The anesthetic management and the specific features of perioperative management in cases of nephrectomy with thrombectomy from the inferior vena cava in patients with renal cell cancer

Renal cell cancer is one of the most widespread oncourological diseases (90% of all the malignant neoplasms in the kidneys) with high mortality. Every year worldwide, approximately 120,000 new cases of renal cell cancer are diagnosed, which is approximately 2% within the structure of the cancer incidence rates, and 65% of the patients are being diagnosed in the developed countries. Nephrectomy is the main method of radical therapy for such patients. In cases of tumor thrombosis of the inferior vena cava, which develops in 25–30% of the cases of renal cell cancer and represents a lethal complication of this disease due to the fragmentation of the thrombotic masses and developing pulmonary embolism, nephrectomy with thrombectomy is indicated. A special category includes the patients with renal cell cancer, complicated by the tumor thrombosis of the inferior vena cava with grades III (thrombus located at the level or above the hepatic veins, but below the diaphragm) and IV (thrombus spreading into the supradiaphragmatic inferior vena cava or into the right atrium) according to the classification by the Mayo Clinic, in which the surgical strategy is accompanied by significantly traumatic manipulations with the liver, the suprahepatic segment of the inferior vena cava, as well as with the heart chambers, suggesting the parallel cardiosurgical intervention. Surgical interventions with this background are accompanied by the complete or the parallel methods of extracorporeal circulation. The initially burdened status of the patient (tumor-related intoxication, anemia, hyperazotemia, in a number of cases thrombosis of the venous system in the lower limbs along with the concomitant abnormalities) and the extent of surgical intervention determine the high risk of complications (up to 93%) and hospital mortality (up to 10%). The preoperative evaluation of the risks of surgery, defining the most favorable tactics for the patient and the thorough preoperative preparation are necessary for the safest course of surgery and for the early rehabilitation of the patient. Currently, there is no unified commonly accepted algorithm adopted for managing such patients, while the developed commonly available standards often have a generalized type, not reflecting the specific features found in the patients with tumor thrombosis of the inferior vena cava. This review attempts to compile the specific features of the anesthetic management in cases of nephrectomy with thrombectomy in patients with renal cell cancer, to describe the main pathophysiological features of the tumor thrombosis of the inferior vena cava, the complications of the perioperative period, the methods for their prevention and treatment. The main directions were provided for the combined diagnostics and treatment, special attention was paid to the multi-disciplinary (urologists, oncologists, cardiovascular and cardiosurgery specialists, anesthesiologists and intensivists) team-based approach to perioperative management of the patients with tumor thrombosis of the inferior vena cava.