Surgical and Oncological Outcomes of Level III-IV Versus Level I-II Inferior Vena Cava Thrombectomy: A Decennial Experience of a High-Volume European Referral Center.

BACKGROUND: In patients with renal cell carcinoma (RCC) the role of the extent of tumor thrombus into the inferior vena cava (IVC) has never been addressed from a surgical and oncologic standpoint. This study aims to evaluate differences between level III-IV versus level I-II patients concerning peri- and postoperative morbidity, additional treatments and long-term oncological outcomes. PATIENTS AND METHODS: Overall, 40 patients with RCC underwent radical nephrectomy (RN) with IVC thrombectomy at a single European institution between 2010 and 2023. Complications were reported according to the European Union (EAU) guidelines recommendations. Spider chart served as graphical depiction of surgical and oncologic outcomes. RESULTS: Overall, 22 (55%) and 18 (45%) patients harbored level III-IV and I-II IVC thrombus. Level III-IV patients experienced significantly higher rates of intraoperative transfusions (68 vs 39%), but not significantly higher rates of intraoperative complications (32% vs 28%). Level III-IV patients had significantly higher rates of postoperative transfusions (82% vs 33%) and Clavien Dindo ≥3 complications (41% vs 15%). In level III-IV versus level I-II patients, median follow up was 482 and 1070 days, the rate of distant recurrence was 59% and 50%, the rate of systemic progression was 27% and 13%, and the rate of additional treatment/s was 64% and 61%, respectively (all p values > 0.05). Overall survival was 36% in level III-IV patients and 67% in level I-II (p = 0.001). CONCLUSIONS: Our findings suggest that patients with level III-IV RCC who are candidates for IVC thrombectomy should be counselled about the higher likelihood of postoperative severe adverse events and worse overall survival relative to level I-II counterparts.

Prevalence and risk factors of myocardial and acute kidney injury following radical nephrectomy with vena cava thrombectomy: a retrospective cohort study.

BACKGROUND: Radical nephrectomy with thrombectomy is the mainstay treatment for patients with renal cell carcinoma with vena cava thrombus. But the procedure is full of challenge, with high incidence of major complications and mortality. Herein, we investigated the incidence and predictors of myocardial injury and acute kidney injury (AKI) in patients following radical nephrectomy with inferior vena cava thrombectomy. METHODS: Patients who underwent nephrectomy with thrombectomy between January 2012 and June 2020 were retrospectively reviewed. Myocardial injury was diagnosed when peak cardiac troponin I was higher than 0.03 ng/ml. AKI was diagnosed according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Multivariable logistic regression models were used to identify predictors of myocardial injury or AKI after surgery. RESULTS: A total of 143 patients were included in the final analysis. Myocardial injury and AKI occurred in 37.8 and 42.7% of patients after this surgery, respectively. Male sex (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.10-0.71; P = 0.008) was associated with a lower risk, whereas high level Mayo classification (compared with Mayo level I + II, Mayo level III + IV: OR 4.21, 95% CI 1.42-12.4; P = 0.009), acute normovolemic hemodilution before surgery (OR 2.66, 95% CI 1.10-6.41; P = 0.029), long duration of intraoperative tachycardia (per 20 min: OR 1.49, 95% CI 1.10-2.16; P = 0.036), and long duration of surgery (per 1 h, OR 1.48, 95% CI 1.03-2.16, P = 0.009) were associated with a higher risk of myocardial injury. High body mass index (OR 1.18, 95% CI 1.06-1.33; P = 0.004) and long duration of intraoperative hypotension (per 20 min: OR 1.30, 95% CI 1.04-1.64; P = 0.024) were associated with a higher risk, whereas selective renal artery embolism before surgery (OR 0.20, 95% CI 0.07-0.59, P = 0.004) was associated with a lower risk of AKI. CONCLUSION: Myocardial injury and AKI were common in patients recovering from radical nephrectomy with inferior vena cava thrombectomy. Whether interventions targeting the above modifiable factors can improve outcomes require further studies.

Nephrectomy and IVC thrombectomy in renal cancer: a narrative review.

Renal cell carcinoma accounts for two to three percent of adult malignancies and can lead to inferior vena cava (IVC) thrombosis. This condition can decrease the rate of 5-year survival for patients to 60%. The treatment of choice in such cases is radical nephrectomy and inferior vena cava thrombectomy. This surgery is one of the most challenging due to many perioperative complications. There are many controversial methods reported in the literature. Achieving the free of tumor IVC wall and the possibility of thrombectomy in cases of level III and level IV IVC thrombosis are two essential matters previously advocated open approaches. Nevertheless, open approaches are being replaced by minimally invasive techniques despite the difficulty of the surgical management of IVC thrombectomy. This paper aims to review recent evidence about new surgical methods and a comparison of open, laparoscopic, and robotic approaches. In this review, we present the latest surgical strategies for IVC thrombectomy and compare open and minimally invasive approaches to achieve the optimal surgical technique. Due to the different anatomy of the left and right kidneys and variable extension of venous thrombosis, we investigate surgical methods for left and right kidney cancer and each level of IVC venous thrombosis separately.

Partial Inferior Vena Cava Reconstruction with Cryopreserved Aortic Homograft Following Resection for Malignancy.

Malignant invasion of the inferior vena cava (IVC) often necessitates complete tumor thrombectomy and IVC reconstruction. Bovine pericardial xenografts and prosthetic grafts are frequently used for partial or entire IVC reconstruction with adequate subsequent patency and freedom from thrombosis. Cryopreserved aortic homografts represent an alternative conduit for vena cava replacement with resistance to infection in contaminated fields or following extensive retroperitoneal dissection. Specific reports of aortic homograft use for IVC reconstruction are scarce. Described are 2 cases of cryopreserved aortoiliac artery allograft use for long segment cava patch repair while avoiding extensive caval reconstruction, mobilization and the need for renal vein and hepatic vein re-implantation.

Renal Angiomyolipoma Causing Inferior Vena Cava Thrombus in a Young Girl With Tuberous Sclerosis.

Angiomyolipomas (AML), also known as hamartomas, are benign mesenchymal tumors of the kidneys which consist of vascular tissue, smooth muscles, and adipose tissue, with a higher prevalence in females than males. AML may be associated with tuberous sclerosis, and the growth of the mass may present as hematuria or flank pain. We present a case of a 14-year-old female patient who had a known case of tuberous sclerosis since early childhood. She has a history of numerous bilateral renal masses radiographically consistent with AML. A special and unique entity of our case is the age of presentation which is 14 years and the presence of TSC. In contrast to our case, which was invading the right renal vein and IVC at a young age, AML is well known for its benign nature. According to a recent literature review, the youngest patient reported was 16 years old. Typically, non-complicated AMLs less than 4 cm in size are managed by annual radiological imaging which is preferably a CT scan, while larger AMLs of more than 4 cm that present with perinephric hemorrhages or intralesional aneurysms are treated by partial nephrectomy or selective angioembolization. A radical nephrectomy and IVC thrombectomy are typically necessary due to the risks that the IVC thrombus carries as well as the AML itself and its unpredictable behavior. In cases like ours with the extension into the renal vein and IVC, the surgical approach is similar to the venous invasion of renal cell carcinomas.

Influence of tumor size in the progression of venous tumor thrombus in renal cell carcinoma: A 7-year single-center experience.

Objective: The objective of the study is to describe the perioperative outcomes, disease-specific, and overall survival status in patients diagnosed with renal cell carcinoma with inferior vena cava (IVC) tumor thrombus. Patients and Methods: We did a retrospective analysis of all patients who underwent radical nephrectomy along with IVC thrombectomy from the year 2013 to 2020. Mayo's classification was used to stratify the level of IVC thrombus. Demographic, perioperative, histopathology data, complications, and survival status were analyzed. Results: Total number of patients included in the study was 39, (Male: Female = 84.6%: 15.4%). Median age of patients was 58 (interquartile range [IQR] 50-63) years. Median size of renal tumor (in cms) was 9.5 (IQR 7.5-12), 8 (IQR 7-11.5), 8.5 (IQR 7-11.75), and 11 (IQR 9.5-11) (P = 0.998) in level 1,2,3, and 4 tumors, respectively. Clear cell variant was seen in 32 patients (82%) with R0 resection in 17 patients. Twelve patients (30.7%) had systemic metastasis on presentation. The overall mean survival time was 66.4 months with 95% confidence interval (CI) (52.4-80.5 months). Mean recurrence-free survival is 76 months with (63-90) CI of 95%. Mean survival in patients who presented with metastasis is 47 months with 95% CI (52.4-80.5). Perioperative mortality rate was 5.12% in this study. Conclusion: The tumor size does not have an influence on the progression of tumor thrombus into IVC. Significant difference in survival was observed between different levels of thrombus with high mortality in level four tumors.

Metastatic stage vs complications at radical nephrectomy with inferior vena cava thrombectomy.

BACKGROUND: To investigate perioperative complication rates at radical nephrectomy (RN) according to inferior vena cava thrombectomy (IVC-T) status and stage (metastatic vs non-metastatic) within kidney cancer patients. MATERIALS AND METHODS: We ascertained perioperative complication rates within the National Inpatient Sample database (2016-2019). First, log-link linear Generalized Estimating Equation function (GEE) regression models (adjusted for hospital clustering and weighted for discharge disposition) tested complication rates in IVC-T patients, according to metastatic stage. Subsequently, a subgroup analysis relied on RN patients with or without IVC-T. Here, multivariable logistic regression models tested complication rates in RN patients according to IVC-T status, after propensity score matching including metastatic stage. RESULTS: Of 26,299 RN patients, 461 (2%) patients underwent IVC-T. Of those, 252 (55%) were non-metastatic vs 209 (45%) were metastatic. Rates of acute kidney injury (AKI), transfusion, cardiac, thromboembolic and other medical complications in non-metastatic vs metastatic patients were 40 vs 40%, 25 vs 22%, 21 vs 23%, 19 vs 14% and 38 vs 40%, respectively (all p ≥ 0.2). Metastatic stage in IVC-T patients did not predict differences in complications in log-link linear GEE regression models (all p > 0.1). However, in logistic regression models with propensity score matching, relying on the overall cohort of RN patients, IVC-T status was associated with higher complication rates (all p < 0.001): AKI (Odds ratio [OR]:2.60; 95%-CI [95%-Confidence interval: 1.97-3.44), transfusions (OR:2.40; 95%-CI: 1.72-3.36), cardiac (OR:2.27; 95%-CI: 1.49-3.47), thromboembolic (OR:9.07; 95%-CI: 5.21-16.58) and other medical complications (OR:2.01; 95%-CI: 1.52-2.66). CONCLUSIONS: The current analyses indicate that presence of concomitant IVC-T is associated with higher complication rate at RN. Conversely, metastatic stage has no effect on recorded complication rates.

Characterizing Tumor Thrombus Arising from Non-Clear Cell Renal Cell Carcinoma.

Background: Renal cell carcinoma (RCC) can exhibit a unique vascular tropism that enables tumor thrombus extension into the inferior vena cava (IVC). While most RCC subtypes that form tumor thrombi are of clear cell (cc) histology, non-clear cell (ncc) subtypes can also exhibit this unique growth pattern. Objective: To characterize clinicopathologic differences and survival outcomes among patients with IVC tumor thrombus arising from ccRCC versus nccRCC. Design setting and participants: Patients diagnosed with IVC tumor thrombus secondary to RCC in our institutional experience from 2003 to 2021 were identified. Outcome measurements and statistical analysis: Clinicopathologic characteristics were compared by histology. Perioperative and oncologic outcomes including recurrence-free (RFS), overall (OS), and cancer-specific (CSS) survival were assessed using multivariable Cox regression analyses. Results and limitations: The analyzed cohort included 103 patients (82 ccRCC and 21 nccRCC). There were no significant differences in baseline demographic parameters. Patients with nccRCC were more likely to have regional lymph node involvement (42.9% vs 20.7%, p = 0.037). No differences in perioperative outcomes, IVC resection, or IVC reconstruction were observed between groups. The median follow-up time was 30 mo. The median RFS was 30 (nccRCC) versus 53 (ccRCC) mo (p = 0.1). There was no significant difference in OS or CSS. This study was limited by its small sample size. Conclusions: Patients with IVC tumor thrombus arising from ccRCC and nccRCC exhibit similar perioperative and oncologic outcomes. While surgical appropriateness was not impacted by histologic subtype, multimodal strategies are needed to improve outcomes for patients with tumor thrombus. Patient summary: Renal cell carcinoma (RCC) can uniquely invade vasculature and form a tumor thrombus. This study examined the difference in outcomes of patients with tumor thrombus based on RCC subtype (clear cell vs non-clear cell). We found that patients exhibited similar surgical and survival outcomes regardless of RCC type.

En Bloc Resection of Right Renal Cell Carcinoma and Inferior Vena Cava Tumor Thrombus Without Caval Reconstruction: Is It Safe to Divide the Left Renal Vein?

Introduction: It has been suggested that inferior vena cava (IVC) reconstruction following resection of retroperitoneal tumors with IVC tumor thrombus (TT) is not required when adequate collateral circulation is present. There are no reports evaluating mid-term effects on renal function in these patients. The purpose of this study was to assess renal function after en bloc resection of right renal cell carcinoma (RCC) with obstructing IVC TT and the possible risks that may arise after left renal vein division. Materials and Methods: A bi-institutional retrospective review was performed over a 15-year period, assessing patients with right RCC and obstructing level II-IV TT. All patients underwent extensive evaluation and cardiology clearance, and informed consent was obtained for right radical nephrectomy and thrombectomy with or without IVC reconstruction with possible cardiopulmonary bypass (CPB). Patient demographics, tumor characteristics, intraoperative factors, complications, length of stay, and patient survival were evaluated. Preoperative creatinine was recorded, as was creatinine on the day of discharge and at 6 and 12 months postoperatively. Results: Twenty-two patients were included in the study. Median age at surgery was 62.5 (range: 45-79) years, and 19 (86%) of the patients were men. One patient (5%) had a level II thrombus, 14 patients (64%) had a level III thrombus (IIIa, n = 3; IIIb, n = 6; IIIc, n = 3; IIId, n = 2), and seven patients (32%) had a level IV thrombus. Intraoperatively, median estimated blood loss was 1.35 (range: 0.2-25) L. The median length of hospital stay was 11 (range: 5-50) days. Median preoperative creatinine was 1.20 (range: 0.40-2.70) mg/dl, and postoperatively, median creatinine was 1.3 (range: 0.86-2.20) mg/dl. Median creatinine levels at 6 months and 12 months postoperatively were 1.10 (range: 0.5-1.8) mg/dl and 1.40 (range: 0.6-2.0) mg/dl, respectively. Four patients died (range: 0.1-1.3 years), and median postoperative follow-up among the 18 ongoing survivors (at last follow-up) was 1.5 (range: 0.5-7.0) years. Conclusions: Resection of right RCC with an obstructing level II-IV TT without reconstruction of the IVC appears to not have a significant adverse effect on mid-term renal function after division of the left renal vein.

Robotic renal and adrenal oncologic surgery: A contemporary review.

Robot-assisted surgery has evolved over time. Radical nephrectomy with inferior vena cava thrombectomy is feasible and safe for level I, II and III thrombus in high volume centers. Though it is feasible for level IV thrombus, this procedure needs a multi-departmental co-operation. However, the safety of robot-assisted procedures in this subset is still unknown. Robot-assisted partial nephrectomy has been universally approved and found oncologically safe. Robotic adrenalectomy has been increasingly utilized for select cases, especially in bilateral tumors and for retroperitoneal adrenalectomy.

Robotic renal surgery for renal cell carcinoma with inferior vena cava thrombus.

Surgical management of renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombus is inherently complex, posing challenges for even the most experienced urologists. Until the mid-2000s, nephrectomy with IVC thrombectomy was exclusively performed using variations of the open technique initially described decades earlier, but since then several institutions have reported their robotic experiences. Robotic IVC thrombectomy was initially reported for level I and II thrombi, and more recently in higher-lever III thrombi. In general, the robotic approach is associated with less blood loss and shorter hospital stays compared to the open approach, low rates of open conversion in reported cases, relatively low rates of high-grade complications, and favorable overall survival on short-term follow-up in limited cohorts. Operative times are longer, costs are significantly higher, and left-sided tumors always require intraoperative repositioning and usually require preoperative embolization. To date, criteria for patient selection or open conversion have not been defined, and long-term oncologic outcomes are lacking. While the early published robotic experience demonstrates feasibility and safety in carefully selected patients, longer-term follow-up remains necessary. Patient selection, indications for open conversion, logistics of conversion particularly in emergent settings, necessity and safety of preoperative embolization, the value proposition, and long-term oncologic outcomes must all be clearly defined before this approach is widely adopted.

Robot-assisted laparoscopic radical nephrectomy and inferior vena cava thrombectomy: A multicentre Indian experience.

OBJECTIVE: To assess feasibility of robot-assisted laparoscopic radical nephrectomy (RALRN) and inferior vena cava thrombectomy (IVCT) in treating renal tumours with level I-III IVC thrombi and to assess their outcomes. PATIENTS AND METHODS: We conducted a retrospective analysis of RALRN-IVCTs, involving four centres across India, from September 2015 to June 2019. We analysed patients who underwent RALRN-IVCT for level I-III thrombi according to the Mayo classification. The total operative duration with console time, length of hospital stay, preoperative and postoperative creatinine, IVC clamp time and intraoperative blood loss were recorded. RESULTS: Of the 13 patients that underwent RALRN-IVCT, five had a level I thrombus, seven had level II, and one had a level III thrombus. In all, 11 of the patients had right-sided tumours and the remaining two had left-sided tumours. The mean (SD) age of the patients was 56.5 (12.3) years, the mean (SD) operative time was 329.5 (97.22) min, the mean (SD) console time was 222.5 (70) min, the mean (SD) blood loss was 395 (170) mL, and the mean (SD) IVC clamp time was 19.14 (9.5) min. The mean (SD) length of hospital stay was 7.8 (3.27) days. Of the 13 patients, 12 had clear cell renal cell carcinoma (RCC) and one had papillary RCC. The mean (range) follow-up was 19 (4-50) months. One patient had upfront metastasis and two patients developed metastasis, while 10 patients remained disease-free during the follow-up. CONCLUSION: With appropriate patient selection, surgical planning and robotic experience, completely intracorporeal robotic level I-III IVCT is feasible and can be performed efficiently. Larger experiences, with longer follow-ups and comparisons with open surgery are needed to confirm these initial outcomes. ABBREVIATIONS: ECOG: Eastern Cooperative Oncology Group; IVC: inferior vena cava; IVCT: inferior vena cava thrombectomy; (RAL)RN: (robot-assisted laparoscopic) radical nephrectomy.

Robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy for metastatic mixed testicular germ cell cancer: a case report.

BACKGROUND: The robot-assisted laparoscopic management of post-chemotherapy retroperitoneal metastasis and inferior vena cava tumor thrombus secondary to testicular cancer is a challenging task for urologists. CASE PRESENTATION: A pathological examination of a 36-year-old Caucasian man who had undergone a right radical orchiectomy showed mixed testicular germ cell cancer (70% embryonal cancer and 30% seminoma); he had undergone four prior courses of cisplatin, etoposide, and bleomycin chemotherapy and was found to have residual retroperitoneal enlarged lymph nodes close to the right renal hilum and a 9.8 cm inferior vena cava tumor thrombus (pT1, N2, M1, S2). Pre-surgical three-dimensional image reconstruction was performed based on contrast computed tomography data. The inferior vena cava tumor thrombus was found in the vena cava at the level of the celiac trunk and the inferior mesenteric artery. Our patient accepted treatment with robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy and cava reconstruction on September 12, 2018. During the procedure, a drop-in robotic ultrasound probe was used to define the thrombus. Vena cavoscopy using a flexible ureteroscope found that the tumor thrombus adhered to the cava wall in all directions. The tumor thrombus was dissected free from the inferior vena cava lumen, and vena cava reconstruction was achieved using the da Vinci™ Si HD surgical system. The operative time was 550 minutes. The intraoperative estimated blood loss was 2300 ml. Intraoperative blood transfusions consisted of 10 units of red blood cells (Clavien-Dindo grade II). No Clavien-Dindo grade III or above perioperative complications occurred. The length of hospital stay was 7 days. Pathology revealed no viable cancer cells in any of the residual lymph node tissues or in the vena cava tumor thrombus. CONCLUSION: This is the first case of robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy and reconstruction for metastatic mixed testicular germ cell cancer published to date. This complicated surgical procedure was facilitated by the innovative usage of three-dimensional image reconstruction for defining the vena cava tumor thrombus, a robotic ultrasound probe for intraoperatively defining the vena cava tumor thrombus, and vena cavoscopy using a flexible ureteroscope.

Radical nephrectomy and intracaval thrombectomy for advanced renal cancer with extensive inferior vena cava involvement utilising cardiopulmonary bypass and hypothermic circulatory arrest: Is it worthwhile?

OBJECTIVE: To report our long-term outcomes of surgical treatment of renal tumours with inferior vena cava (IVC) tumour thrombus above the hepatic veins, utilising cardiopulmonary bypass (CBP) and hypothermic circulatory arrest (HCA), as surgical resection remains the only effective treatment for renal cancers with extensive IVC tumour thrombus. PATIENTS AND METHODS: We retrospectively reviewed 48 consecutive patients (median age 58 years) who underwent surgical treatment for non-metastatic renal cancer with IVC tumour thrombus extending above the hepatic veins. Perioperative, histological, disease-free (DFS) and overall survival (OS) data were recorded. RESULTS: Tumour thrombus was level III in 23 patients and level IV in 25 patients. The median (range) CBP and HCA times were 162 (120-300) min and 35 (9-64) min, respectively. Three patients underwent synchronous cardiac surgical procedures. There were three (6.3%) perioperative deaths. American Society of Anesthesiologists grade and perioperative blood transfusion requirement were significant factors associated with perioperative death (P < 0.05). Despite extensive preoperative screening for metastases the median (range) DFS was only 10.2 (1.2-224.4) months. The median (range) OS was 23 (0-224.4) months. Cox regression analysis revealed that perinephric fat invasion conferred a significantly poorer DFS (P = 0.005). CONCLUSIONS: Radical surgery for patients with extensive IVC tumour thrombus has acceptable operative morbidity and mortality. It provides symptom palliation and the possibility of long-term survival. Improvements in preoperative detection of occult metastasis may improve case selection and newer adjuvant therapies may improve survival in this high-risk group.

Advances in Robotic Vena Cava Tumor Thrombectomy: Intracaval Balloon Occlusion, Patch Grafting, and Vena Cavoscopy.

Robotic level III inferior vena cava (IVC) tumor thrombectomy was described recently. We present ongoing robotic advances in this arena in a case series of six patients with Mayo level II-III thrombi who underwent robotic caval thrombectomy, radical nephrectomy, and retroperitoneal lymphadenectomy. In four patients, proximal intra- or retrohepatic IVC control was obtained solely with an intracaval Fogarty balloon catheter; in one patient, robot-guided flexible cystoscopy of the IVC lumen was performed to rule out any residual or secondary skip thrombi. In one patient, the caval wall defect after thrombus excision was reconstructed robotically using a bovine pericardial patch. Finally, a patient with concomitant renal and adrenal tumors had two distinct thrombi of levels I and III; a robotic double thrombectomy was performed. Mean renal tumor size was 8.4cm (±1.6). Four thrombi (66%) were level III. Mean operative time was 6.4h (±1.7); IVC clamp time, 53.5min (±29.8); blood loss, 668ml (±692); and hospital stay, 5.5 d (±3.8). Two patients required blood transfusions. Complications included Clavien grade 1 (n=2), grade 3a (n=1), and grade 5 (n=1). Mean follow-up was 5.8 mo (±4.3). Robotic IVC thrombectomy is a viable alternative to open surgery for appropriately selected cases by experienced teams. PATIENT SUMMARY: We present ongoing robotic surgical advances in a case series of six patients with blood clots in the inferior vena cava. These innovations will help further advance the field.

Radiologic indicators prior to renal cell cancer thrombectomy: Implications for vascular reconstruction and mortality.

BACKGROUND: Renal cancer may invade the inferior vena cava (IVC) creating more complex surgical intervention. We investigate radiologic findings that may predict vascular reconstruction prior to surgery and future renal cancer-specific mortality. MATERIALS AND METHODS: Radiologic findings included Mayo Clinic risk factors for vascular reconstruction: Right-sided tumor, anteroposterior diameter of the IVC at the ostium of the renal vein ≥24.0 mm, and radiologic identification of complete occlusion of the IVC. Additional factors included thrombus in the lumen of the hepatic veins and metastasis. Along with other demographic factors, analysis included Chi-squared analysis for vascular reconstruction and logistic regression for mortality. A Kaplan-Meier curve was created for the most significant radiologic factor. RESULTS: Thirty-seven patients underwent IVC tumor thrombectomy at two institutions from April 2007 to February 2015. We found that Mayo risk factors of 0, 1, 2, and 3 and the proportions of vascular reconstruction of 0%, 0%, 12.5%, and 13.6%, respectively (P = 0.788). Hepatic vein involvement was the most significant determinate of renal cell carcinoma-specific mortality in multivariable analysis, controlling for the size of IVC at the hepatic veins, pulmonary metastasis, and Fuhrman grade (P = 0.02, Log-rank P = 0.002). CONCLUSION: Mayo risk factors did not predict vascular reconstruction in our small cohort of Level II-Level IV IVC thrombus undergoing IVC thrombectomy. Tumor thrombus traveling into the lumen of the hepatic veins was a significant risk factor for accelerated mortality.