A 44-year-old, 150.0 cm, 85.0 kg female was transferred to our hospital complaining of dyspnea. T1-weighted magnetic resonance imaging revealed a large left adrenal tumor extending into the IVC with its proximal position at the level of the hepatic vein (Fig. 1), and contrast-enhanced CT revealed a massive PTE occluding the right pulmonary artery (PA) (Fig. 2). Transthoracic echocardiography (TTE) revealed moderate tricuspid regurgitation (TR) and a diastolic D-shaped left ventricle. IVC filter placement was not performed due to technical difficulties. Laboratory test results revealed elevated levels of serum cortisol and reduced levels of serum adrenocorticotropic hormone. These findings were suggestive of an ACC. Surgical treatment was considered necessary for the prevention of a lethal PTE, and one-stage surgery was scheduled. This procedure included a left nephrectomy, resection of the IVC tumor thrombus, and removal of the PTE under CPB.
General anesthesia was induced with Propofol, rocuronium, and fentanyl and was followed by endotracheal intubation. After the placement of a transesophageal echocardiography (TEE) probe (Fig. 3) and left radial arterial catheter, a pulmonary artery catheter (PAC) were inserted from the right internal jugular vein and placed with its tip temporarily in the right atrium. A median sternotomy was initially performed for the preparation of an emergent CPB and was followed by abdominal incision. After IVC clamping at the proximal level of the abdominal IVC, the tumor mass was removed coupled with the left adrenal tumor, left renal vein, and IVC tumor thrombus. The hemostasis procedure was a bit challenging due to the bleeding from the swollen abdominal vessels surrounding the tumor. In total, 2800 mL of blood was lost during the abdominal procedure.
After the confirmation that abdominal hemostasis had been complete, PTE resection started. After systemic heparinization, followed by cannulation of the ascending aorta, a total flow bypass with superior vena cava (SVC) and IVC cannulation was established. Significant abdominal bleeding was not observed. PA tumor embolectomy was completed under cardiac arrest, and the tip of the PAC was manually guided into the main PA. The patient was successfully weaned from the CPB. The total aortic cross-clamping and CPB times were 38 and 97 min, respectively. Pulmonary arterial pressure (PAP) was maintained within normal limits. The total duration of the operation was 13 h and 55 min. The total amount of bleeding was 4900 mL, and 1960 mL of red blood cell products were infused. The patient was extubated on the next day and was discharged from hospital on postoperative day 16, without any complications.