Is Left Renal Vein Ligation Benign? A Novel Method for Maintaining Left Renal Venous Outflow During Extensive Inferior Vena Caval Resection.
Charles S Kiell, Andrew R Barksdale
St Francis Hospital, Indianapolis, IN
Ligation of the left renal vein (LRV) has been felt to be a relatively benign maneuver with renal venous outflow maintained through existing venous branches. LRV has shown to be of negligible long-term renal function in the setting of aneurysm repair with dual kidneys; the effect of LRV in the setting of solitary left kidney however are less well-described. Case reports, primarily in the urology literature, have described sudden deterioration in renal function with LRV during right nephrectomy and hence, the consequences of acute LRV ligation might better be described as “unpredictable”.This report describes a patient who suffered rapid renal deterioration from LRV obstruction secondary to recurrent renal cell carcinoma, underwent extensive IVC resection, and on whom a novel method for intra-operative maintenance of left renal venous drainage during level III vena caval resection was employed.
METHODS: Patient is a 62 year old male evaluated for rapidly progressive lower extremity edema. Patient had undergone laparoscopic right nephrectomy nine years earlier without venous or extra renal spread. An echocardiogram noted a mass in the inferior vena cava and subsequent MRI demonstrated a suspected recurrent tumor involving the IVC and extending to the level of the right hepatic vein. Creatinine had concomitantly risen from 1.2 to 2.9 over an 8 day period. The left renal vein was patent with some flow into IVC along with patent left gonadal, adrenal and lumbar veins. Metastatic survey was negative.The patient was offered vena caval resection. Exposure was performed through a right thoracoabdominal incision with confirmation of tumor extent and absence of metastases. The left renal vein was extensively mobilized and caval resection and reconstruction from the L3 level to right hepatic vein was planned.A veno-venous circuit was created using percutaneously-placed cannulas in the right common femoral and right internal jugular veins. With concerns for further compromise of renal function from even temporary renal vein occlusion, a 24Fr right angle single-stage venous cannula was placed in the left renal vein and bypass with left renal vein decompression was instituted using full-heparinization. Potentially curative resection was performed uneventfully and the IVC reconstructed using a 24mm Dacron graft with a 10mm sidearm left renal graft. Total bypass time was 139 minutes and urine output during the bypass period was 240cc.
RESULTS: Excellent urine output was seen throughout the perioperative period with creatinine returning to value of 1.1 mg/dl by post-operative day #5. Patient was discharged on post-operative day #7. Post-operative venous-phase CT has demonstrated patent IVC and left renal vein interposition grafts.
CONCLUSIONS: The effect of LRV with solitary left kidney are unpredictable; the negligible effects of LRV following aneurysm repair may be more an effect of right kidney compensation rather than a reflection on the benignity of LRV. When planning pararenal vena caval resection and reconstruction, reconstruction of the LRV is advisable and intra-operative renal function can be optimized using the renal vein drainage technique described above.
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