Background: Pulmonary embolism (PE) accounts for almost 40% of perioperative deaths after bariatric surgery. Placement of prophylactic inferior vena cava (IVC) filter before bariatric surgery to improve outcomes has shown varied results. We performed a meta-analysis to evaluate postoperative outcomes associated with the preoperative placement of IVC filters in these patients. Methods: A systematic review was conducted by three investigators independently in PubMed, EMBASE, the Web of Science and Scopus until February 28, 2013. Our search was restricted to studies in adult patients undergoing bariatric surgery with and without IVC filters. Primary outcomes were postoperative deep vein thrombosis (DVT), pulmonary embolism (PE), and postoperative mortality. Meta-analysis used random effects models to account for heterogeneity, and Sidik-Jonkman method to account for scarcity of outcomes and studies. Associations are shown as Relative Risks (RR) and 95% Confidence Intervals (CI). Results: Seven observational studies were identified (n=102,767), with weighted average incidences of DVT (0.9%), PE (1.6%), and mortality (1.0%) for a follow-up ranging from 3 weeks to 3 months. Use of IVC filters was associated with an approximately 3-fold higher risk of DVT and death that was nominally significant for the former outcome, but not the latter (RR 2.81, 95%CI 1.33-5.97, p=0.007; and RR 3.27, 95% CI 0.78-13.64, p=0.1, respectively); there was no difference in the risk of PE (RR 1.02, 95%CI 0.31-3.77, p=0.9). Moderate to high heterogeneity of effects was noted across studies. Conclusions: Placement of IVC filter before bariatric surgery is associated with higher risk of postoperative DVT and mortality. A similar risk of PE in patients with and without IVC filter placement cannot exclude a benefit, given the potential large imbalance in risk at baseline. Randomized trials are needed before IVC placement can be recommended. / Revisión por pares

Context: Inferior vena cava (IVC) anomalies have a 0.5% incidence rate and could be associated with other congenital abnormalities. In later stage of the disease, trophic ulcers with or without deep vein thrombosis (DVT) is consistent finding.Case Report: A 29-year-old male patient presented with recurrent lower extremity ulcers. Further workup revealed an absent infrahepatic inferior vena cava, prominently dilated azygos and hemiazygos veins with enlarged retroperitoneal collaterals without DVT.Conclusion: IVC anomaly should be suspected in a young patient presenting with unexplained venous thrombosis and recurrent ulcers of a lower extremity. IVC anomaly would inherently lead to blood flow stasis and endothelial injury. Thus per Virchow's triad, other risk factors for hypercoagulability such as physical inactivity, smoking tobacco, oral contraceptive pills should be avoided and when hereditary thrombophilias or other irreversible risk factors are present, lifelong anticoagulation should be considered.

Magnetic Resonance Imaging (MRI) was used to determine changes in the size of the Inferior Vena Cava (IVC) as a result of blood pooling induced by lower body negative pressure (LBNP). Images of the IVC of supine human subjects (10 males, 10 females) were obtained under four conditions: 1) steady-state 0 mmHg LBNP, 2) steady-state –35 mmHg LBNP, 3) ramping from 0 to –35 mmHg LBNP, 4) ramping from –35 to 0 mmHg LBNP. Volumes for a given IVC segment were obtained under the first two conditions during both end inspiration and end expiration breath-holds. Inferior Vena Cava widths were measured under all four conditions at the levels of portal entry and portal exit. The IVC volume for men and women combined decreased 41% due to LBNP (p andlt; 1.02 x 10-9). The IVC was 64.4% wider at portal exit than at portal entry in men (p andlt; 0.0003). Lower Body Negative Pressure induced a decrease in men's vena cava width up to 46% at portal exit and up to 62% at portal entry. Supported by NASA EPSCoR WKU 522611 and NIH GCRC MO1 RR262.

Kidney and inferior vena cava (IVC) abnormalities with extensive deep vein thrombosis (DVT) is a very rare cause of DVT and has a diverse clinical presentation. Computed tomography (CT) angiography is the gold standard for diagnosis and treatment including thrombectomy, thrombolysis and systemic anticoagulation. We present a rare case of active young healthy male admitted with acute onset of right lower extremity pain and swelling who was found to have extensive DVT on doppler ultrasound. CT abdomen showed extensive clot burden involving right common femoral vein extending into internal and external iliac veins associated with IVC hypoplasia and hypoplastic left kidney. Patient underwent urgent thrombectomy, catheter directed thrombolysis and was discharged home in stable condition on oral anticoagulation.

No description available.

No description available.

O óxido nítrico (NO) é o principal agente vasodilatador endógeno que regula o tônus e a homeostase vascular, além de controlar o fluxo sanguíneo. Doadores de NO, entre eles os nitratos orgânicos, são importantes medicamentos para o tratamento de doenças cardiovasculares. O grande benefício clínico desses nitratos é atribuído ao seu efeito venodilatador. Isto se deve ao seu efeito sobre a redução do retorno venoso, da pré-carga cardíaca e da demanda de oxigênio pelo miocárdio. Porém, um dos efeitos adversos mais comuns dos nitratos orgânicos é a cefaléia causada pela vasodilatação cerebral. Os doadores de NO utilizados clinicamente, nitroglicerina (NTG) e nitroprussiato de sódio (NPS), possuem algumas limitações como indução de tolerância e toxicidade, respectivamente. Dentre os compostos amplamente estudados, que são capazes de liberar NO, estão os complexos nitrosilos de rutênio. Estes complexos têm interesse terapêutico devido à sua baixa toxicidade. Recentemente, verificamos que o complexo de rutênio [Ru(terpy)(bdq)NO]3+ (Terpy), sintetizado em nosso departamento, reduz a pressão de ratos hipertensos renais 2R-1C e promove relaxamento vascular da aorta desses animais e de ratos normotensos controles (2R). Desta forma, a hipótese deste trabalho é de que o Terpy seja capaz de induzir relaxamento vascular em anéis de artéria basilar e veia cava inferior, tanto de ratos normotensos (2R) quanto de ratos 2R-1C. O nosso estudo teve como objetivo estudar os efeitos deste composto doador de NO e do doador de NO de referência, NPS, e os seus mecanismos de relaxamento vascular na artéria basilar e veia cava inferior de ratos normotensos 2R e hipertensos renais 2R-1C. Nossos resultados demonstram que o Terpy, ao contrário do NPS, não promoveu relaxamento vascular na artéria basilar de ratos 2R e 2R-1C. Da mesma forma, o Terpy não liberou NO nas células do músculo liso vascular. O NPS liberou NO e induziu relaxamento da artéria basilar pela ativação da enzima guanililciclase solúvel (GCs), com conseqüente ativação da proteína quinase dependente de GMPc (GK) e ativação dos canais para K+(KV, KATP e KIR). Ambos doadores, assim como a NTG, promoveram relaxamento vascular em anéis de veia cava e artéria basilar de ratos 2R e 2R- 1C de forma dependente da concentração. O relaxamento das veias de ratos 2R-1C foi menor do que em veias de 2R para os doadores de NO: Terpy, NPS e NTG. A liberação do NO pelo Terpy foi menor nas veias de 2R-1C. O NPS induz relaxamento da veia cava inferior pela ativação da enzima GCs com conseqüente ativação da proteína GK e ativação de canais para K+ sensíveis ao TEA. O Terpy induziu relaxamento da veia cava inferior pela ativação da enzima GCs, com conseqüente ativação da GK, ativação da Ca2+-ATPase reticular (SERCA) e ativação dos canais para K+ (KV, SKca e BKca). Em conjunto, nossos resultados mostraram que o Terpy é menos potente que o doador de referência (NPS) na veia cava inferior de ratos 2R e 2R-1C. Sua resposta vasodilatadora se deve principalmente à ativação da GCs, de canais para K+,proteína GK e SERCA. O Terpy, ao contrário do NPS, não induz relaxamento na artéria basilar de ratos 2R e 2R-1C. A resposta vasodilatadora do NPS nesses vasos se deve principalmente à ativação da GCs, de canais para K+ e proteína GK. A SERCA parece não estar envolvida no mecanismo de relaxamento vascular induzido pelo NPS. / Nitric oxide (NO) is an endogenous vasodilator that regulates vascular tone, homeostasis and blood flow. NO donors, including organic nitrates are important drugs for the treatment of cardiovascular diseases. A major clinical benefit of NO donors is attributed to their venodilator effect, resulting in decreased venous return, cardiac preload, arterial pressure and decreased myocardial oxygen demand. But the most common side effect of these drugs is the headache, which is caused by cerebral vasodilatation. The clinically used NO donors, nitroglycerin (NTG) and sodium nitroprusside (SNP), have some limitations such as induction of tolerance and toxicity, respectively. Among the widely studied compounds, which are capable of releasing NO are the nitrosyl ruthenium complexes, which have therapeutic interest due to its low toxicity. Recently, we found that the ruthenium complex [Ru (terpy)(BDQ)NO]3+ (Terpy) reduces the blood pressure of renal hypertensive rats (2K- 1C) and promotes vascular relaxation in aorta from 2K-1C and normotensive rats (2R). Thus, the hypothesis of the present work was that Terpy is able to induce vascular relaxation in basilar artery and inferior vena cava rings in 2K and 2K-1C rats. Our study aimed to investigate the effects of Terpy and SNP (the classical NO donor) and their vascular mechanisms in basilar artery and inferior vena cava from 2K and 2K-1C rats. Our results demonstrate that Terpy, unlike the SNP, did not promote vascular relaxation in basilar artery of 2K and 2K-1C. Terpy did not release NO in vascular smooth muscle cells. SNP released NO and induced relaxation in basilar artery rings by activating the enzyme soluble guanylyl cyclase (sGC) with consequent activation of cGMP-dependent protein kinase (GK) and activation of K + channels (KV, KATP and KIR). Both NO donors and NTG promoted vascular relaxation in vena cava rings from 2K and 2K-1C rats in concentration-dependent way. We have observed an impaired relaxation to NO in cava vein from 2K-1C rats. The NO release by Terpy was lower in 2K-1C veins. NPS induces relaxation in inferior vena cava by the activation of GCs, GK and K+ channels. Terpy induced relaxation in inferior vena cava by the activation of the enzyme sGC, with consequent activation of GK, reticular Ca2 + ATPase (SERCA) and activation of K + channels (KV and BKCa SKca). Taken together, our results demonstrate that Terpy is less potent than the reference NO donor (SNP) in the inferior vena cava of 2K and 2K-1C. Its vasodilator effect is mainly due to activation of sGC, K + channels, SERCA and GK protein. In basilar artery Terpy, unlike SNP, does not induce relaxation in 2K and 2K-1C rats. Vasodilator response to SNP in basilar artery is mainly due to activation of sGC, K + channels and GK protein. SERCA appears not to be involved in the mechanism of vascular relaxation by SNP.

O óxido nítrico (NO) é o principal agente vasodilatador endógeno que regula o tônus e a homeostase vascular, além de controlar o fluxo sanguíneo. Doadores de NO, entre eles os nitratos orgânicos, são importantes medicamentos para o tratamento de doenças cardiovasculares. O grande benefício clínico desses nitratos é atribuído ao seu efeito venodilatador. Isto se deve ao seu efeito sobre a redução do retorno venoso, da pré-carga cardíaca e da demanda de oxigênio pelo miocárdio. Porém, um dos efeitos adversos mais comuns dos nitratos orgânicos é a cefaléia causada pela vasodilatação cerebral. Os doadores de NO utilizados clinicamente, nitroglicerina (NTG) e nitroprussiato de sódio (NPS), possuem algumas limitações como indução de tolerância e toxicidade, respectivamente. Dentre os compostos amplamente estudados, que são capazes de liberar NO, estão os complexos nitrosilos de rutênio. Estes complexos têm interesse terapêutico devido à sua baixa toxicidade. Recentemente, verificamos que o complexo de rutênio [Ru(terpy)(bdq)NO]3+ (Terpy), sintetizado em nosso departamento, reduz a pressão de ratos hipertensos renais 2R-1C e promove relaxamento vascular da aorta desses animais e de ratos normotensos controles (2R). Desta forma, a hipótese deste trabalho é de que o Terpy seja capaz de induzir relaxamento vascular em anéis de artéria basilar e veia cava inferior, tanto de ratos normotensos (2R) quanto de ratos 2R-1C. O nosso estudo teve como objetivo estudar os efeitos deste composto doador de NO e do doador de NO de referência, NPS, e os seus mecanismos de relaxamento vascular na artéria basilar e veia cava inferior de ratos normotensos 2R e hipertensos renais 2R-1C. Nossos resultados demonstram que o Terpy, ao contrário do NPS, não promoveu relaxamento vascular na artéria basilar de ratos 2R e 2R-1C. Da mesma forma, o Terpy não liberou NO nas células do músculo liso vascular. O NPS liberou NO e induziu relaxamento da artéria basilar pela ativação da enzima guanililciclase solúvel (GCs), com conseqüente ativação da proteína quinase dependente de GMPc (GK) e ativação dos canais para K+(KV, KATP e KIR). Ambos doadores, assim como a NTG, promoveram relaxamento vascular em anéis de veia cava e artéria basilar de ratos 2R e 2R- 1C de forma dependente da concentração. O relaxamento das veias de ratos 2R-1C foi menor do que em veias de 2R para os doadores de NO: Terpy, NPS e NTG. A liberação do NO pelo Terpy foi menor nas veias de 2R-1C. O NPS induz relaxamento da veia cava inferior pela ativação da enzima GCs com conseqüente ativação da proteína GK e ativação de canais para K+ sensíveis ao TEA. O Terpy induziu relaxamento da veia cava inferior pela ativação da enzima GCs, com conseqüente ativação da GK, ativação da Ca2+-ATPase reticular (SERCA) e ativação dos canais para K+ (KV, SKca e BKca). Em conjunto, nossos resultados mostraram que o Terpy é menos potente que o doador de referência (NPS) na veia cava inferior de ratos 2R e 2R-1C. Sua resposta vasodilatadora se deve principalmente à ativação da GCs, de canais para K+,proteína GK e SERCA. O Terpy, ao contrário do NPS, não induz relaxamento na artéria basilar de ratos 2R e 2R-1C. A resposta vasodilatadora do NPS nesses vasos se deve principalmente à ativação da GCs, de canais para K+ e proteína GK. A SERCA parece não estar envolvida no mecanismo de relaxamento vascular induzido pelo NPS. / Nitric oxide (NO) is an endogenous vasodilator that regulates vascular tone, homeostasis and blood flow. NO donors, including organic nitrates are important drugs for the treatment of cardiovascular diseases. A major clinical benefit of NO donors is attributed to their venodilator effect, resulting in decreased venous return, cardiac preload, arterial pressure and decreased myocardial oxygen demand. But the most common side effect of these drugs is the headache, which is caused by cerebral vasodilatation. The clinically used NO donors, nitroglycerin (NTG) and sodium nitroprusside (SNP), have some limitations such as induction of tolerance and toxicity, respectively. Among the widely studied compounds, which are capable of releasing NO are the nitrosyl ruthenium complexes, which have therapeutic interest due to its low toxicity. Recently, we found that the ruthenium complex [Ru (terpy)(BDQ)NO]3+ (Terpy) reduces the blood pressure of renal hypertensive rats (2K- 1C) and promotes vascular relaxation in aorta from 2K-1C and normotensive rats (2R). Thus, the hypothesis of the present work was that Terpy is able to induce vascular relaxation in basilar artery and inferior vena cava rings in 2K and 2K-1C rats. Our study aimed to investigate the effects of Terpy and SNP (the classical NO donor) and their vascular mechanisms in basilar artery and inferior vena cava from 2K and 2K-1C rats. Our results demonstrate that Terpy, unlike the SNP, did not promote vascular relaxation in basilar artery of 2K and 2K-1C. Terpy did not release NO in vascular smooth muscle cells. SNP released NO and induced relaxation in basilar artery rings by activating the enzyme soluble guanylyl cyclase (sGC) with consequent activation of cGMP-dependent protein kinase (GK) and activation of K + channels (KV, KATP and KIR). Both NO donors and NTG promoted vascular relaxation in vena cava rings from 2K and 2K-1C rats in concentration-dependent way. We have observed an impaired relaxation to NO in cava vein from 2K-1C rats. The NO release by Terpy was lower in 2K-1C veins. NPS induces relaxation in inferior vena cava by the activation of GCs, GK and K+ channels. Terpy induced relaxation in inferior vena cava by the activation of the enzyme sGC, with consequent activation of GK, reticular Ca2 + ATPase (SERCA) and activation of K + channels (KV and BKCa SKca). Taken together, our results demonstrate that Terpy is less potent than the reference NO donor (SNP) in the inferior vena cava of 2K and 2K-1C. Its vasodilator effect is mainly due to activation of sGC, K + channels, SERCA and GK protein. In basilar artery Terpy, unlike SNP, does not induce relaxation in 2K and 2K-1C rats. Vasodilator response to SNP in basilar artery is mainly due to activation of sGC, K + channels and GK protein. SERCA appears not to be involved in the mechanism of vascular relaxation by SNP.

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No. of bitstreams: 1 josemunizpazelijunior.pdf: 868943 bytes, checksum: 7c1afb9837b6e1d73d18f7ea10b1401f (MD5) Previous issue date: 2012-11-29 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / A Doença Renal Crônica (DRC) é um problema de saúde pública mundial e o número de pacientes inscritos em programas de terapia de substituição de função renal vem crescendo progressivamente. A morbimortalidade dos pacientes com DRC é impressionante e se deve principalmente a doença cardiovascular. A remoção inadequada de líquidos durante a hemodiálise é um dos principais fatores responsáveis por esta evolução desfavorável. A hipervolemia crônica leva a hipertensão, hipertrofia ventricular esquerda, congestão pulmonar e aumenta as taxas de hospitalização e mortalidade. A hipovolemia, por outro lado, se associa com náuseas, vômitos, diminuição da qualidade de vida, perda da função renal residual, trombose do acesso venoso e redução da adequação da diálise, devido às frequentes interrupções das sessões de diálise. O peso seco, definido como o menor peso atingido pelo paciente no final das sessões, quando a maior parte do excesso de líquido acumulado tenha sido removido, ainda é avaliado clinicamente, mas tem fraca correlação com a verdadeira volemia. Apesar de não podermos contar com método que seja “padrão-ouro”, devido às limitações na acurácia e aplicabilidade, várias exames complementares tem sido estudados e validados para a determinação mais precisa da volemia em pacientes dialíticos, incluindo a avaliação ultrassonográfica da veia cava inferior (VCI). O alto custo dos ecocardiógrafos e a necessidade de um ecocardiografista para operá-los têm impedido a disseminação da ultrassonografia para avaliar a VCI e, consequentemente, a volemia. Nós hipotetizamos que a classificação volêmica baseada na determinação do diâmetro expiratório da VCI indexado pela superfície corpórea (DVCIi) e o índice de colabamento inspiratório da VCI (ICVCI) realizada por médico nefrologista, sem especialização em ultrassonografia, é similar àquela obtida no mesmo exame realizado por médico especialista em ecocardiografia utilizando um ecocardiógrafo padrão (ECO) ou um equipamento de ultrassom convencional (US). Neste estudo transversal, um ecocardiografista experiente e um nefrologista sem especialização formal em ultrassonografia avaliaram consecutivamente o DVCIi e o ICVCI de 52 pacientes, durante as sessões de hemodiálise. No protocolo I, o nefrologista usou o US e o cardiologista usou o ECO; no protocolo II os aparelhos foram invertidos entre os pesquisadores. Em ambos os protocolos, os coeficientes de Pearson e kappa foram utilizados para avaliar a correlação entre as variáveis contínuas e categóricas, respectivamente. A concordância entre os examinadores foi avaliada pelo Bland-Altman. Obtivemos imagens de boa qualidade da VCI em 96% dos pacientes. As avaliações do DVCIi apresentaram forte correlação em ambos os protocolos (r= 0,88 e 0,84, nos protocolos I e II, respectivamente). A correlação entre as classificações volêmicas foi excelente no protocolo I (kappa = 0,82 e 0,93 pelo DVCIi e ICVCI, respectivamente) e substancial no protocolo II (kappa = 0,77 e 0,75 pelo DVCIi e ICVCI, respectivamente). A concordância entre os examinadores pelo gráfico de Bland-Altman das avaliações de DVCIi foi também muito boa em ambos os protocolos. Nefrologistas sem especialização formal em ultrassonografia usando um US podem avaliar a volemia de pacientes dialíticos através da ultrassonografia de VCI. O mesmo equipamento que já equipa as clínicas de diálise e é utilizado para diversas outras finalidades, como biópsia renal guiada, acesso venoso guiado, avaliação do trato urinário, mapeamento vascular e estudo das fístulas e enxertos, pode ser utilizado para determinação do peso seco. Esperamos assim, reduzir custos e melhorar a qualidade do atendimento dos pacientes dialíticos, através da disseminação da avaliação ultrassonográfica da VCI. / Chronic kidney disease has emerged as a public health problem of substantial proportions, and the number of patients who require renal replacement therapy has been growing over the years. The mortality rate of patients with ESRD remains amazing, and a large part of this mortality is due to cardiovascular disease. The inadequate fluid removal during hemodialysis is a major factor responsible for this unfavorable development. The hypervolemia leads to chronic hypertension, left ventricular hypertrophy, pulmonary congestion and increased rates of hospitalization and mortality. The hypovolemia, moreover, is associated with nausea, vomiting, diminished quality of life, loss of residual renal function, access thrombosis and reduction of dialysis adequacy, due to frequent interruptions of dialysis sessions. Clinically estimated dry weight, defined as the lowest post-dialysis weight at which most excess body fluid will have been removed, is widely used but is poorly predictive of volemic status. Despite the lack of gold standards, related to limitations in accuracy and feasibility, fluid volume has been assessed by using various tools, including ultrasonographic evaluation of the inferior vena cava (IVC). We sought to determine whether a nephrologist with limited ultrasound training can accurately assess the IVC in patients undergoing haemodialysis compared with a cardiologist by using a regular ultrasound system (RUS) or a full cardiovascular ultrasound system (CVUS). In a cross-sectional study, an experienced cardiologist and a nephrologist without formal ultrasound training consecutively measured the indexed IVC expiratory diameter (VCDi) and IVC collapsibility index (IVCCI) of 52 patients during haemodialysis sessions. In protocol I, the nephrologist used an RUS and the cardiologist used a CVUS; in protocol II, the machines were interchanged. In both protocols, Pearson and kappa correlation coefficients were used to evaluate the 11 interobserver correlation of continuous and categorical data, respectively. The interexaminer agreement was determined by the Bland–Altman method. High-quality IVC images were obtained in 96% of the patients. The VCDi measurements showed strong correlation in both protocols (r = 0.88 and 0.84 in protocols I and II, respectively). The volaemic classifications were excellent in protocol I (kappa = 0.82 and 0.93 by the VCDi and IVCCI, respectively) and substantial in protocol II (kappa = 0.77 and 0.75 by the VCDi and IVCCI, respectively). The interexaminer agreement on the VCDi measurements was also very good in both protocols. Ultrasound evaluation of the IVC can be performed by nephrologists without formal training using an RUS to assess volaemic status in patients undergoing haemodialysis. The same equipment that is already being used in dialysis clinics for several other purposes, such as guided renal biopsy, guided venous access, evaluation of the urinary tract, vascular mapping and study of fistulas and grafts can be used to determine the dry weight. We hope reduce costs and improve the quality of care for dialysis patients, through the spread of ultrasound evaluation of the IVC.

Malgré des progrès significatifs dans le diagnostic précoce, on constate ces dernières années une nette tendance à l'augmentation du nombre de patients atteints de carcinome à cellules rénales (CCR) présentant une complication spécifique sous la forme d'un thrombus tumoral (TT) s'étendant le long de la lumière de la veine cave inférieure (VCI) au-dessus du niveau du diaphragme, jusqu'à l'atrium droit. Le seul traitement efficace du CCR avec TT reste la chirurgie. La chirurgie conventionnelle comprend la néphrectomie radicale avec thrombectomie, nécessitant des techniques de pontage cardio-pulmonaire et l'arrêt de la circulation sanguine, ce qui implique toujours des complications graves. Pour les éviter, diverses options d'accès chirurgical à la partie supradiaphragmatique de la VCI et à l'atrium droit ont été proposées exclusivement par le côté abdominal, en utilisant diverses options de diaphragmotomie et de péricardotomie avec isolement de la VCI dans la cavité péricardique. L'un des points les plus importants dans le traitement chirurgical du CCR avec TT supradiaphragmatique, est le contrôle de l'extrémité distale du TT. Cette étape dépend largement de l'accès choisi. Dans ce travail, afin d'optimiser les techniques chirurgicales pour les patients atteints de TT supradiaphragmatique, nous avons comparé la faisabilité et la sécurité des différents accès chirurgicaux transdiaphragmatiques. Nous avons également proposé un accès transdiaphragmatique transpéricardique combiné comprenant des diaphragmotomies en forme de T et circulaires, combinées à des péricardotomies longitudinales et circulaires. Nous avons utilisé quatre corps préservés avec la méthode Thiel pour réaliser les simulations chirurgicales. La néphrectomie radicale avec thrombectomie a été réalisée par deux experts de manière indépendante. Quatre approches chirurgicales de la VCI supradiaphragmatique ont été réalisées consécutivement. Nous avons utilisé des simulateurs de TT de différents diamètres et densités pour étudier la palpation de l'apex du TT et son déplacement. La faisabilité et la sécurité de chaque accès et de chaque procédure chirurgicale ont été évaluées à l'aide du test du Chi carré, avec correction des comparaisons multiples (Bonferroni). Notre travail a confirmé la faisabilité et la sécurité des approches transdiaphragmatiques. Les accès transpéricardiques sont préférables dans les cas où les TT sont plus élevés. Ils constituent une alternative adéquate à la chirurgie conventionnelle en cas de TT flottant supradiaphragmatique, jusqu’à l’atrium droit. / Despite significant progress in early diagnosis, there has been a clear trend in recent years towards an increasing number of renal cell carcinoma (RCC) patients with a specific complication in the form of a tumor thrombus (TT) extending along the lumen of the inferior vena cava (IVC) above the level of the diaphragm into the right atrium. The only effective treatment for RCC with TT remains surgery. Conventional surgery includes radical nephrectomy with thrombectomy, requiring cardiopulmonary bypass techniques and cessation of blood flow, which always involves serious complications. To avoid them, various options for surgical access to the supradiaphragmatic part of the IVC and the right atrium have been proposed exclusively from the abdominal side, using various options of diaphragmotomy and pericardotomy with isolation of the IVC in the pericardial cavity. One of the most important issues in the surgical treatment of RCC with supradiaphragmatic TT is the control of the distal end of the TT. This step depends largely on the access chosen. In this work, to optimize surgical techniques for patients with supradiaphragmatic TT, we compared the feasibility and safety of different transdiaphragmatic surgical accesses. We also proposed a combined transdiaphragmatic transpericardial access including T-shaped and circular diaphragmotomies combined with longitudinal and circular pericardotomies. We used four bodies preserved with the Thiel method to perform the surgical simulations. Radical nephrectomy with thrombectomy was performed by two experts independently. Four supradiaphragmatic ICV surgical approaches were performed consecutively. We used TT simulators of different diameters and densities to study palpation of the TT apex and its displacement. The feasibility and safety of each access and surgical procedure were evaluated using the Chi-square test with correction for multiple comparisons (Bonferroni). Our work confirmed the feasibility and safety of transdiaphragmatic approaches. Transpericardial accesses are preferable in cases with higher TT. They are an adequate alternative to conventional surgery in cases of supradiaphragmatic floating TT, up to the right atrium.