Cuff Of Inferior Vena Cava Research Articles

The Promise of Single Kidney Transplants from Small Pediatric Donors

The Promise of Single Kidney Transplants from Small Pediatric Donors

Primary Leiomyosarcoma of inferior vena cava: a Case of Rare Malignancy

Vascular leiomyosarcoma is a rare tumor, only about 200 cases have been reported worldwide. It commonly arises from inferior vena cava (IVC). There is a strong predilection for females and middle segment of IVC is most commonly affected. The diagnosis is often challenging as patients present with non-specific complaints such as dyspnoea, abdominal discomfort, or back pain. Computed tomography (CT) and Magnetic resonance imaging (MRI) individually or in combination with cavography, ultrasonography (US) and echocardiography, allow an early preoperative diagnosis. Here in, we present a rare case report of leiomyosarcoma of IVC in a 70 year old male patient who presented with vague abdominal discomfort. Ultrasound of abdomen detected a mass in retro peritoneum with mixed echogenicity. CT scan revealed a 10.5 x 6 x 6 cm lobulated, heterogeneously enhancing luminal mass with necrotic changes in supra-renal segment of IVC. Diagnosis of primary Vena caval tumor was made. En bloc resection of the tumor with 1 cm cuff of IVC with closure of the lower end of IVC was performed with excision of a cuff of the liver which was adherent to the IVC. Specimen grossly revealed a soft tissue mass adherent to vessel measuring 10 x 6.5 x 6 cm. External surface was smooth and bosselated. Cut section was nodular, grey white and firm in consistency. Microscopically diagnosis of Leiomyosarcoma was made. IHC study revealed positivity for Smooth muscle actin and desmin and Ki 67 positivity in 12-15 % of tumor cells and was consistent with diagnosis of Leiomyosarcoma. Key words: Desmin, Inferior vena cava, Leiomyosarcoma, Smooth muscle actin, Vascular tumor.

Unusual Presentation of Left Hepatic Vein in Deceased Donor: Case Report

An anomaly of the left hepatic vein was discovered in a deceased donor for whole liver transplantation. This vein was attached by a thin bridge of tissue to the suprahepatic inferior vena cava cuff, which received the right and middle hepatic vein in a common trunk. The left hepatic vein and the common trunk drained together into the right atrium. The thin bridge of tissue connecting the 2 independent vessels was severed, and ex situ reduction of the left lateral segments was using a harmonic scalpel. Although a graft with reduced size is not ideal, ex situ reduction should be considered a valuable option when viability of the left lateral segments is uncertain in the donor or at the back table.

Obtaining Cuff of Inferior Vena Cava by Use of the Endo-TA Stapler in Retroperitoneoscopic Right-Side Donor Nephrectomy

To determine the feasibility of obtaining an adequate cuff of the inferior vena cava (IVC) for vascular anastomosis during retroperitoneoscopic donor nephrectomy. Between September 2004 and May 2005, a total 100 retroperitoneoscopic donor nephrectomies were performed. Fifteen cases were performed on the right side. The Endo-TA stapler was used to obtain the cuff of IVC in all cases of right-side donor nephrectomy. Mean warm ischemia time was 4.9 minutes (range, 2.96 to 8.0 minutes). Mean length of the cuff of IVC was 4 mm (range, 3 to 6 mm) at the upper end and 6 mm (range, 4 to 8 mm) at the lower end of the vein. All grafts functioned immediately, and there was one graft loss due to vascular rejection. Control of the renal vein by use of the Endo-TA stapler during retroperitoneoscopic donor nephrectomy helps in obtaining a good vascular cuff of the IVC.

Precaval Right Renal Artery During Laparoscopic Donor Nephrectomy

Since its introduction in 1995 (1), laparoscopic donor nephrectomy (LDN) has rapidly become the standard of care for the procurement of allografts from potential kidney donors (2). Preoperative evaluation of both the donor and recipient is extensive and often includes cross-sectional imaging to help determine if allograft harvest is feasible. Computed tomography (CT) with intravenous contrast is commonly utilized to evaluate not only which kidney to procure, but also to help plan the procurement. This “CT angiogram” allows visualization of the renal vasculature in order to determine the best operative approach, and to prevent unforeseen difficulties with adequate length of vasculature for anastomosis in the recipient. A healthy 29-year-old female underwent a preoperative workup for kidney donation, including an contrast- enhanced CT scan, which revealed an isolated finding of a single, precaval right renal artery (Fig. 1). The right kidney also had a simple cyst, while the left was larger, with multiple arteries and veins. These findings made the right kidney preferable for donation. CT imaging did not reveal any other anomalies, and we elected to proceed with a right LDN. During the procedure, after the gonadal vein was ligated and transected, the renal artery was mobilized, stapled, and transected at its junction with the aorta. This maneuver allowed for maximal length of the vasculature (both arterial and venous) for anastomosis in the recipient. Both the donor and the recipient tolerated their respective procedures well and had excellent postoperative outcomes.FIGURE 1.: A contrast-enhanced computed tomography image demonstrating the single right renal artery (A) passing anterior to the inferior vena cava.During the eighth week of gestation, the renal arteries develop from the lateral portion of an arterial plexus arising from the aorta. The posterior vessels of this plexus develop into lumbar arteries, while ventral vessels become mesenteric arteries. A precaval right renal artery is likely the result of a persistent caudal vessel, arising ventrally from the aorta after formation of the inferior vena cava (IVC), but before gonadal vein descent (3, 4). The prevalence of this anomaly has been reported between 0.8% (5) and 5% (6). The precaval artery is commonly an accessory to the lower pole, (3, 6) associated with an enlarged kidney or a bifid collecting system (4). We present a case of a precaval right renal artery during LDN without any of these associated findings. Usually during right donor nephrectomy, great care is taken to maximize renal vein length, often taking a cuff of IVC during its transection. However, the length of the renal artery can be suboptimal if its dissection is not adequate. Our common practice is to place the kidney in a “flipped” position and to dissect the renal artery to its origin at the aorta (7). By taking both renal vessels at their insertion/origin, maximum length for anastomosis can be successfully attained. In this case, however, dissection was actually facilitated by the presence of the right renal artery anterior to the IVC. After careful dissection exposed the vessels, the ligation and transection of the artery was performed without having to flip the kidney to work posteriorly. In our brief experience, a precaval right renal artery does not preclude a successful right laparoscopic donor nephrectomy. Bartholomew Radolinski Eric K. Diner Department of Urology Washington Hospital Center Washington, DC Seyed R. Ghasemian Departments of Urology and Transplantation Services Washington Hospital Center Washington, DC

Bovine valved xenograft conduits in the extracardiac Fontan procedure

Total cavopulmonary connection has been proposed as a rational alternative to atriopulmonary connection for complex Fontan operations. de Leval and colleagues proposed the concept of direct cavopulmonary connection as a way to minimize kinetic energy loss in the Fontan circuit. Total cavopulmonary anastomosis with the extracardiac conduit technique has gained favor because it streamlines the venous flow pattern and reduces the incidence of atrial arrhythmias. There are a number of potential advantages of the extracardiac conduit approach over other modifications of the Fontan procedure, including the improved hydrodynamics in the cavopulmonary connection. Conduits of different material have been used for the extracardiac Fontan procedure, examples of these conduits are the Dacron tube, the polytetrafluoroethylene tube (Gore-Tex; W. L. Gore & Associates, Inc, Flagstaff, Ariz), the homograft, and the pericardial tube, and each one has advantages and disadvantages. Bovine jugular vein xenograft (Medtronic’s Contegra, Medtronic, Inc, Minneapolis, Minn) has been used successfully to reconstruct the right ventricular outflow tract in patients with congenital heart disease, with promising early results. The Contegra conduit is a biologic valved conduit consisting of a glutaraldehyde-preserved heterologous bovine jugular vein with a trileaflet venous valve. The advantages of using the Contegra xenograft are easy availability, different size options, and the presence of a valve in the conduit. In this report we present potential advantages of using a xenograft valved conduit to construct the extracardiac Fontan connection between the inferior vena cava (IVC) and the pulmonary artery (PA).