Shuch Brian, Larochelle Jeffrey C, Onyia Thomas, Vallera Cristianna, Margulis Dan, Pantuck Allan J, Smith Robert B, Belldegrun Arie S
Department of Urology, University of California-Los Angeles, Los Angeles, California 90095-1738, USA.
J Urol. 2009 Feb;181(2):492-8; discussion 498-9. doi: 10.1016/j.juro.2008.10.036. Epub 2008 Dec 24.
Vascular invasion commonly occurs in renal cell carcinoma and intraoperative thrombus embolization is a known complication of tumor thrombectomy. We reviewed our experience with this complication to determine frequency, mortality, common factors and management strategies.
We retrospectively reviewed a prospective database of cases of open nephrectomy/tumor thrombectomy performed from 1989 to 2008. All cases were reviewed to identify clinicopathological variables, the thrombus extent and intraoperative complications. All cases with events were reviewed to identify preoperative pulmonary embolism, preoperative imaging, thrombus extent, presentation, management and outcome.
A total of 282 cases of venous tumor thrombus were identified. Tumor thrombus level was 0 in 133 cases (47.2%), I to II in 85 (30.1%), III in 27 (9.6%) and IV in 29 (10.3%). Thrombus embolization was identified in 5 patients (1.8%). The incidence in level 0 vs I to IV was 0 of 133 cases (0%) vs 5 of 149 (3.4%), which was statistically significant (p = 0.04). Three patients (60%) died of the event. A review of recent series demonstrated a 1.49% incidence with 75% mortality.
Intraoperative thrombus embolization is rare but when it occurs, mortality is extremely high. Strict attention to surgical principles is necessary to decrease risk. Extension into the vena cava, preoperative pulmonary embolism and a bland thrombus component may indicate increased risk. Adjunct procedures, such as preoperative filters and endoluminal occlusive balloons, may be justified in patients at high risk. Even with prompt recognition and embolectomy survival is rare.
血管侵犯在肾细胞癌中常见，术中血栓栓塞是肿瘤血栓切除术已知的并发症。我们回顾了我们在该并发症方面的经验，以确定其发生率、死亡率、常见因素及处理策略。
我们回顾性分析了1989年至2008年行开放性肾切除术/肿瘤血栓切除术病例的前瞻性数据库。对所有病例进行回顾以确定临床病理变量、血栓范围及术中并发症。对所有发生相关事件的病例进行回顾，以确定术前肺栓塞、术前影像学检查、血栓范围、临床表现、处理及结果。
共识别出282例静脉肿瘤血栓病例。肿瘤血栓水平为0级的有133例（47.2%），Ⅰ至Ⅱ级的有85例（30.1%），Ⅲ级的有27例（9.6%），Ⅳ级的有29例（10.3%）。5例患者（1.8%）发生血栓栓塞。0级与Ⅰ至Ⅳ级的发生率分别为133例中的0例（0%）和149例中的5例（3.4%），差异有统计学意义（p = 0.04）。3例患者（60%）死于该事件。近期系列研究显示发生率为1.49%，死亡率为75%。
术中血栓栓塞罕见，但一旦发生，死亡率极高。严格遵循手术原则对于降低风险很有必要。肿瘤延伸至腔静脉、术前肺栓塞及血栓存在非血栓成分可能提示风险增加。对于高危患者，术前放置滤网和腔内闭塞球囊等辅助操作可能是合理的。即使能及时识别并进行栓子切除术，存活也很罕见。
