic procedures. Fluid therapy and vasoactive medications were administered on the discretion of anesthetist managing the case. Blood products were transfused based on estimated blood loss and hemoglobin levels. Thromboelastography was used to manage massive blood transfusion. For goal directed fluid management trends of CVP and SVV were used along with urine output and serum lactate levels. Plasmalyte was used as crystalloid and Gelofusion as colloid. Noradrenalin in the dose range of 0.1 to 0.5 mcg/kg was used to maintain MAP during IVC cross clamp phase. Hemodynamic variables (HR, MAP) and cardiac parameters (CO, SV, SVV, SVR, CVP) were recorded in six different phases of surgery including after induction of anaesthesia, after radical nephrectomy, just before and 10 mins after IVC clamping, after IVC declamping and at the end of surgery. Ten mins before IVC clamping, mannitol (0.5 gm/kg) was given in all cases as free radical scavenger. Arterial blood gas analysis was done at baseline, 10 mins before IVC clamping and 10 mins after opening of IVC clamping. Metabolic and electrolyte disturbances were corrected accordingly. Intraoperative and immediate post operative complications were noted.

Patient Demographics and Baseline Characteristics are described in Table 1. A total of 27 patients underwent radical nephrectomy with inferior vena cava (IVC) thrombectomy between January 2015 and December 2025. Four patients were excluded due to incomplete records making a total of 23 patients for the study. The mean age of the cohort was 54.3 ± 11.2 years, with a predominance of males (n = 21, 91%). The mean body weight was 68.5 ± 9.6 kg. On preoperative imaging, the mean tumor size was 15 ± 4.95 cm. Most tumors originated from the right kidney (82%). Common comorbid conditions were Hypertension (70%) and Chronic obstructive pulmonary disease (COPD) (60%) secondary to chronic smoking. Most procedures were performed using the open surgical approach (n =19, 82%), while 4 cases were performed laparoscopically. The distribution of tumor thrombus levels in the inferior vena cava (IVC) was as follows: Level I in 9 patients (39%), Level II in 10 patients (43%), Level III 3 patients (13%) and Level IV in 1 patient (4%). The mean duration of surgery was 312 ± 64 minutes. Estimated blood loss varied widely due to tumor vascularity and surgical complexity. The average intraoperative blood loss was 1450 ± 520 mL. Packed red blood cell transfusion was required in 19 patients, with a mean transfusion requirement of 2.6 ± 1.4 units. Mean IVC cross-clamp duration was 29.35 ± 7.35 min.

Heart rate demonstrated significant variation across intraoperative phases (p < 0.001) (Figure 1). The mean HR decreased from 99.5 ± 10 bpm after induction to 80.5 ± 9 bpm in the pre-clamp phase. A significant rise was observed during IVC clamping (101.5 ± 10 bpm), with peak values occurring following clamp release (109.5 ± 9 bpm). Heart rate returned toward baseline values by the end of surgery. Post hoc analysis revealed significant differences between pre-clamp, clamp, and post-release phases.

Mean arterial pressure showed significant variation across surgical phases, (p < 0.001) (Figure 2). MAP decreased significantly during IVC clamping (58.9 ± 9.5 mmHg) compared to pre-clamp values (85.1 ± 7.5 mmHg), followed by a significant increase after clamp release (101.9 ± 9.8 mmHg), indicating marked hemodynamic fluctuations during thrombectomy.

Cardiac output showed significant variation across intraoperative phases (p < 0.001) (Figure 3). The mean CO decreased significantly from 5.93 ± 0.65 L/min after induction to 4.01 ± 0.85 L/min during IVC clamping (p < 0.001). A significant increase was observed following clamp release (6.06 ± 0.75 L/min, p < 0.001), with values remaining stable at the end of surgery. Bonferroni post hoc analysis demonstrated significant differences between clamp and post-release phases, as well as between post-nephrectomy and post clamp-release phases.

Systemic vascular resistance (SVR) demonstrated significant variation across surgical phases (p < 0.001) (Figure 4). Mean SVR increased from 1444 ± 179 dynes·sec/cm⁵ after induction to a peak of 1829 ± 165 dynes·sec/cm⁵ during inferior vena cava (IVC) cross-clamping. Following clamp release, SVR decreased to 1296 ± 185 dynes·sec/cm⁵ and subsequently increased to 1497 ± 261 dynes·sec/cm⁵ by the end of surgery.

Stroke Volume Variation (SVV) also had significant variation across surgical phases (p < 0.001) (Figure 5). SVV increased significantly during IVC clamping (21.3 ± 5.4%) compared to pre-clamp values (6.9 ± 4.7%), followed by a significant decrease after clamp release (10.3 ± 4.5%).

Most patients had favourable postoperative outcomes. Majority of patients were extubated immediately postoperatively. Three patients required postoperative mechanical ventilation. Most patients had adequate urine output after contralateral kidney perfusion, suggesting preserved renal function. Two patients developed acute kidney injury (AKI). Other complications observed were major intraoperative blood loss(n=3), delayed recovery from anaesthesia (n=1), pulmonary embolism. Two patients died due to postoperative pulmonary embolism. Hospital stays ranged from 5 to 7 days in most patients.

Table 1: Demographic characteristics:

Figure 1: Changes in heart rate (beats per minute) across different surgical phases. ***p < 0.001. Brackets indicate statistically significant pairwise comparisons between pre-clamp, clamp, and post-release phases

Figure 2: Changes in mean arterial pressure (mmHg) across different surgical phases. ***p < 0.001. Brackets indicate statistically significant pairwise comparisons between pre-clamp, clamp, and post-release phases.

Figure 3: Changes in cardiac output (L/min) across different surgical phases. ***p < 0.001. Brackets indicate statistically significant pairwise comparisons between pre-clamp, clamp, and post-release phases.

Figure 4: Changes in systemic vascular resistance (dynes·sec/cm⁵) across different surgical phases. ***p < 0.001. Brackets indicate statistically significant pairwise comparisons between pre-clamp, clamp, and post-release phases.

Figure 5: Changes in stroke volume variation (%) across different surgical phases. ***p < 0.001. Brackets indicate statistically significant pairwise comparisons between pre-clamp, clamp, and post-release phases.

Radical nephrectomy with inferior vena cava thrombectomy remains one of the most challenging uro-oncological surgeries from an anesthetic perspective. The presence of tumor thrombus within the IVC results in significant alterations in venous return, particularly during vascular manipulation and cross-clamping. [2,5]

In our study, the majority of tumors originated from the right kidney (80%) with male predominance. [6,7] Level II tumor thrombus was the commonest presentation (40%) of our population.

The most significant hemodynamic disturbances were observed during IVC clamping, where a marked reduction in mean arterial pressure (40%) and cardiac output (60%) was noted. This occurs due to sudden obstruction of venous return from the lower body, leading to decreased preload and subsequent reduction in stroke volume. The significant rise in SVV during IVC clamping and its subsequent reduction following clamp release highlights the dynamic changes in preload and intravascular volume status. Instead of intravenous fluids, vasoactive medications (especially noradrenalin) were used in most cases to maintain MAP during this phase. Patients who had extensive collateral circulation developed less hemodynamic changes. Patients with complete occlusion of IVC due to tumor thrombus had extensive collaterals and tolerated IVC cross clamp very well. Similar hemodynamic patterns have been reported in previous studies evaluating anesthetic management during IVC thrombectomy. [3, 8]

In our study, systemic vascular resistance increased during IVC occlusion, reflecting a compensatory sympathetic response aimed at maintaining arterial pressure. After clamp release, rapid restoration of venous return resulted in increased cardiac output and transient tachycardia, highlighting the need for vigilant hemodynamic monitoring during this phase. [3,4,5]

Advanced hemodynamic monitoring techniques, including cardiac output monitoring and stroke volume variation analysis can aid anesthesiologists in optimizing fluid therapy and vasopressor support during these complex procedures. Such monitoring allows early detection of preload changes and facilitates goal-directed hemodynamic management. [3,4]  Intraoperative Transoesophageal Echocardiography (TEE) monitoring can be considered as a valuable tool for assessing cardiac function and detecting tumour thrombus migration.[9]

Blood loss remains a major challenge in these procedures due to extensive surgical dissection and large tumor burden. The average blood loss in our study was approximately 1.6 liters, which is comparable to previously published series. [3,10]

Prolonged IVC cross clamp were required in two patients (> 30 mins) for level 3 and above IVC thrombectomies. [10] One patient with extensive collaterals tolerated well but one patient developed significant hypotension (MAP < 50 mmHg) for 10 mins after cross clamping due to limited collaterals. Patient required very high dose of inotropes post clamp release.a Another significant perioperative concern is the risk of tumour embolism and pulmonary embolism. Two patients in our series succumbed to postoperative pulmonary embolism, emphasizing the need for meticulous surgical technique and perioperative vigilance. [11,12]

Routine use of anticoagulant drugs are not recommended as per recent evidence for tumor thrombus in IVC as it does not decrease the risk of pulmonary embolism while increasing the risk of surgical bleeding and morbidity.[13] In our study not a single patient received any anticoagulation.

Tabbara MM et al demonstrated that liver transplant techniques, specifically comprehensive liver mobilization (“piggyback” technique) and vascular exclusion, can safely be used in level III IVC thrombectomies, allowing the tumor removal without cardiopulmonary bypass effectively. [14] In our study 3 patients with level III IVC thrombus were successfully managed using the piggyback surgical technique.

Laparoscopic approach is safe and feasible alternative to open approach for these surgeries with Mayo level II and less thrombus offering less complications and faster recovery. Open surgery remains preferred choice for higher level (III-IV) or complex thrombus.[15] Laparoscopic surgeries also helped anaesthetically to maintain hemodynamic stability due to pneumoperitoneum related sympathetic activity.

Despite the complexity of these surgeries, most patients in our series had favourable outcomes with early extubation and relatively shorter hospital stay. This underscores the importance of multidisciplinary collaboration between anaesthesiologists, urologists, and vascular surgeons in achieving optimal perioperative outcomes. [3]

Limitations

This study has several limitations. It is a retrospective analysis from a single centre with a relatively small sample size. In addition, detailed statistical analysis of hemodynamic parameters was limited by the retrospective nature of data collection.

Radical nephrectomy with IVC thrombectomy is associated with significant intraoperative hemodynamic fluctuations, particularly during IVC clamping and declamping. Careful anaesthetic planning with advanced hemodynamic monitoring, vigilant fluid management, and timely vasoactive support is essential to maintain cardiovascular stability. Early recognition of complications such as massive blood loss, acute kidney injury, and pulmonary embolism is crucial to improve perioperative outcomes.

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