Borrowing From Liver Transplantation: Piggyback Caval Exposure and Arch-Isolated Cerebral Perfusion for Level IV Tumor Thrombus

Renal cell carcinoma extends into the venous system in up to 10 percent of cases. When the thrombus reaches the right atrium (Mayo level IV), three factors determine operative risk (1):

1. Tumor embolization during mobilization
2. Hemorrhage from a retrohepatic cava without proximal control
3. The need for cardiopulmonary bypass

Liver transplantation techniques give circumferential control of the retrohepatic cava (2), while arch-isolated selective cerebral perfusion allows circulatory arrest at milder hypothermia with a liberal arrest interval (3). These techniques were combined in a single operation.

Patient Evaluation

A 66-year-old hypertensive man presented with pyrexia, chills, weakness, exertional dyspnea and right loin pain. Imaging showed a 10 cm right renal mass with metabolically active tumor thrombus (SUVmax 8.7) extending from the right renal vein into the right atrium (atrial component 4.5 × 3.3 cm). The thrombus extended caudally to the iliac confluence and involved the middle and left hepatic veins, resulting in hepatic congestion. A right lower-lobe pulmonary embolus was also present, with no distant metastasis. Biopsy confirmed renal cell carcinoma, and the ejection fraction was 60 percent.

The Innovation

No new device was used. The innovation involved integrating and sequencing established techniques performed by three surgical teams: piggyback hepatic mobilization by the liver transplant team to expose the entire cava; radical nephrectomy completed off bypass; and two-clamp arch isolation, which allowed antegrade cerebral perfusion to continue throughout circulatory arrest at 28 °C.

Operative Steps

Transesophageal echocardiography (TEE) confirmed the presence of the atrial thrombus. Urology secured the renal pedicle and ligated the right renal artery early. The liver transplant team mobilized the liver in piggyback fashion, exposing the cava from the infrarenal segment to the hepatic venous confluence.

After sternotomy, the nephrectomy was completed before bypass. Following cannulation of the aorta, superior vena cava (SVC), and right atrial appendage, the patient was cooled to 28 °C. Circulatory arrest was instituted with clamps placed on the ascending aorta and on the arch between the left carotid and left subclavian arteries.

The atrium and cava were opened, and the thrombus delivered in continuity, followed by the removal of the atrial component. Anadherent thrombus was removed with endarterectomy instruments. After closure and rewarming, completion TEE showed an empty right atrium with restored hepatic venous flow.

Postoperative Course

Recovery was uneventful. A computed tomography (CT) scan on postoperative day 12 showed the suprahepatic cava and a clear right atrium. The patient was discharged on postoperative day 14. Histopathology showed clear cell renal cell carcinoma, ISUP grade 3, pT3c. He received anticoagulation and adjuvant pembrolizumab. By postoperative day 61, he was asymptomatic and gaining weight.

Key Takeaways

A level IV thrombus that appears inoperable to a single discipline becomes a controlled resection when each team contributes the step it performs routinely. Piggyback mobilization converts the most hazardous caval dissection into a controlled one; completing the nephrectomy before bypass shortens the duration of bypass and arrest; and arch isolation with antegrade cerebral perfusion removes the time pressure, which is what permits complete clearance.

This video is the third-place winner from the 2026 Innovation Video Competition. Watch all entries from the competition, including the other winning videos. 

References

1. Blute ML, Leibovich BC, Lohse CM, Cheville JC, Zincke H. The Mayo Clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumour thrombus. BJU Int. 2004;94(1):33-41. doi:10.1111/j.1464-410X.2004.04897.x
2. Ciancio G, Gonzalez J, Shirodkar SP, Angulo JC, Soloway MS. Liver transplantation techniques for the surgical management of renal cell carcinoma with tumor thrombus in the inferior vena cava: step-by-step description. Eur Urol. 2011;59(3):401-6. doi:10.1016/j.eururo.2010.07.028
3. Zacek P, Dominik J, Brodak M, Louda M. Selective aortic arch perfusion enables to avoid deep hypothermic circulatory arrest for extirpation of renal cell carcinoma with tumour thrombus extension into the right atrium. Interact Cardiovasc Thorac Surg. 2014;18(4):411-4. doi:10.1093/icvts/ivt545
4. Ciancio G, Livingstone AS, Soloway M. Surgical management of renal cell carcinoma with tumor thrombus in the renal and inferior vena cava: the University of Miami experience in using liver transplantation techniques. Eur Urol. 2007;51(4):988-94. doi:10.1016/j.eururo.2006.11.055
5. Zacek P, Brodak M, Gofus J, et al. Renal cell carcinoma with intracardiac tumor thrombus extension: radical surgery yields 2 years of postoperative survival in a single-center study over a period of 30 years. Front Oncol. 2023;13:1137804. doi:10.3389/fonc.2023.1137804
6. Mazzola A, Gregorini R, Villani C, et al. Cavoatrial tumor thrombectomy with systemic circulatory arrest and antegrade cerebral perfusion. Ann Thorac Surg. 2007;83(4):1564-5. doi:10.1016/j.athoracsur.2006.04.028
7. Shuch B, Crispen PL, Leibovich BC, et al. Cardiopulmonary bypass and renal cell carcinoma with level IV tumour thrombus: can deep hypothermic circulatory arrest limit perioperative mortality? BJU Int. 2011;107(5):724-8. doi:10.1111/j.1464-410X.2010.09488.x

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