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Renal cell carcinoma (RCC) with inferior vena cava (IVC) tumour thrombus represents a high-risk surgical and anaesthetic scenario requiring meticulous multidisciplinary coordination. We report the peri-operative management of a patient in his late 60s with right-sided clear-cell RCC extending to level III of the IVC, who underwent open radical nephrectomy with tumour thrombectomy under continuous transoesophageal echocardiographic monitoring. The procedure was complicated by a total blood loss of 6.4 L and a 26-min period of supra-hepatic IVC clamping. Haemodynamic stability was maintained through early activation of a predefined massive transfusion protocol, vasopressor support and real-time transoesophageal echocardiography-guided assessment of cardiac filling and thrombus position. A regional anaesthesia–based, opioid-sparing analgesic strategy facilitated on-table extubation despite major fluid shifts and prolonged vascular clamping. The patient had an uncomplicated postoperative course and was discharged on postoperative day five. This case demonstrates that, within an established peri-operative framework, emphasis on anticipatory planning, structured blood-management strategies and continuous intraoperative imaging can support predictable recovery even in complex caval thrombectomy surgery.