Robot-assisted partial nephrectomy during simultaneous extracorporeal membrane oxygenation and impella®in a candidate for left ventricular assist device as a bridge for cardiac transplant: a case report.
Robot-assisted partial nephrectomy (RAPN) is standard for cT1 renal masses, but its feasibility in patients on temporary mechanical circulatory support is poorly documented. We report RAPN performed while a patient was simultaneously supported with venous-arterial extracorporeal membrane oxygenation (VA ECMO) and Impella®, as part of a staged plan for left ventricular assist device (LVAD) implantation and eventual heart transplantation.
A 51-year-old man presented with ST-elevation myocardial infarction complicated by cardiogenic shock requiring percutaneous coronary intervention with stenting, dual antiplatelet therapy, and combined VA ECMO-Impella® support. During workup for cardiac transplant, computed tomography (CT) staging revealed a 16-mm left renal mass suspicious for renal cell carcinoma. A multidisciplinary team prioritized definitive treatment to preserve transplant eligibility and elected RAPN under systemic heparinization alongside aspirin continuation (cangrelor briefly withheld). Therefore, RAPN was performed with 9 min of warm ischemia. The intraoperative course was hemodynamically stable. On postoperative day (POD) 4, late arterial bleeding from the resection bed was controlled by selective angioembolization. On POD 7, a durable LVAD was implanted as a bridge to heart transplantation. Final pathology showed pT1a, G2, R0 clear cell renal cell carcinoma. At 6 months, contrast-enhanced CT showed no recurrence and no major cardiovascular complications.
RAPN during simultaneous ECMO and Impella® support is technically feasible with meticulous anticoagulation management, interventional radiology standby, and coordinated planning. This approach enables oncologic control while preserving a trajectory to transplant candidacy.
A 51-year-old man presented with ST-elevation myocardial infarction complicated by cardiogenic shock requiring percutaneous coronary intervention with stenting, dual antiplatelet therapy, and combined VA ECMO-Impella® support. During workup for cardiac transplant, computed tomography (CT) staging revealed a 16-mm left renal mass suspicious for renal cell carcinoma. A multidisciplinary team prioritized definitive treatment to preserve transplant eligibility and elected RAPN under systemic heparinization alongside aspirin continuation (cangrelor briefly withheld). Therefore, RAPN was performed with 9 min of warm ischemia. The intraoperative course was hemodynamically stable. On postoperative day (POD) 4, late arterial bleeding from the resection bed was controlled by selective angioembolization. On POD 7, a durable LVAD was implanted as a bridge to heart transplantation. Final pathology showed pT1a, G2, R0 clear cell renal cell carcinoma. At 6 months, contrast-enhanced CT showed no recurrence and no major cardiovascular complications.
RAPN during simultaneous ECMO and Impella® support is technically feasible with meticulous anticoagulation management, interventional radiology standby, and coordinated planning. This approach enables oncologic control while preserving a trajectory to transplant candidacy.
Authors
Cianflone Cianflone, Cirulli Cirulli, Villano Villano, Ali Ali, Belliato Belliato, Veronesi Veronesi, Bichisao Bichisao, Marchetti Marchetti, Secondino Secondino, Pedrazzoli Pedrazzoli, Pelenghi Pelenghi, Pellegrini Pellegrini, Ringressi Ringressi, Naspro Naspro
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