Inferior vena caval (IVC) thrombus is present in 4-10% patients with renal cell carcinoma (RCC). However, concomitant preoperative gross pulmonary artery tumor embolism is rare in such cases. Complete resection in the form of nephrectomy with caval thrombectomy with pulmonary artery embolectomy is technically challenging. We demonstrate our experience with one such case.

We describe a case of a 61-year old gentleman who presented with left renal mass of 12.5 X 9.9 cm with level IV IVC thrombus with gross right pulmonary artery tumor embolus (Clinical stage cT3cN0M0). There was no shortness of breath and normal ejection fraction on echocardiography. We performed left radical nephrectomy with caval tumor thrombectomy along with pulmonary artery tumor embolectomy through midline laparotomy and median sternotomy under cardiopulmonary bypass (CPB) with deep hypothermic arrest.

Total duration of operation, CPB, circulatory arrest time were 9 hours, 160 min and 7 min respectively. The body temperature was 18℃ during circulatory arrest with an estimated blood loss of 3L and transfusion of 8 PRBCs. There was complete removal of the tumor from IVC and right pulmonary artery. The patient was kept in cardiothoracic ICU for 1 day and was discharged on day 8. Histopathology revealed clear cell RCC with tumor in IVC and pulmonary artery thrombus (pT3cN0M0). Patient is currently doing well on 1 month of follow up and is planned for a follow up CT at 3 months.

Pulmonary tumor embolism in patients with renal carcinoma should be considered as extension of caval tumor and not as distant metastasis. Pulmonary artery embolic tumor removal, concomitant with nephrectomy and caval tumor thrombectomy for RCC is technically feasible and can be performed safely using multidisciplinary approach.