Renal Carcinoma With Supradiaphragmatic Tumor Thrombus: Avoiding Sternotomy and Cardiopulmonary Bypass Gaetano Ciancio, MD, Samir P. Shirodkar, MD, Mark.

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Renal Carcinoma With Supradiaphragmatic Tumor Thrombus: Avoiding Sternotomy and Cardiopulmonary Bypass Gaetano Ciancio, MD, Samir P. Shirodkar, MD, Mark S. Soloway, MD, Alan S. Livingstone, MD, Michael Barron, MD, Tomas A. Salerno, MD The Annals of Thoracic Surgery Volume 89, Issue 2, Pages 505-510 (February 2010) DOI: 10.1016/j.athoracsur.2009.11.025 Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Intraoperative photo shows diaphragm of dissected suprahepatic inferior vena cava (IVC). The intrapericardial IVC is exposed through the abdominal cavity. Curved arrow shows mobilization of the diaphragm. The Annals of Thoracic Surgery 2010 89, 505-510DOI: (10.1016/j.athoracsur.2009.11.025) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Drawing shows abdominal removal of renal cell carcinoma with level IV thrombus (intraatrial tumor thrombus). (A) The abdominal inferior vena cava (IVC) is exposed by mobilizing the liver off the retrohepatic IVC. (B) The central tendon of the diaphragm and the IVC are dissected off the posterior abdominal wall (dotted lines). The right atrium, distal IVC, porta hepatis, and left renal vein are clamped. (C) The surgeon's fingers are wrapped around the IVC to perform the milking down process. A vascular clamp is placed below the hepatic veins, and the porta hepatis clamp is released. Hepatic venous drainage is permitted during closure or reconstruction and the IVC. The Annals of Thoracic Surgery 2010 89, 505-510DOI: (10.1016/j.athoracsur.2009.11.025) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions