Ohwada Susumu, Ishikawa Susumu, Kawashima Yoshiyuki, Yoshikawa Daisuke, Hamada Yoshiro, Tomizawa Naoki, Kawate Susumu, Morishita Yasuo
Second Department of Surgery, Gunma University Faculty of Medicine, Maebashi, Japan.
Hepatogastroenterology. 2004 Jul-Aug;51(58):987-9.
Malignant neoplasms rarely extend into the inferior vena cava and up to the right side of the heart. Although massive pulmonary tumor embolism occurs relatively rarely, it can be a catastrophic problem. Intraoperative pulmonary tumor embolism and cardiac arrest occurred in a 68-year-old woman while dissecting the inferior vena cava to resect a pararenal tumor extending into the retrohepatic inferior vena cava. Abrupt arterial hypotension, tachycardia, and increased central venous pressure lead to the diagnosis of massive pulmonary tumor embolism. Emergency cardiopulmonary bypass was commenced under profound hypothermia and cardiac arrest. The tumors in the main pulmonary artery were extracted, and fragments of remnant tumor were retrieved by a vascular endoscope, a Fogarty catheter, and milking of the lung. Following embolectomy, the tumor in the retrohepatic to infrarenal inferior vena cava was removed and the primary tumor together with the infrarenal inferior vena cava was resected under hepatic vascular exclusion and partial cardiopulmonary bypass. The inferior vena cava below the renal veins was not reconstructed. The patient recovered with slight retrograde amnesia. A postoperative pulmonary perfusion scintigram showed no defect in the pulmonary circulation. She is well now 8 months after surgery. Safe prevention measures should be accomplished as a part of the perioperative management of patients with inferior vena cava tumor thrombus that may be fragile, and cardiopulmonary bypass should always be stand-by on surgery.
恶性肿瘤很少延伸至下腔静脉并直至心脏右侧。尽管大量肺肿瘤栓塞相对少见,但它可能是一个灾难性问题。一名68岁女性在解剖下腔静脉以切除延伸至肝后下腔静脉的肾旁肿瘤时发生术中肺肿瘤栓塞和心脏骤停。动脉血压骤降、心动过速和中心静脉压升高导致大量肺肿瘤栓塞的诊断。在深度低温和心脏骤停下开始紧急体外循环。取出主肺动脉内的肿瘤,并通过血管内窥镜、Fogarty导管和肺部挤压取出残余肿瘤碎片。血栓切除术之后,切除肝后至肾下下腔静脉内的肿瘤,并在肝血管阻断和部分体外循环下切除原发肿瘤及肾下下腔静脉。肾静脉下方的下腔静脉未重建。患者恢复,伴有轻微逆行性失忆。术后肺灌注闪烁扫描显示肺循环无缺损。术后8个月她目前状况良好。对于可能易碎的下腔静脉肿瘤血栓患者,应作为围手术期管理的一部分采取安全预防措施,并且手术时体外循环应随时待命。