Emergency Cardiopulmonary Bypass for Massive Pulmonary Embolism Occurring During Nephrectomy Karim Fikry, MD,* Michael L. Blute, MD,† Thoralf M. Sundt III, MD,‡ and Mark McKeen, MD* We report a case of cardiac arrest secondary to pulmonary tumor embolization occurring in a patient undergoing nephrectomy for renal cell carcinoma with a tumor thrombus invading the inferior vena cava infrahepatically. Tumor embolization in such cases is very rare (1.5%), but if it occurs, mortality is 75%. In our case, resources were rapidly mobilized, and cardiopulmonary bypass was initiated for pulmonary embolectomy within 34 minutes of the cardiac arrest. The patient’s trachea was extubated on postoperative day 1, and he was discharged home 9 days later neurologically intact. Excellent preoperative and intraoperative communication among all involved health care providers, as well as rapid mobilization of the available resources, played important roles in the patient’s positive outcome.  (A&A Case Reports. 2015;4:117–9.)


The authors declare no conflicts of interest.

The IVC was dissected infrahepatically, but before gaining proximal control of the tumor thrombus, his systolic arterial blood pressure decreased to approximately 50 mm Hg and his CVP increased significantly (39 mm Hg from 10 mm Hg), followed by a pulseless electric activity (PEA) cardiac arrest. Chest compressions were immediately started, and a transesophageal echocardiogram (TEE) was requested simultaneously with notification of the cardiothoracic surgery team. The patient regained pulse and blood pressure after 2 minutes of chest compressions and 1 mg epinephrine. However, PEA arrest occurred twice more, requiring cardiopulmonary resuscitation as above, but spontaneous circulation could not be maintained for >10 minutes. TEE performed by the cardiac anesthesia team showed severe dilation and diffuse hypokinesis of the right ventricle and a collapsed left ventricle with septal flattening, increasing the suspicion for massive pulmonary embolism. However, no clots were visualized in either the bicaval or the transgastric views. An arterial blood gas was obtained, and it showed pH 7.27, Pco2 40 mm Hg, and Po2 335 mm Hg. Of note, there were no hypoxic events preceding the initial cardiac arrest, signifying that the pulmonary embolism most probably occurred suddenly as opposed to ongoing small embolic showers. The decision was made by the primary surgeon, anesthesiologist, and cardiothoracic surgeon to proceed to immediate sternotomy and cardiopulmonary bypass. Within 34 minutes from the initial cardiac arrest, cardiopulmonary bypass was initiated along with full heparin-induced anticoagulation. The patient’s temperature was eventually decreased to 33°C. The right kidney was removed by the urologists, while the cardiac surgeon explored the pulmonary vasculature. A massive tumor embolus was eventually evacuated from the pulmonary arteries (Fig. 2). Subsequently, an IVC filter was placed. The patient was separated from cardiopulmonary bypass and taken to the intensive care unit with his trachea intubated and requiring low doses of epinephrine and milrinone infusions that were completely discontinued in the intensive care unit within several hours. The patient’s trachea was extubated the next day, and he was discharged home on postoperative day 9 without neurological or cardiovascular deficits.

Address correspondence to Karim Fikry, MD, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114. Address e-mail to [email protected].


his is a case of a patient undergoing nephrectomy for a level 2 renal cell carcinoma (RCC) with tumor thrombus invading the inferior vena cava (IVC) infrahepatically in whom tumor embolism to the pulmonary arteries necessitated emergency cardiopulmonary bypass. In this case, thoughtful preparation and awareness of the available resources, excellent communication among all involved health care providers, as well as quick mobilization of resources played an important role in this patient’s positive outcome. The patient reviewed the case report and gave permission for publication of the report.


A 69-year-old man with newly diagnosed right RCC measuring 7 × 7 cm with a tumor thrombus invading the renal vein and infrahepatic IVC (Fig.  1) presented for right nephrectomy, IVC thrombectomy, and IVC filter placement. His medical history was significant for hypertension, chronic obstructive pulmonary disease, and diet-controlled diabetes. He was admitted 1 day before surgery to receive a heparin infusion with a goal for partial thromboplastin time of 60 to 80 seconds. On the day of surgery, he received all scheduled antihypertensive medications, and the heparin infusion was discontinued 4 hours before the surgical start time. After confirming a normal partial thromboplastin time, a low thoracic epidural catheter was placed along with an intra-arterial catheter before induction. Anesthesia was induced with 1 mcg/kg fentanyl, 1 mg/kg propofol, and 1 mg/kg rocuronium. After tracheal intubation, a central venous catheter introducer was placed into the right internal jugular vein for intravascular volume and drug administration. His baseline central venous pressure (CVP) was 12 mm Hg. A midline subxiphoid incision was performed, and the right kidney was completely mobilized. From the *Department of Anesthesia, Critical Care and Pain Medicine, †­Department of Urology, and ‡Department of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts. Accepted for publication October 16, 2014. Funding: None.

Copyright © 2015 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000142

May 1, 2015 • Volume 4 • Number 9

Tumor thrombus in the IVC has an incidence of 4% to 15% of patients with RCC.1,2 To this date, the relationship cases-anesthesia-analgesia.org


Figure 1. Preoperative magnetic resonance imaging showing right renal mass with tumor thrombus invading the inferior vena cava (IVC) infrahepatically, with patent IVC intra- and suprahepatic.

Figure 2. Part of the thrombus retrieved from the pulmonary vasculature.

between the level of IVC thrombus and long-term prognosis is unclear3–5; however, the mere presence of vascular involvement poses a great challenge for surgeons, as well as anesthesiologists, intraoperatively. It has been shown that the incidence of thrombus embolization is about 1.5%, but if it occurs, mortality is 75%.6 Preoperatively, anesthesiologists should be aware of the extent of tumor thrombus involvement, which has been classified by the Mayo Clinic: level 0 = thrombus extending to the renal vein only; level I = extension to the IVC to no >2 cm above the renal vein; level II = IVC extension >2 cm above the renal vein, but below the level of the hepatic veins; level III = extension above the hepatic veins, but below the diaphragm; level IV = extension into the supradiaphragmatic IVC and/or right atrium.7 Resections involving level IV and occasionally level III clot burden are commonly done with cardiopulmonary bypass to confirm control of thrombus before or during mobilization of the tumor. Level II tumors, however, are usually performed without the use of cardiopulmonary bypass, and this was the surgical plan for our patient. In another case series by the Mayo Clinic, only 1 case of 77 level II tumors (1.3%) was resected on cardiopulmonary bypass.8 Perioperative morbidity and mortality in these cases are typically related to massive blood loss or thromboembolic events, along with other common causes. In preparation for

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potential blood loss, 2 large bore peripheral IVs (14 and 16 gauge) were placed, as well as a large bore central venous catheter introducer sheath. In addition, 4 units of blood were cross-matched and available in the operating room and an intra-arterial catheter was placed to rapidly detect any hemodynamic changes, as well as to facilitate laboratory detection of acidosis and anemia. Given the potential for thromboembolic events, specifically pulmonary embolism, CVP was transduced and monitored closely throughout the case. The evidence for continuous monitoring with TEE in these cases is scarce, and recommendation for its use is based solely on similar case reports.9 Per the American Society of Anesthesiologists/ Society of Cardiovascular Anesthesiologists guidelines, TEE monitoring is indicated during noncardiac surgery if there is unexplainable life-threatening cardiovascular collapse not responding to corrective therapy. Despite the limited evidence that monitoring with TEE is advantageous intraoperatively in such cases10,11 and that the risk to the patient may be minimal, it is still an invasive procedure that requires careful attention, resources, and consideration.12,13 In addition, with invasive arterial blood pressure and CVP monitoring already in place, it is not clear that TEE would have led to earlier diagnosis or treatment of pulmonary embolism in this particular case. Before the case, the surgical and anesthesia teams discussed whether a TEE was warranted. Given that the imaging was obtained just days before surgery and that it showed only infrahepatic IVC thrombus and no pulmonary vasculature involvement, as well as the absence of pulmonary symptoms that may have indicated migration of IVC thrombus, the team decided that continuous TEE was not essential from the beginning of the case. If the risk of tumor embolization was deemed great enough, it would suggest that the case should be performed in a cardiac operating room with early TEE surveillance and cardiopulmonary bypass on standby. However, in our case, TEE availability was confirmed if hemodynamic changes occurred that would raise the suspicion for pulmonary embolism, as well as the availability of a TEE-certified anesthesiologist. In addition, preoperatively, the patient had consented to possible TEE placement. Another important factor in the positive outcome of our case was effective communication among all team members. In this case, the surgeons were immediately alerted to the sudden onset of the hypotension, and they confirmed that they were not compressing the IVC and that there were no signs of acute massive blood loss, both of which concurred with the sudden increase in CVP. This rapidly progressed to PEA arrest, which was rapidly communicated between the anesthesiologists and the surgeons. In response to these circumstances, cardiopulmonary resuscitation was directed by the anesthesiologist, and advanced cardiovascular life support was immediately started with effective chest compressions by the surgeons. Extra help was called for, along with the TEE, portable cardiopulmonary bypass circuit, and cardiac surgeon, which all played a vital role in the prompt management of this massive intraoperative pulmonary embolism. In our case, the duration of time from cardiac arrest to cardiopulmonary bypass was 34 minutes, which we believe was an important factor in this patient’s positive outcome.

A & A case reports

In addition, the use of TEE was an additional aid in confirming the suspected pulmonary embolism, as the TEE was being read simultaneously as the cardiac surgeon was scrubbing in and preparing the chest for sternotomy. It also was of great help to manage hemodynamics during separation from cardiopulmonary bypass. In summary, it is crucial for the anesthesiologist to understand the extent of the disease, tumor burden, and possible intraoperative complications of these high-risk cases. The location of the procedure and the degree of invasive monitoring must be carefully considered preoperatively and a decision made in conjunction with the surgical team. Moreover, excellent communication between the surgical and anesthesia teams is of great importance during crisis events. Finally, knowledge of all the available resources and expeditiously obtaining help clearly correlate with improved patient outcomes in these challenging cases. E REFERENCES 1. Marshall FF, Dietrick DD, Baumgartner WA, Reitz BA. Surgical management of renal cell carcinoma with intracaval neoplastic extension above the hepatic veins. J Urol 1988;139:1166–72 2. Ljungberg B, Stenling R, Osterdahl B, Farrelly E, Aberg T, Roos G. Vein invasion in renal cell carcinoma: impact on metastatic behavior and survival. J Urol 1995;154:1681–4 3. Miyake H, Terakawa T, Furukawa J, Muramaki M, Fujisawa M. Prognostic significance of tumor extension into venous system in patients undergoing surgical treatment for renal cell carcinoma with venous tumor thrombus. Eur J Surg Oncol 2012;38:630–6 4. Martínez-Salamanca JI, Huang WC, Millán I, Bertini R, Bianco FJ, Carballido JA, Ciancio G, Hernández C, Herranz F, Haferkamp A, Hohenfellner M, Hu B, Koppie T, MartínezBallesteros C, Montorsi F, Palou J, Pontes JE, Russo P, Terrone C, Villavicencio H, Volpe A, Libertino JA; International Renal Cell Carcinoma-Venous Thrombus Consortium. Prognostic impact

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of the 2009 UICC/AJCC TNM staging system for renal cell carcinoma with venous extension. Eur Urol 2011;59:120–7 5. Kim HL, Zisman A, Han KR, Figlin RA, Belldegrun AS. Prognostic significance of venous thrombus in renal cell carcinoma. Are renal vein and inferior vena cava involvement different? J Urol 2004;171:588–91 6. Shuch B, Larochelle JC, Onyia T, Vallera C, Margulis D, Pantuck AJ, Smith RB, Belldegrun AS. Intraoperative thrombus embolization during nephrectomy and tumor thrombectomy: critical analysis of the University of California-Los Angeles experience. J Urol 2009;181:492–8 7. Neves RJ, Zincke H. Surgical treatment of renal cell carcinoma with vena cava extension. Brit J Urol 1987;59:390–5 8. 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;94:33–41 9. Thys DM, Brooker RF, Cahalan MK, Connis RT, Duke PG, Nickinovich DG, Reeves ST, Rozner MA, Russell IA, Streckenbach SC, Sears-Rogan P, Stewart WJ. Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 2010;112:1084–96 10. Oikawa T, Shimazui T, Johraku A, Kihara S, Tsukamoto S, Miyanaga N, Hattori K, Kawai K, Uchida K, Takeshima H, Saito S, Toyooka H, Akaza H. Intraoperative transesophageal echocardiography for inferior vena caval tumor thrombus in renal cell carcinoma. Int J Urol 2004;11:189–92 11. Chen H, Ng V, Kane CJ, Russell IA. The role of transesophageal echocardiography in rapid diagnosis and treatment of migratory tumor embolus. Anesth Analg 2004;99:357–9 12. Cote G, Denault Aj. Transesophageal echocardiograpy-related complications. Can J Anaesth 2008;55:622–47 13. Daniel WG, Erbel R, Kasper W, Visser CA, Engberding R, Sutherland GR, Grube E, Hanrath P, Maisch B, Dennig K. Safety of transesophageal echocardiography. A multicenter survey of 10,419 examinations. Circulation 1991;83:817–21



Emergency cardiopulmonary bypass for massive pulmonary embolism occurring during nephrectomy.

We report a case of cardiac arrest secondary to pulmonary tumor embolization occurring in a patient undergoing nephrectomy for renal cell carcinoma wi...
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