Abstract
BackgroundHepatocellular carcinoma (HCC) with tumor thrombus (TT) in the right atrium is a critical condition. The general consensus is to perform hepatectomy prior to cavo-atrial thrombectomy because of the risk of uncontrollable bleeding during the liver transection after heparinization. However, sudden cardiac arrest due to the ball-valve effect and pulmonary embolism have been reported in cases of TT. Cavo-atrial thrombectomy prior to hepatectomy for HCC with TT in the right atrium was successfully performed to prevent sudden cardiac arrest and pulmonary embolism.Case presentationTumor thrombectomy under cardiopulmonary bypass with heparin and electrical ventricular fibrillation prior to hepatectomy was successfully performed to prevent sudden cardiac arrest or pulmonary embolism in a 75-year-old woman with a huge HCC and TT in the right atrium. After the neutralization of heparin, right hepatectomy with tumor thrombectomy in the inferior vena cava was performed. The total operation time was 9 h, and the total blood loss was 8200 mL. The patient’s postoperative course was uneventful, and she was discharged 14 days after surgery. One year after surgery, she is alive with HCC recurrence in the lung.ConclusionsCavo-atrial thrombectomy prior to hepatectomy for HCC with TT in the right atrium can be performed safely to prevent sudden cardiac arrest and pulmonary embolism by collaboration of cardiovascular surgeons and gastroenterological surgeons.
Highlights
Hepatocellular carcinoma (HCC) with tumor thrombus (TT) in the right atrium is a critical condition
Cavo-atrial thrombectomy prior to hepatectomy should be considered in cases with TT which fully enters the right atrium, reaches the tricuspid valve, and is of the pedunculated type, in order to prevent the ball-valve effect or pulmonary embolism [2]
After the removal of TT, the inferior vena cava (IVC) was clamped with a tourniquet above the diaphragm and the right atrium was sutured with 5–0 Prolene
Summary
Hepatocellular carcinoma (HCC) with tumor thrombus (TT) in the right atrium is a critical condition [1]. Cavo-atrial thrombectomy prior to hepatectomy should be considered in cases with TT which fully enters the right atrium, reaches the tricuspid valve, and is of the pedunculated type, in order to prevent the ball-valve effect or pulmonary embolism [2]. CT scans showed a huge tumor, 21 cm in diameter, in the right liver and TT, 37 mm in diameter, in the right atrium After the removal of TT, the IVC was clamped with a tourniquet above the diaphragm and the right atrium was sutured with 5–0 Prolene. A reverse T incision was made, and right hepatectomy by anterior approach and IVC tumor thrombectomy were performed. The tumor was of the massive type macroscopically (Fig. 5), and cancer cells showed moderately to poorly differentiated HCC with invasion to the portal vein, hepatic vein, and diaphragm. She is still alive 14 months after surgery with recurrence in the lung
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