Cardiovascular surgery in the management of malignant renal neoplasms: survey of 187 cases in the literature.

Transmural or endovascular invasion of regional veins is often a characteristic of malignant renal neoplasms. Tumor thrombus that ascends in the inferior vena cava and sometimes invades the heart seldom adheres to intima. Radical surgical management of malignant renal neoplasms necessitates concomitant extraction of tumor thrombus. This may be achieved by cavotomy alone, but often resection of portions of the suprarenal inferior vena cava (either partial mural cavectomy, or circumferential cavectomy) is also required. Atriotomy is mandatory whenever intracardiac tumor thrombus exists. Most of the 187 reported operations for venous extension related to malignant renal neoplasms were done in the past decade. Technical problems have included embolism, hemorrhage, and incomplete removal. Because the left kidney is endowed with vast collateral venous channels, right nephrectomy and suprarenal caval interruption are usually well tolerated. Conversely, since the right kidney lacks venous collaterals, survival after left nephrectomy and suprarenal cavectomy hinges on creation of a shunt to divert venous outflow from the remaining kidney.