Thrombectomy under deep hypothermic circulatory arrest (DHCA) for renal cell carcinoma with atrio-caval thrombus

Renal cell carcinoma accounts for 85–90 % of all primary renal neoplasms and has the propensity to expand and directly invade contiguous structures such as the inferior vena cava predisposing to thrombus formation in approximately 10 % of cases. Overall, 70 % of patients survive for 5 years. While several classifications have been published to characterize the level of thrombus involvement and subsequently define the appropriate surgical treatment, the prognosis of such remains to be ascertained. Furthermore, controversies exist as to the most appropriate surgical approach particularly for atrial thrombus (Level IV). Although traditionally such thrombus level is addressed using cardiopulmonary bypass with or without deep hypothermic arrest, there have been recent reports of a less invasive maneuver using a transdiaphragmatic approach, essentially milking the thrombus down, avoiding sternotomy. We present our initial case of a 59-year-old male having a right renal mass with extensive thrombus from the inferior vena cava up to the right atrium managed with radical nephrectomy and thrombectomy under cardiopulmonary bypass with deep hypothermic circulatory arrest. Patient remains tumor-free after 1 year of follow-up.