Exceptional surgery at the Gemelli Polyclinic in Rome: in the same session, a coronary bypass was performed, a kidney tumor was removed and a huge thrombus in the inferior vena cava was removed. The extremely complex operation involved three different teams (urology, heart surgery and hepato-biliary surgery) for 10 hours. The case of rare complexity involved a 62-year-old Roman, who presented with an incredible series of pathologies, each of which was potentially fatal. The patient was discharged a few days ago and is doing well.
“Everything begins in the Gemelli Emergency Room – recalls Marco Racioppi, interim director of the Urological Clinic of the Agostino Gemelli Irccs University Hospital Foundation and associate professor of Urology at the Catholic University of the Sacred Heart – where Mr. Marco goes because that morning he had seen the urine red with blood, but without any symptoms that could suggest a bad cystitis.The doctors of the Emergency Department study the case, immediately requesting a renal ultrasound, which shows the presence of a 7 cm mass in the right kidney A kidney tumor is therefore suspected, which can start with a silent hematuria”.
The patient is hospitalized and tests begin to be requested in anticipation of nephrectomy. And here comes the first ‘surprise’. “The CT scan with contrast medium – continues Racioppi – reveals that the tumor has unfortunately invaded the pelvis of the kidney and the renal vein, where an enormous thrombus has formed which ascends throughout the inferior vena cava. In some places the thrombus, along about 15 cm, has a diameter of 6 cm and extends to the heart, where it ‘peeps’ at the opening of the inferior vena cava, occupying part of the right atrium”.
In short, a very complex and delicate situation. “Usually – explains Piero Farina of the UOC of Cardiac Surgery – despite its presence inside the heart it is possible to ‘remove’ the thrombus from below, i.e. from the level of the kidney, where it originates, under strict cardiac surgical control (the thrombus could in fact crumble and cause a potentially fatal massive pulmonary embolism). In this case, the exceptional size of the thrombus and its intracardiac portion required the connection of the patient to an extracorporeal circulation machine, to avoid prolonged periods of hypotension and reduce blood loss”. Furthermore, the usual preoperative cardiological assessments reveal the presence of a critical narrowing in the anterior descending artery, the ‘queen’ of the coronaries. Under these conditions, the heart would not be able to withstand the surgery. It would be possible to unblock the coronary artery by implanting a stent, but this would require therapy with two antiplatelet drugs for at least 3 months, which would significantly increase the risk of bleeding during the operation.
The case is discussed in a crowded Heart Team session and in the end it is decided to solve all of Marco’s problems in a single operating session. The first move is up to the cardiac surgeon: having isolated the internal mammary artery (an artery in the chest), Farina proceeds to prepare – with a beating heart – the bypass which secures Marco’s heart for the entire duration of the operation. At this point, Racioppi can devote himself to the delicate maneuver of removing the tumor and the thrombus in the vena cava. To do this, the inferior vena cava must be exposed along its entire length, up to the heart. The thoracic part is already visible (thanks to the median sternotomy), but in the abdomen the vena cava is ‘hidden’ by the liver for a good stretch. A problem which Agostino De Rose, a hepato-biliary surgeon, is called upon to deal with, who carries out a ‘derotation’ of the liver, to expose the tract of the vena cava behind it. At this point everything is ready to remove the diseased kidney and simultaneously free the large vein from this giant thrombus. Racioppi then proceeds to ‘prepare’ the diseased kidney (isolating the ureter, the veins and the renal artery).
The cardiac surgery team comes back in to connect the patient to the extracorporeal circulation machine, inserting cannulae into the heart and groin. This will allow the kidney to be removed and the thrombus removed, minimizing blood loss and avoiding dangerous drops in blood pressure. The urological team finally removes the kidney and ‘removes’ the thrombus from the vena cava (open and closed at the bottom). Transesophageal echocardiographic control confirmed the disappearance of the thrombus from the right atrium. This last delicate maneuver is completed in just 15 minutes. After 4 days of cardiac surgery intensive care, 2 in cardiac surgery and a few more days of hospitalization in urology, the patient is finally discharged. It’s February 3 and Marco comes out (incredibly) on his legs. At home, his son is waiting for him. He’s the one who gave him the strength to face this incredible surgery, but the boy is autistic and his dad knows he can’t make him wait any longer.