Background. Retroperitoneal tumours propagate intrathoracic caval tumour thrombi (ICTT) of which we consider two subgroups: ICTT-III (extracardiac) and ICTT-IV (intracardiac). Methods. Case series review. Results. 29 series with 784 patients, 453 with extracardiac and 331 with intracardiac ICTT. Average age was 59 years. 98% of the tumours were RCC, 1% adrenal and Wilms’ tumours, and 1% transitional cell carcinomas. The prevalent incision was rooftop with or without sternotomy. Mortality was 10% (5% for ICTT-III, 15% for ICTT-IV). Morbidity was 56% (36% for ICTT-III, 64% for ICTT-IV) and reoperation for bleeding was the commonest complication (14%). Mean Blood loss was 2.6 litres for ICTT-III and 3.7 litres for ICTT-IV. Mean blood product use was 2.4 litres for ICTT-III and 3.5 litres for ICTT-IV. Operative and anaesthetic times exceeded 5 hours. Hospital stay averaged 13 days. Variations in perioperative care included preoperative embolisation, perioperative transoesophageal echo, surgical incisions, and extracorporeal circulation. Brief Summary. Surgery for ICTT has high transfusion, operating/anaesthetic time, and in-hospital stay requirements, and intracardiac ICTT also attract higher risk. Preoperative tumour embolisation is controversial. The cardiothoracic team offers proactive optimisation of blood loss and preemptive management of intracardiac thrombus impaction: we should always be involved in the management the ICTT. 1. Introduction Tumour thrombus, as opposed to bland (i.e., blood) thrombus, is a collective term for intravascular metastases with thrombotic elements. Tumour thrombi propagate in the Inferior Vena Cava (IVC) from retroperitoneal primaries such as renal cell carcinoma (RCC). 10% of the 50,000 RCC diagnosed internationally every year [1] present with IVC thrombosis [2]. Similar caval tumour thrombi are found in less common retroperitoneal primaries such as Wilms’ tumour [3] and various adrenal, uterine, and bladder tumours. The Levels of tumour thrombi have been defined by Neves and Zincke of Mayo Clinic [4].？Level I, extension into the renal vein;？Level II, extension into the infrahepatic IVC;？Levels III, IVC, extension to the level of hepatic veins but below the diaphragm; and？Levels IV, IVC, extension above the diaphragm and into the right atrium or beyond.This classification (not to be confused with the MAYO scoring system for metastases) has been more or less established in the literature with small minutiae in definitions [5–8]. Aggressive surgical resection has been the treatment of choice. In RCC, this usually
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