Relato de caso: manejo anestésico de nefrectomia com trombectomia cavoatrial sob circulação extracorpórea

Abstract

Introduction: Clear cell carcinoma (CCC) is the most prevalent histological subtype of renal cell carcinoma (RCC), accounting for 70–80% of cases. A characteristic feature of RCC is its propensity for venous invasion, with tumor thrombus formation in the renal vein and extension into the inferior vena cava (IVC), observed in 4–10% of patients. Cases in which the thrombus extends to the right atrium (RA) are rarer, occurring in approximately 1% of patients, and require a complex surgical approach and invasive anesthetic support. Case report: Male patient, A.B.C., 44 years old, previously healthy, ASA II, diagnosed with CCC of the left kidney, associated with a tumor thrombus extending from the left renal vein through the intrahepatic IVC to the RA. The procedure was performed by three surgical teams: Urology for left nephrectomy, Digestive Surgery for left colectomy, and Cardiovascular Surgery for atriotomy with cardiopulmonary bypass (CPB) and thrombus removal via cavotomy under direct visualization, with complete extraction of the thrombus. Balanced general anesthesia combined with thoracic epidural anesthesia at the T7–T8 level was performed, with catheter placement on the day prior to surgery. Hemodynamic monitoring included invasive arterial pressure, central venous catheterization, transesophageal echocardiography, and cerebral oximetry. Anesthetic maintenance was achieved with sevoflurane (with gas analyzer) and target-controlled infusion of remifentanil. Tranexamic acid was administered at 2 mg/kg/h. Three units of packed red blood cells were transfused, 560 mL was reinfused via intraoperative blood salvage, and 1,000 IU of prothrombin complex concentrate was administered. Calcium replacement was performed. Cerebral oxygen saturation remained stable between 55–60%. Total surgical duration was 7 hours, with 22 minutes of CPB. Heparin was reversed with protamine. The patient was admitted to the intensive care unit (ICU) receiving norepinephrine at 0.3 mcg/kg/min, under mechanical ventilation and post-anesthetic sedation. He received 1,000 mL of Ringer’s lactate and 3,000 mL of Plasma-Lyte, with a urine output of 900 mL. Final hemoglobin was 9.4 g/dL and lactate was 2.13 mmol/L. The patient was extubated in the immediate postoperative period, three hours after ICU admission. Vasoactive support was discontinued after 24 hours, and the patient was transferred to the general ward on postoperative day five. Postoperative analgesia was managed via the epidural catheter until postoperative day four, using continuous infusion of 0.12% ropivacaine at 5 mL/h, with intermittent boluses on patient demand. Hospital discharge occurred on postoperative day 21. Discussion: Integration and effective communication between surgical teams and anesthesiology are fundamental pillars in the management of complex cases involving multiple specialties. Continuous alignment throughout the perioperative period enabled more accurate surgical planning, individualized anesthetic and analgesic strategies, and more rational use of hospital and healthcare resources. By promoting a shared understanding of therapeutic goals, such collaboration directly contributes to patient safety, optimization of operative time, and improved clinical outcomes.