[Case Review] Bypassing DHCA & Sternotomy: A Normothermic, Beating-Heart Approach to Mayo III IVC Thrombus

[Case Review] Bypassing DHCA & Sternotomy: A Normothermic, Beating-Heart Approach to Mayo III IVC Thrombus

Peking University (PKU) First Hospital recently completed a highly challenging MDT surgery on a patient with Renal Cell Carcinoma and a Mayo Level III IVC thrombus, complicated by a rare Rh-negative blood type. The surgical decision-making and execution provide a critical reference for managing complex thrombi.

📌 Surgical Rationale (The "Why")
The traditional gold standard for Mayo III thrombus involves a median sternotomy and Deep Hypothermic Circulatory Arrest (DHCA). However, DHCA causes significant trauma and severe coagulopathy. Given the patient's rare blood type, massive hemorrhage would be fatal due to the lack of compatible blood. Therefore, the team opted against sternotomy, choosing an alternative approach to minimize trauma and preserve coagulation.

📌 Surgical Process (The "How")
🔹 Approach: Sternotomy was completely avoided. Using a single abdominal midline incision, the team opened the diaphragm anterior to the SVC to expose the right atrium.
🔹 Cannulation: Cardiopulmonary Bypass (CPB) was established via the abdominal aorta and right atrium.
🔹 Thrombectomy: The procedure was performed on a normothermic, beating heart. The IVC and right atrium were opened to swiftly and completely extract the thrombus.

📌 Patient Blood Management (PBM)
To support this strategy, CPB prime volume was reduced from 1750ml to 1250ml. Vacuum-Assisted Venous Drainage (VAVD), zero-balance ultrafiltration, and 100% intraoperative cell salvage were strictly applied.

Clinical Outcome:
This innovative approach limited CPB time to just 20 minutes, entirely avoiding DHCA-induced coagulopathy. The patient was extubated 2 hours post-op. This pathway offers a highly valuable, minimally invasive option for complex thrombus patients with high bleeding risks.