The management of RCC with tumour thrombus, extending upto right atrium requires a multidisciplinary approach in its management, considering the involvement of vital structures and potential surgical morbidity [2]. Imaging modalities such as CECT, MRI, and Transesophageal/transthoracic echocardiogram are an integral part of evaluation. While considering surgical removal in this scenario, careful preoperative planning is crucial. Complete cardiopulmonary bypass may become essential in cases where the tumor extends into the supradiaphragmatic intrapericardial inferior vena cava (IVC) or infiltrates the right atrium and extends further, requiring atriotomy for the management of level IV tumor thrombi [3]. Intraoperative use of Transesophageal echocardiography (TEE) is the standard of care during surgeries for RCC with IVC thrombus at our institution. It allows for real-time monitoring of the tumor thrombus throughout the procedure, to detect any embolization of tumour thrombus during manipulation and also helps confirm complete thrombus removal. Collaborative efforts between urologists, cardiovascular specialists and a dedicated Anaesthetic team are imperative in devising comprehensive treatment strategies tailored to individual cases.

The actual occurrence rate of RTAD remains undetermined, but it is increasingly recognized, with an estimated overall frequency ranging from 1 to 4%. Modalities for diagnosing RTAD include transesophageal echocardiography, CT angiography, and MRI. Aortic specialists need to be vigilant as RTAD can manifest either acutely or with a delayed onset, potentially occurring during the indexed TEVAR procedure or in the postoperative period [4]. In cases of RTAD, the primary entry tear typically arises distal to the left subclavian artery (LSA), leading to retrograde dissection into the ascending aorta. RTAD can be spontaneous or iatrogenic, linked to both open and endovascular aortic surgeries, particularly when the proximal aorta exceeds a dilation of 40 mm [5]. To our knowledge, this is the first reported case of RTAD occurring during radical nephrectomy. Although urologists rarely encounter this complication during nephrectomy, acute RTAD is a feared occurrence that may go unnoticed on numerous occasions. Utilization of TEE in our case along with the visible color change helped identify this rare yet significant complication.

The management of spontaneous RTAD currently lacks standardized protocols, with documented success in treatment using optimized medical therapy, open surgery, and/or endovascular repair [6]. In our case, we narrowly averted a critical situation as the false lumen was obliterated upon transfixing the renal artery, indicating that the origin of the dissection was probably from the renal artery and had progressed to the ascending aorta (Fig. 3). Conversely, a fatal outcome could have ensued if the patent false lumen in the ascending aorta had not closed, necessitating prompt surgical intervention to address complications such as pericardial effusion, aortic regurgitation, or malperfusion. As this was our first encounter with such a complication, we cannot definitively suggest preventive measures; however, using a transfixation suture for ligation might help. The operating surgeons should thereby be mindful of the potential for retrograde aortic dissection and its implications during radical nephrectomy and IVC Thrombectomy, as seen in our case. The long-term prognosis following such an event requires further study, necessitating a stringent follow-up schedule and multidisciplinary assessment. Based on our case, the prognosis appears favorable provided resolution of the dissection flap is achieved, with no concerning sequelae observed so far, although extended follow-up remains necessary.