A 68 year old man presented with the complain of painless, gross haematuria since past 1 month. His medical history was remarkable for presence hypertension and Type 2 diabetes mellitus. He had a history of smoking for 10 years with complete abstinence from smoking for last 6 months. He underwent a detailed pre-anaesthetic checkup. A blood haemogram revealed normocytic hypochromic anaemia with a haemoglobin level of 10 gm/dl. Biochemical parameters were significant for a creatinine level of 1.9

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... mg/dl. Ultrasonography of whole abdomen showed a 3 × 2.3 cm space occupying lesion in the left renal mid-pelvic region with evidence of hypoechoic lesion seen in left renal vein extending to inferior vena cava. Magnetic resonance images confirmed the presence of a mass in lower pole of left kidney with nodular component measuring 3.4 × 2.6 × 2.1 cm. The medial aspect of the mass was ill-defined. Almost entire length of the vena cava was involved sparing proximal pre-hepatic part and extending to the site of drainage into right atrium. There were no enlarged lymph nodes and the vena caval wall was free. A transthoracic echocardiogram showed tumour infiltration in inferior vena cava and thrombus protruding into right atrium (Figures 1 and 2) . Biventricular function was good and there was no evidence of tricuspid regurgitation, pulmonary arterial hypertension or pericardial effusion. All the cardiac valves had normal morphology and function. Management of the case A radial arterial cannula was placed in the left hand for continuous invasive blood pressure monitoring before induction of anaesthesia. Intravenous midazolam was given at dose of 0.05 mg/kg for anxiolysis. Co-induction was done using fentanyl at a dose of 5 µ/kg and titrated doses of thiopentone sodium. The end point of anaesthetic induction was the loss of eyelash reflex. After an uneventful endotracheal intubation, a central venous catheter was placed in right internal jugular vein under ultrasound guidance. Care was taken not to insert the guide wire beyond 15 cm and the catheter was fixed on the skin at a distance of 13 cm. A rooftop incision was given for exposure of left kidney and its vascular pedicles and the inferior vena cava. The arteries to the left Figure 1. Transthoracic echocardiography showing tumour thrombus protruding from right atrium into right ventricle through tricuspid valve on apical four chamber view. Figure 2. Transthoracic echocardiography image showing dilated hepatic veins and tumour completely obstructing junction of IVC and right atrium.