Abstract: Renal cell carcinoma is known for endovascular thrombus migration, commonly to the renal vein, occasionally to different levels of inferior vena cava and very rarely (1%) to the right atrium (Stage 4). The importance of attempting a radical nephrectomy and thrombectomy lies in the fact that after successful removal, a stage 4 cancer patient has comparable outcome to that of a stage 1 cancer. However, anaesthetic management of such surgeries is challenging because of the extensive dissection involving laparotomy and sternotomy, major fluid shift, haemodynamic instability, blood loss, risk of tumour embolism and considerations related to cardiopulmonary bypass (CPB), aortic cross clamp and selection of venous access cannula sites for CPB.

Bypass related anticoagulation in patients with accessory venous collaterals from inferior vena cava obstruction and extensive retroperitoneal dissection may be problematic especially if deep hypothermic cardiac arrest is used. Knowledge of transesophageal echocardiography (TEE) is a must for the optimal perioperative management to scan the thrombus in real time and confirm its complete removal. Post operative pain management is another area of concern. Our case report describes the anaesthetic management of a radical nephrectomy with thrombectomy in a 70 year old woman presenting with right renal cell carcinoma with cavoatrial thrombus. We could successfully remove the entire thrombus along with the primary tumour through a bilateral subcostal chevron incision and sternotomy with CPB support and TEE guidance.