Page 14 - ANZCP Gazette NOVEMBER 2022

CASE REPORT:
A RESECTION OF A PRIMARY LEIOMYOSARCOMA WITH NORMOTHERMIC VV-ECMO
Peter Frantzis CCP, FANZCP
Royal Adelaide Hospital, South Australia
Inferior Vena Cava Leiomyosarcoma (IVCL) is a rare tumour with a poor prognosis. Surgical intervention of IVCL remains challenging, with the only potential curative treatment being surgery with a survival rate of five years.
A 71-year-old male presented to the Royal Adelaide Hospital (RAH) with a right sided primary Leiomyosarcoma. Initial incidental findings via ultrasound discovered a large 179 x 89 x 178 mm mass in the right upper quadrant, separate to the liver and right kidney. Further investigation via CT, MRI and Venogram indicated a large right adrenal mass (161 x 96 x 189 mm) involving the renal vein, portal vein and inferior vena cava (IVC).
A multi-disciplinary team meeting at the RAH, involving Breast and Endocrine, Vascular, Cardiothoracic, Anaesthesia and Perfusion, was held to discuss the various potential technical difficulties of this type of procedure. Historically, depending on the extent of the IVC cancerous invasion, patients would be put on bypass with the possibility of DHCA. In this situation, it was decided a normothermic VV ECMO bypass would be the best option for this patient to avoid any coagulopathies or haemodynamic instability upon application of IVC clamping.
The Cardiohelp ECMO HLS Advanced Set 7.0 circuit was set up and primed with Ringer’s solution. A primed giving set with a drip chamber was also connected to the luer port of the pre-membrane portion of the Cardiohelp. An infusion pressure bag was implemented, sustaining pressures of > 150 mmHg for the purpose of: (a) intermittently flushing both cannulation sites post-cannulation prior to initiation of ECMO; and (b) transfusion requirements during VV ECMO. The patient weight was 88 kg, height 181 cm with a BSA of 2.10 m2.
Intraoperatively, prior to the commencement of surgery, catheter sheaths were introduced to the right femoral vein (access) and the right internal jugular vein (return), making accessibility available. Surgery proceeded with a midline laparotomy with right-costal extension, as the palpable large right retroperitoneal mass was encasing the right kidney.
Resection of the tumour occurred to the point of leaving it attached at the proximal and distal IVC. Upon clamping of the IVC, haemodynamic instability with hypotension occurred with mean arterial pressures falling below 50 mmHg. It was decided to release the clamp and proceed with cannulation of the accessible catheter sheaths for VV ECMO.
5000 IU of Heparin was administered prior to cannulation. The right femoral vein was cannulated with a 23fr Medtronic Cortiva coated cannula (CB96605-023; drainage side-ports at the distal tip) and introduced and positioned very proximal – just above the bifurcation of the IVC. The right internal jugular vein was cannulated with a short 21fr Getinge Bioline coated arterial cannula (BE-PAS2115). Normothermic VV ECMO was implemented uneventfully, as blood flow rates were maintained at 1.8–2.0 L/min with haemodynamic stability. Activated clotting times were sustained at 225–250 seconds, with a total of 10,000 IU of heparin administered during the bypass. The vascular team proceeded with resection and reconstruction of the IVC with total support for 52 mins.
Ultimately the procedure performed by the surgical team involved resection of the right retroperitoneal leiomyosarcoma, right nephrectomy and resection with reconstruction of the IVC.
The patient was weaned off VV-ECMO uneventfully with minimal surgical blood loss and no requirement of allogenic blood transfusion. The patient arrived in ICU with a haemoglobin of 95 g/L. One unit of red blood cells was administered on day two (Hb 78 g/L), with the discharge haemoglobin being 107 g/L. The pre-operation creatinine was 75 mmol/L, peaking to 149 mmol/L on post-operation day two – likely due to the resection of the right nephrectomy. Overall, urine output for the patient remained adequate throughout the entire hospital admission. The patient was discharged from hospital on day 10.
With the multiple uses of ECMO these days, whether it be VV or VA, this procedure was another unique situation requiring the application of VV-ECMO.
11 NOVEMBER 2022 | www.anzcp.org