Impact of Hospital Case Volume on Outcomes Following Radical Nephrectomy and Inferior Vena Cava Thrombectomy.
ABSTRACT: BACKGROUND:Radical nephrectomy with inferior vena cava thrombectomy (RN-IVCT) is a complicated procedure for which the impact of hospital case volume on overall survival (OS) is unknown. OBJECTIVE:To assess the degree to which renal cell carcinoma (RCC) with inferior vena cava tumor thrombus (IVC-TT) care is centralized and to evaluate the impact of hospital case volume on outcomes following RN-IVCT. DESIGN, SETTING, AND PARTICIPANTS:The National Cancer Data Base was queried for patients with pT3b-c RCC treated with RN-IVCT. Hospitals were classified by case volume percentile as low (<75th percentile, <0.67 cases annually), intermediate (75th-95th percentile, 0.67-2.99 cases annually), or high (>95th percentile, >3 cases annually). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS:The primary outcome was OS. Secondary outcomes were short-term (30- and 90-d) mortality rates according to hospital case volume. Kaplan-Meier curves and Cox regression model were used to evaluate OS and the effect of covariables. RESULTS AND LIMITATIONS:There were 2664 cases of RN-IVCT for pT3b-c tumors reported by 573 institutions, of which 435, 108, and 30 were classified as low, intermediate, and high volume, accounting for 28.5%, 34.5%, and 37% of cases, respectively. Treatment at high-volume institutions was associated with better OS: the median OS was 42, 53, and 60 months for low, intermediate and high-volume centers, respectively (p=0.009). After multivariable adjustment, treatment at a high-volume institution was associated with a 24% relative risk reduction for all-cause mortality compared to treatment at a low-volume institution (hazard ratio 0.76, 95% confidence interval 0.65-0.89; p=0.001). There was no significant difference in short-term mortality following RN-IVCT when stratified by hospital case volume. CONCLUSIONS:Higher hospital case volume was associated with longer OS for patients undergoing RN-IVCT. These findings support efforts to centralize care for cases of advanced RCC. PATIENT SUMMARY:In this study we looked at the impact of hospital case volume on survival following surgery for renal cell carcinoma and inferior vena cava thrombectomy. Survival was significantly better in high-volume hospitals performing three or more procedures per year.
Project description:BACKGROUND:Wilms tumor is the most common renal tumor of childhood. Duplication of the inferior vena cava is an uncommon anomaly. In the present study, we present a case of Wilms tumor with the inferior vena cava duplication, which has not been reported previously. CASE PRESENTATION:A 14-month-old female presented with an enlarging abdominal mass. Computed tomography imaging demonstrated a large mass in the right kidney, duplication of the inferior vena cava below the renal veins and compression of the right inferior vena cava caused by the enormous mass. A right radical nephrectomy was performed. Final pathology was consistent with Wilms tumor. Postoperative adjuvant chemotherapy was executed. Computed tomography imaging at 3 months postoperatively showed the right inferior vena cava played a dominant role and the left inferior vena cava was not detected clearly. During the follow-up of 18 months, no local recurrence or metastasis has been observed. CONCLUSION:It is important to recognize the case of Wilms tumor with the inferior vena cava duplication to avoid injury of retroperitoneal venous anomalies and life-threatening hemorrhage during surgery through preoperative computed tomography.
Project description:Twenty percent of patients with Cancer Associated Thrombosis receive an inferior vena cava filter annually. Insertion is guided by practice guidelines, which do not specify or discuss the use of inferior vena cava filters in malignancy. Adherence to these guidelines is known to be variable. We aimed to see if there was consistent management of venous thromboembolism among Medical Oncologists/Haematologists and Respiratory Physicians, with respect to inferior vena cava filter use in the setting of suspected and confirmed malignancy. Medical Oncologists, Haematologists and Respiratory Physicians were surveyed with four theoretical cases. Case 1 concerns a patient who develops a pulmonary embolism following spinal surgery. Cases 2 and 4 explore the use of inferior vena cava filters in the setting of malignancy. Case 3 covers the role of inferior vena cava filters in recurrent thrombosis despite systemic anticoagulation. There were 56 responses, 32 (57%) Respiratory Physicians and 24 (43%) Haematologists/Oncologists. Respiratory Physicians were significantly more likely to insert an inferior vena cava filter in case 1 (<i>p</i>?=?0.04) whilst Haematologists/Medical Oncologists were more likely to insert an inferior vena cava filter in case 3 (<i>p</i>?=?0.03). No significant differences were found in cases 2 and 4. There were significant disparities in terms of type and timing of anticoagulation. Consistency of recommendations with guidelines was variable likely in part because guidelines are themselves inconsistent. The heterogeneity in responses highlights the variations in venous thromboembolism management, especially in Cancer Associated Thrombosis. International Societies should consider addressing inferior vena cava filter use specifically in the setting of Cancer Associated Thrombosis. Collaboration between interested specialities would assist in developing consistent, evidence-based guidelines for the use of inferior vena cava filters in the management of venous thromboembolism.
Project description:A porcine microarray study of right ventricular failure due to coronary artery ligation of the right ventricular free wall and subsequent treatment of right ventricular failure by volume unloading using a shunt between superior vena cava and the pulmonary artery (Glenn-shunt) 1. Surgical preparation with a 12 mm graft between superior vena cava and pulmonary artery, the graft is then clamped - Baseline sample using a biopsy needle. 2. After surgical preparation the coronary arteries of the right ventricular free wall are ligated, then heart failure develops over 120 minutes - Failure sample using a biopsy needle. 3. The shunt is then opened and the superior vena cava closed between the shunt and right atrium, diverting the blood from superior vena cava through the shunt for a period of 15 minutes partially unloading the right ventricle - Shunt sample using a biopsy needle. A series of six pigs, three samples from each animal: baseline, failure and shunt/treatment.
Project description:<h4>Background</h4>Leiomyosarcoma is a rare malignant mesenchymal tumour. Some cases of leiomyosarcoma of the renal vein (LRV) have been reported in the literature, but no analysis of data and search for prognostic factors have been done so far. The aim of this review was to describe the LRV, to analyse overall survival (OS), local recurrence free survival (LRFS) and distant metastases free survival (DMFS) in LRV world case series and to identify significant predictors of OS, LRFS and DMFS.<h4>Methods</h4>Cases from the literature based on PubMed search and a case from our institution were included.<h4>Results</h4>Sixty-seven patients with a mean age of 56.6 years were identified; 76.1% were women. Mean tumour size was 8.9 cm; in 68.7% located on the left side. Tumour thrombus extended into the inferior vena cava lumen in 13.4%. All patients but one underwent surgery (98.5%). After a median follow up of 24 months, the OS was 79.5%. LRFS was 83.5% after a median follow up of 21.5 months and DMFS was 76.1% after a median follow up of 22 months. Factors predictive of OS in univariate analysis were surgical margins, while factors predictive of LRFS were inferior vena cava luminal extension and grade. No factors predictive of DMFS were identified. In multivariate analysis none of the factors were predictive of OS, LRFS and DMFS.<h4>Conclusions</h4>Based on the literature review and presented case some conclusions can be made. LRV is usually located in the hilum of the kidney. It should be considered in differential diagnosis of renal and retroperitoneal masses, particularly in women over the age 40, on the left side and in the absence of haematuria. Core needle biopsy should be performed. Patients should be managed by sarcoma multidisciplinary team. LRV should be surgically removed, with negative margins.
Project description:<h4>Background</h4>Whether the respiratory changes of the inferior vena cava diameter during a deep standardized inspiration can reliably predict fluid responsiveness in spontaneously breathing patients with cardiac arrhythmia is unknown.<h4>Methods</h4>This prospective two-center study included nonventilated arrhythmic patients with infection-induced acute circulatory failure. Hemodynamic status was assessed at baseline and after a volume expansion of 500 mL 4% gelatin. The inferior vena cava diameters were measured with transthoracic echocardiography using the bi-dimensional mode on a subcostal long-axis view. Standardized respiratory cycles consisted of a deep inspiration with concomitant control of buccal pressures and passive exhalation. The collapsibility index of the inferior vena cava was calculated as [(expiratory-inspiratory)/expiratory] diameters.<h4>Results</h4>Among the 55 patients included in the study, 29 (53%) were responders to volume expansion. The areas under the ROC curve for the collapsibility index and inspiratory diameter of the inferior vena cava were both of 0.93 [95% CI 0.86; 1]. A collapsibility index ??39% predicted fluid responsiveness with a sensitivity of 93% and a specificity of 88%. An inspiratory diameter?<?11 mm predicted fluid responsiveness with a sensitivity of 83% and a specificity of 88%. A correlation between the inspiratory effort and the inferior vena cava collapsibility was found in responders but was absent in nonresponder patients.<h4>Conclusions</h4>In spontaneously breathing patients with cardiac arrhythmias, the collapsibility index and inspiratory diameter of the inferior vena cava assessed during a deep inspiration may be noninvasive bedside tools to predict fluid responsiveness in acute circulatory failure related to infection. These results, obtained in a small and selected population, need to be confirmed in a larger-scale study before considering any clinical application.
Project description:Background: Previous observational studies suggest that inferior vena cava filter placement in pulmonary embolism patients complicated with congestive heart failure, mechanical ventilation, and shock may have a mortality benefit. We sought to analyze the survival benefits of inferior vena cava filter in pulmonary embolism patients complicated with acute myocardial infarction, acute respiratory failure, shock, or requiring treatment with thrombolytics. Methods: This retrospective observational study used hospital discharge data from the National Inpatient Sample Data (NIS). ICD-9-CM coding was used to identify complicated pulmonary embolism patients (N?=?254,465) in NIS from 2002 to 2014, including the subgroups of acute myocardial infarction, acute respiratory failure, shock, and thrombolytics. Inferior vena cava filter recipients were 1:1 propensity score-matched on age, sex, race, deep vein thrombosis, Elixhauser comorbidities, and other pulmonary embolism comorbidities (45 covariates) to non-inferior vena cava filter recipients in complicated pulmonary embolism patients and separately in each subgroup. Clinical outcomes were compared between the inferior vena cava filter group and the non-inferior vena cava filter group. Results: Mortality rate in complicated pulmonary embolism patients with inferior vena cava filter placement was lower (20.9% vs. 33%; NNT?=?8.28, 95% confidence interval (CI) 7.91-8.69, E-value?=?2.53) and in the subgroups; acute myocardial infarction (17.9% vs. 30.1%; NNT?=?8.19, 95% CI 7.52-8.92, E-value?=?2.76), acute respiratory failure (19.5% vs. 29.7%; NNT?=?9.76, 95% CI 8.67-11.16, E-value?=?2.38), shock (30.7% vs. 47.1%; NNT?=?6.08, 95% CI 5.73-6.47, E-value?=?2.43), and with the use of thrombolytics (7% vs. 12.9 %; NNT 17.1, 95% CI 14.88-20.12, E-value?=?3.01) (p?<?0.001 for all). Conclusion: Inferior vena cava filter placement in pulmonary embolism complicated with acute myocardial infarction, acute respiratory failure, shock, or requiring thrombolytic therapy was associated with reduced mortality.
Project description:Invasion of a renal cell carcinoma thrombus into the inferior vena cava and right atrium is infrequent. Reaching and completely excising a tumor from the inferior vena cava is particularly challenging because the liver covers the surgical field. We report the case of a 61-year-old man who underwent surgery for a renal cell carcinoma of the right kidney that extended into the inferior vena cava and right atrium. During dissection of the liver to expose the inferior vena cava, transesophageal echocardiograms revealed right atrial mass migration into the tricuspid valve. On emergency sternotomy, the tumor embolized into the main pulmonary artery. We used a selective upper-body perfusion technique involving moderately hypothermic cardiopulmonary bypass, cardioplegic arrest, and clamping of the descending aorta, which provided a bloodless surgical field for precise removal of the mass and resulted in minimal blood loss. Our technique might be useful in other patients with tumor thrombus extending into the right atrium because it reduces the need for transfusion and avoids the deleterious effects of deep hypothermic circulatory arrest. Our case also illustrates the importance of continuous transesophageal echocardiographic monitoring to detect thrombus embolization.
Project description:Superior vena cava obstruction typically results from either primary pulmonary malignancies, lymphoma, or fibrosis related to central catheters. Endovascular stenting of superior vena caval obstruction is a common first approach, due to the rapid clinical improvement typically seen. The commonest complications are recurrence of obstruction and stent migration. We present herein the case of a phrenic nerve palsy secondary to endovascular stenting in a patient with superior vena cava obstruction due to primary small cell lung cancer.
Project description:Total anomalous systemic venous return is a very rare anomaly, where vena cava inferior, vena cava superior, and coronary sinus drain into left atrium. Two-day-old male baby was admitted with cyanosis and tachypnea after the birth. Left atrial isomerism with anomalous systemic venous drainage was found on echocardiographic examination. We present an unusual case of total anomalous systemic venous drainage in to the left atrium.
Project description:Open aorta and vena cava surgeries are usually associated with substantial blood loss which may result in postoperative acute kidney injury (AKI). The present study is designed to investigate the prevalence, outcome and risk factors of postoperative AKI associated with open aorta and vena cava surgeries, with a focus on the role of anemia in these conditions. A retrospective review of medical records of Peking Union Medical College Hospital was conducted. Patients who underwent open aorta and vena cava surgeries during January 1, 2010 and June 30, 2014 were included in this study. The primary analysis was between patients underwent open aorta and vena cava surgeryies, with or without postoperative AKI. Multivariable logistic regression models were used to determine risk factors of postoperative AKI. The study included 79 patients (63.3% male) with a mean age of 52.5±17.3 years (range, 17-81 years). Postoperative AKI occurred in 23/79 (29.1%) of the patients. Anemia was present in 11/79 (16%) at baseline, and increased to 45/79 (52%) postoperatively. After adjustment for various risk factors, postoperative anemia (OR, 5.202; 95% CI 1.403-19.285) was independently associated with postoperative AKI. AKI is a common complication in patients who undergo open aorta and vena cava surgeries, and postoperative anemia was the most relevant predictive factor of AKI. Strategies to minimize bleeding and anemia for all patients may be advisable. Further studies are needed to assess the impact of AKI on long term outcome and to examine preventive strategies to address potentially modifiable risk factors.