Anesthetic Management of Emergency Cardiopulmonary Bypass during Radical Nephrectomy for Renal Cell Carcinoma with Level IV Right Atrial Tumor Thrombus: A Case Report
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Renal cell carcinoma (RCC) extends into the venous system in 4–10% of cases, and in approximately 1% of cases, the tumor thrombus reaches the right atrium (Mayo level IV). We describe the anesthetic management of a 40-year-old man (53 kg, American Society of Anesthesiologists [ASA] physical status III) with cT3N0M0 right-sided RCC and a mobile cavoatrial tumor thrombus that intermittently obstructed the tricuspid valve. He was scheduled to undergo combined open radical nephrectomy and tumor thrombectomy, with cardiopulmonary bypass (CPB) on standby. Relevant comorbidities included anemia, hypoalbuminemia, hypokalemia, prolonged activated partial thromboplastin time, grade III right hydronephrosis, bilateral pleural effusions, and chronic hypertension. Intraoperative monitoring included invasive arterial blood pressure monitoring, internal jugular central venous access, and continuous transesophageal echocardiography (TEE). Midway through the nephrectomy, the patient's condition deteriorated abruptly; TEE demonstrated prolapse of the tumor thrombus into the right atrium, causing obstruction of right ventricular inflow. Emergency median sternotomy was performed, CPB was initiated, and the thrombus was removed. The patient was successfully weaned from CPB with dopamine at 10 µg/kg/min, heparin was reversed until the activated clotting time reached 160 seconds, and the nephrectomy was subsequently completed. He was extubated on the first postoperative day, transferred to the ward on postoperative day 2, and discharged on postoperative day 5 without neurological deficits. This case illustrates that, in patients with Mayo level IV RCC-associated tumor thrombus, continuous TEE surveillance, a rehearsed emergency conversion protocol to CPB, and a coordinated multidisciplinary team can facilitate the rapid recognition and treatment of a potentially fatal intraoperative event.
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