BERKELEY, CA (UroToday.com) - Our decision to use the AngioVac aspiration system to prevent further pulmonary emboli (PE) during this procedure was a difficult one, and despite the unfortunate outcome, we feel our decision was both appropriate and one that should be discussed with patients in similarly difficult situations.
Prior to surgery, the patient had increasingly symptomatic and enlarging bilateral PEs. The patient’s operative date was moved up given the acuity of the situation. A hepatic surgeon and cardiac surgeon were consulted to discuss possible intraoperative solutions to prevent propagation of her already large pulmonary emboli and prevent tumor thrombolic event. The ultimate solution was that which is described in our paper.
The combination of an already morbid surgery with the need to fully anticoagulate the patient intraoperatively absolutely increased the potential morbidity of the surgery, but given her increasing PE burden and significant tumor, our team felt few options were available. Quoted mortality rates for nephrectomy with IVC thrombectomy are as high as 12%, and while the median survival for patients undergoing observation for such tumors is 3-5 months, the life expectancy in a patient with an increasing PE burden is certainly much shorter. The patient understood that her position was perilous -- as well as the potential risks of the procedure -- and was happy to proceed.
Intraoperatively the patient had profuse oozing from her retroperitoneum that was very difficult to control given her fully anticoagulated status. During the operation, the AngioVac system did prevent a number of clots from entering her pulmonary circulation, events that could have proven catastrophic intraoperatively. While the patient ultimately passed away the evening of surgery, her risk of a ruinous event during the operation was deemed unacceptably high and necessitated an alternate approach. In the end, in very selective patients, the use of the AngioVac system is an acceptable means by which to reduce the risk of intraoperative pulmonary embolism.
Matthew A. Uhlman, MD, MBA as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Department of Urology, University of Iowa, Iowa City, IA USA