Interruption Of Inferior Vena Cava Research Articles

V01-12 ROBOTIC SUPRARENAL CAVECTOMY IN A PATIENT WITH KIDNEY TUMOR AND LEVEL III TUMOR THROMBOSIS

You have accessJournal of UrologyKidney Cancer I: Partial Nephrectomy & Kidney Preservation Strategies (V01)1 Apr 2020V01-12 ROBOTIC SUPRARENAL CAVECTOMY IN A PATIENT WITH KIDNEY TUMOR AND LEVEL III TUMOR THROMBOSIS Luis G Medina*, Alireza Ghoreifi, Hatim Thaker, Vinay Duddalwar, and Hooman Djaladat Luis G Medina*Luis G Medina* More articles by this author , Alireza GhoreifiAlireza Ghoreifi More articles by this author , Hatim ThakerHatim Thaker More articles by this author , Vinay DuddalwarVinay Duddalwar More articles by this author , and Hooman DjaladatHooman Djaladat More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000826.012AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inferior vena cava (IVC) thrombosis occurs in less than 10% of patients with renal cell carcinoma (RCC). Up to 25% of these cases will require IVC interruption or resection, yet caval replacement is controversial. Our aim is to present the first reported case of robotic suprarenal cavectomy without reconstruction in a patient with RCC. METHODS: A 50-year-old male was found to have 9-cm right renal mass and level III thrombosis during his workup for pulmonary embolism. The length of IVC thrombus was 112 mm, terminating 3.6 cm below the level of hepatic veins and occluded 100% of the IVC without distal bland thrombosis. CT scan showed suspicious lesion in liver and contralateral adrenal, though supplementary imaging ruled out liver metastasis. He underwent robotic right radical nephrectomy, retroperitoneal lymph node dissection, IVC thrombectomy, and suprarenal cavectomy, using 6-port da Vinci Xi surgical system. Intraoperative ultrasound and Trans-Esophageal Echocardiography were employed to ensure the proper IVC controls and endo-GIA was used for cavectomy. RESULTS: The surgery was completed successfully without intraoperative complication. Operating time was 6 hours and estimated blood loss was 300 cc. Intraoperative ultrasound showed the tip of the thrombus and helped to secure rommel control just above it. After securing/cinching down all controls, IVC was opened and thrombus was removed. Cavectomy was deemed necessary due to multiple areas of tumor adhesions to inner part of IVC. Nephrectomy was completed and all specimens removed through pfannstiel incision. Postoperative course was uneventful and discharged home in 4 days. Baseline GFR was 44 and at discharge was 49 mL/min/1.73m2. Pathology endorsed clear cell RCC (pT3bN0) with negative margins as well as multiple adherent tumors in middle section of IVC (non-invasive). No complication including lower limb edema was reported within 90-day, postoperatively. He is without evidence of disease (NED), 9-month after surgery. CONCLUSIONS: Herein, we are reporting a case of right RCC with level III IVC thrombosis that underwent robotic right radical nephrectomy and suprarenal cavectomy, due to possible infiltration of tumor thrombosis to IVC wall. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e93-e94 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Luis G Medina* More articles by this author Alireza Ghoreifi More articles by this author Hatim Thaker More articles by this author Vinay Duddalwar More articles by this author Hooman Djaladat More articles by this author Expand All Advertisement PDF downloadLoading ...

Management of patients with interrupted inferior vena cava requiring electrophysiology procedures.

Interrupted inferior vena cava (IVC) is a rare venous anomaly that complicates the treatment of patients who require electrophysiology (EP) procedures. We describe five consecutive cases of patients with interrupted IVC who presented to the EP laboratory requiring interventional procedures including catheter ablation for atrial fibrillation and supraventricular tachycardia and left atrial appendage closure. All cases were successfully completed utilizing a variety of approaches to vascular access including transseptal puncture via transhepatic and internal jugular approaches. Procedures in the EP lab can be performed successfully in patients with interrupted IVC.

Diagnostic accuracy of contrast-enhanced ultrasound for detecting bland thrombus from inferior vena cava tumor thrombus in patients with renal cell carcinoma.

ABSTRACTPurpose:To evaluate the role of contrast-enhanced ultrasound (CEUS) in differentiating bland thrombus from tumor thrombus of the inferior vena cava (IVC) in patients with renal cell carcinoma (RCC).Materials and Methods:We retrospectively investigated 30 consecutive patients who underwent robot-assisted radical nephrectomy with IVC thrombectomy and had pathologically confirmed RCC. All patients underwent US and CEUS examination. Two off-line readers observed and recorded thrombus imaging information and enhancement patterns. Sensitivity, specificity, accuracy, positive predictive value and negative predictive value for bland thrombus were assessed.Results:Of the 30 patients, no adverse events occurred during administration of the contrast agent. Early enhancement of the mass within the IVC lumen on CEUS was an indicator of tumor thrombus. Bland thrombus showed no intraluminal flow on CEUS. There were eight (26.7%) patients with bland thrombus, including three level II, two level III, and three level IV. There were three cases with cephalic bland thrombus and five cases with caudal bland thrombus. Three caudal bland thrombi extended to the iliac vein and underwent surgical IVC interruption. Based on no intraluminal flow, for bland thrombus, CEUS had 87.5% sensitivity, 100% specificity, 96.7% accuracy, 100% positive predictive value and 95.6% negative predictive value.Conclusion:Our study demonstrates the potential of CEUS in the differentiation of bland and tumor thrombus of the IVC in patients with RCC. Since CEUS is an effective, inexpensive, and non-invasive method, it could be a reliable tool in the evaluation of IVC thrombus in patients with RCC.

Isomerism of the atrial appendages: morphology and terminology.

Our aim is to identify the pathognomonic anatomical markers and the best terminology to describe the cardiac malformations associated with absent or multiple spleens, which are known as asplenia or polysplenia syndromes or isomerism. We have reviewed 65 hearts with isomerism of atrial appendages of the Anatomical Collections of Congenital Heart Disease, Institute of Pathological Anatomy of the University of Padua consisting of 1800 specimens. All the hearts were classified according to sequential segmental classification. The incidence of isomerism was 3.6%. Of the total, 45 hearts with isomerism of right atrial appendages showed bilateral trilobed lungs, short bronchi, and absent spleen. The atrioventricular junction was univentricular in 49% of cases with a common atrioventricular valve in 91%. Pulmonary atresia and double outlet right ventricle were present in 40% and 47% of cases, respectively. Total anomalous pulmonary venous drainage and absent coronary sinus were always present. In 20 hearts with isomerism of left atrial appendages, bilateral bilobed lungs with long bilateral bronchi and multiple spleens were always found. The biventricular atrioventricular connection was present in 65% with a common valve in 30% of the hearts. The ventriculoarterial connection was concordant in 45% of cases, and aortic atresia and pulmonary atresia were both noted in 15% of each. An anomalous symmetric pulmonary venous drainage was observed in 65% of the hearts and interruption of inferior vena cava was found in 75% of cases. We believe that the appropriate terminology is based on the symmetrical morphology of the atrial appendages. The absence of the coronary sinus and the total anomalous pulmonary venous drainage are the markers of isomerism of the right atrial appendages. Symmetric pulmonary venous drainage and interruption of inferior vena cava are the markers of isomerism of left atrial appendages. In recent years, thanks to the improvement of clinical diagnosis and of surgical techniques these patients have the possibility to survive to adult age.

Counseling in agenesis of ductus venosus secondary to interrupted inferior vena cava

Counseling in agenesis of ductus venosus secondary to interrupted inferior vena cava

Biliary Atresia Splenic Malformation Syndrome: A Single Center Experience

Abstract:
 Introduction: The cause of biliary atresia (BA) is not understood exactly as well as biliary atresia splenic malformation (BASM) syndrome. BA is destructive biliary fibrosis; the etiology may be multifactorial. Association of cytomegalovirus (CMV) and BA have been shown in many reports but CMV and BASM have not been mentioned in the literature. So we aimed to report BASM experiences, an association of CMV infection and need of duodenoduodenostomy if preduodenal portal vein exists.
 Materials and Methods: The data were collected retrospectively from Cukurova University which is one of the largest tertiary hospitals in Turkey between 2005-2017. The patients of sex, age, blood chemistry counts, TORCH infections blood parameters, BA types, operational findings and mortality were noted.
 Results: In total, 59 BA patients were diagnosed between 2005- 2017. Seven of them were classified as BASM. The median age of them was 60 days (45-90 days). Three of them were girl and 4 of them were male in gender. The main complaint of whole patients was jaundice. The jaundice of 6 patients began since birth. One of them began at 20 days-age. Median total / direct blood bilirubin levels were 9.6 / 5.4 mg/dl. Median values of liver function tests; ALT, AST and GGT were 77 IU/L, 201 IU/L and 607 IU/L respectively.
 Five of the patients showed positive results for anti-CMV immunoglobulin M. All had positive anti-CMV Ig G and anti-toxoplasmosis Ig G.
 Evaluation of the types of BA revealed that one patient had type 2, while all others had type 3. Four of BASM patients had polysplenia and one had asplenia. Five of them had a preduodenal portal vein. All of them had midgut malrotation. One had inferior vena cava interruption. One had hepatic artery anomaly which was originated from SMA.
 The median time of follow-up was 4 years (1-5 years). All of them are alive and 1 required liver transplantation.
 Conclusion: BASM should be kept in mind by the surgeon for the requirement of additional surgical procedures such as Ladd procedure, duodenoduodenostomy with Kasai Porto-enterostomy.
 Duodenoduodenostomy may be performed when the existence of preduodenal portal vein.
 Further research is recommended for CMV infection and BASM.

How to perform left atrial transseptal access and catheter ablation of atrial fibrillation from a superior approach.

The standard technique for percutaneous catheter ablation of atrial fibrillation (AF) involves obtaining left atrial access and catheter manipulation from an inferior transfemoral venous access. However, in patients with inferior vena cava interruption, a standard transfemoral venous approach is not possible. In these cases, a percutaneous approach from a superior central vein, such as the internal jugular vein or the axillary/subclavian vein can be considered. In this article, we describe the details of our technique to obtain left atrial catheterization and perform catheter ablation of AF from a superior approach. Our technique involves the use of steerable sheaths, dedicated radiofrequency wires, and intracardiac echocardiography guidance.

Characterisation of computed tomography angiography findings in paediatric patients with heterotaxy.

Heterotaxy refers to the abnormal arrangement of organs across the left-right axis and is typically associated with complex cardiovascular malformations. To characterise the range of cardiac and extracardiac CT angiography findings in children with heterotaxy using the latest nomenclature consensus and to compare the different types of isomerism. We retrospectively analysed the data of 64 consecutive paediatric patients referred to our tertiary paediatric cardiovascular centre who underwent CT angiography for the evaluation of known or suspected heterotaxy within a 52-month period. Right atrial isomerism was identified in 44 (69%) children, while left atrial isomerism was identified in 18 (28%) children. Atrial appendage anatomy and situs could not be determined in 2 children (3%). Associated heart defects included complete atrioventricular canal (CAVC) in 51 (80%) children, total anomalous pulmonary venous return in 43 (67%) and pulmonary atresia in 23 (36%). The bronchial branching pattern corresponded to atrial appendage morphology in all children except in the two in whom atrial appendage morphology could not be defined. In children with right atrial isomerism, the most common associated abnormalities were CAVC (n=41, 93%) and asplenia (n=34, 77%), while in those with left atrial isomerism, the most common associated abnormalities were polysplenia (n=17, 94%) and an interrupted inferior vena cava with azygos continuation (n=15, 83%). CT angiography provides useful cardiovascular and extracardiac data on heterotaxy, which frequently involves a pattern of side-related findings but has great anatomical variability.

Doppler Recognition of Low or Normal Central Venous Pressure from Continuous Flow from Inferior Vena Cava Into Right Atrium

Estimation of right atrial (RA) or central venous pressure (CVP) is a critical component of a comprehensive transthoracic echocardiographic (TTE) examination. We hypothesize that continuous inflow from the inferior vena cava (IVC) into the RA is a surrogate for low/normal CVP and can be reliably imaged in standard echocardiographic parasternal short and right ventricular inflow views. We retrospectively studied 200 patients who underwent right heart catheterization (RHC) within 8 hours of TTE between 2012 and 2016, and selected 60 patients in whom the continuous wave Doppler beam incidentally interrogated IVC inflow into RA during evaluation of the tricuspid valve. From these studies, we sought an uninterrupted Doppler wave (DW) inflow signal. CVP on RHC were then compared in patients with continuous and interrupted DW. Other TTE and RHC parameters were also noted and compared in these 2 groups. The average time interval between TTE and RHC was 266 ± 151 minutes. Of 60 patients (males = 39 (65%); age 63 ± 14 years), 12 patients (20%) had continuous DW and 48 (80%) had interrupted DW inflow signal from IVC into the RA. Of the 12 patients with continuous flow, 11 had RA pressure of ≤7 mm Hg. Similarly, of 48 patients with interrupted flow, RA pressure was >7 mm Hg in 45, and less than ≤7 mm Hg in 3 patients (two-sided p value 0.0001). The continuous DW signal predicted RA of ≤7 mm Hg with a sensitivity and specificity of 98% and 78%, respectively. Additionally, when combined with IVC size and collapsibility (normal-sized collapsible IVC), the sensitivity and specificity of DW signal to predict RA of ≤ 7 mmHg were enhanced to 94% and 92%, respectively. In conclusion, IVC flow pattern can be reliably studied to estimate CVP in standard echocardiographic views. Continuous and interrupted IVC flow predicts normal and elevated RA pressure, respectively.

SMAD2 as risk locus for human left atrial isomerism detected by mother–fetus‐pair exome sequencing and imaging studies

<i>SMAD2</i> as risk locus for human left atrial isomerism detected by mother–fetus‐pair exome sequencing and imaging studies

Anomalous retroaortic paravertebral course of the left innominate vein in a child with atrial septal defect.

We report the case of a 2.5-year-old boy with atrial septal defect in whom anomalous position of the left innominate vein was detected on preoperative ultrasound examination. Before joining the right brachiocephalic vein, the vessel extended from the left to the right and downward beyond the descending aorta. It was considerably flattened by the thoracic vertebral column, and was invisible on ultrasonography in this section. The appearance of the visible segments raised a suspicion of an anomalous course of persistent left superior vena cava draining into the left atrium, dilated azygos vein in a case of interrupted inferior vena cava, or partial anomalous pulmonary venous return. Since all doubts had to be resolved before open heart surgery, a decision was made to expand the diagnostic work-up to include computed tomography angiography. We present the echocardiographic and computed tomography findings of this unusual and previously unreported case of anomalous venous return.

Pre natal evaluation of heterotaxy syndrome by fetal echocardiography and correlating with autopsy.

Heterotaxy syndrome/ isomerism is characterized by an abnormal symmetry of the viscera that are normally dissimilar due to abnormal lateralization of thoracic and abdominal viscera and is frequently associated with complex cardiac anomalies. Isomerism may be of right or left. This article describes the morphological characteristics of heterotaxy and suggests an approach in evaluating the spectrum of abnormalities associated with this syndrome. This study is based on 12 cases diagnosed on antenatal ultrasound as heterotaxy syndrome. Results of the examinations were re-evaluated and compared by fetal autopsy. Based on the following echocardiographic criteria, a diagnosis of left isomerism was made if there was viscerocardiac heterotaxy associated with an interruption of inferior vena cava or with bilateral finger-like atrial appendages or if it was associated with heart block. If there was evidence of viscerocardiac heterotaxy with complex cardiac anomalies then it was diagnosed as right atrial isomerism or visceral heterotaxy syndrome. We diagnosed 6/12 as left isomerism and rest of the cases as right isomerism/visceral heterotaxy syndrome. In Autopsy we evaluated visceral situs and morphology of the lungs and the main bronchi, the state of the liver, spleen, bowel, and the precise anatomy of the heart and confirmed 4/12 as left isomerism 4/12 as right isomerism and two cases as visceral heterotaxy syndrome (VHS). Rest of the two cases were included in the study despite missing autopsy data, as the combination of abnormal situs with interrupted inferior vena cava, and cardiac malformation allowed a diagnosis of left isomerism with high probability. In this study, we aimed to find common features of heterotaxy syndrome on prenatal ultrasound as well as on fetal autopsy. This syndrome should be accurately diagnosed in the prenatal period in order to allow appropriate counseling of parents.

Right varicocele secondary to left-sided inferior vena cava with a retro-aortic left renal vein and azygos continuation.

Varicocele represents the main cause of male infertility. Right-sided varicocele is rare and can be due to renal malignancy or a venous abnormality. The most common anomaly of the inferior vena cava (IVC) is interruption of IVC with azygos continuation, which is recognized as an uncommon congenital anomaly. The prevalence of the interruption of IVC is less than 0.3% in the healthy population. We describe the case of a 26-year-old man who had right varicocele because of a right-sided IVC with a retro-aortic left renal vein and azygos continuation. The right and left IVCs received the right and left common iliac veins, respectively, and the left renal vein crossed posteriorly to the aorta and joined the right IVC. The right IVC continued cephalad as the azygos vein within the retrocrural space. Isolated right-sided varicoceles are uncommon, but practitioners should be aware of such a condition. In case of a venous anomaly, clinicians should aware of the association with other important clinical presentations.

Interrupted inferior vena cava with azygos continuation in an extreme preterm infant: Unusual lower-limb peripherally inserted central catheter line tip position

We report a case of interrupted inferior vena cava (IVC) with azygos continuation in an extremely preterm infant born at 23 weeks of gestation. This anomaly was detected after the insertion of lower-limb peripherally inserted central catheter. The tip of the catheter on lateral chest X-ray was in an unusual position as the catheter continued to run anterior to the spinal vertebrae and posterior to the umbilical arterial catheter within the aorta on two separate insertion attempts. Ultrasound Doppler and echocardiogram confirmed the diagnosis of interrupted IVC with azygos continuation. Neonatal practitioners need to be aware of this anomaly to avoid unnecessary interventions.

A rare case of interrupted inferior vena cava with azygos continuation

A rare case of interrupted inferior vena cava with azygos continuation

Successful Catheter Treatment Using Pre-Operative 3D Organ Model Simulation for Atrial Septal Defect With Dextrocardia and Interrupted Inferior Vena Cava to the Superior Vena Cava

A 31-year-old male patient with a history of situs inversus, dextrocardia, and interrupted inferior vena cava (IVC) with azygous continuation referred to our hospital ([Figure 1A][1]). Transesophageal echocardiography revealed a 9 mm × 16 mm atrial septal defect (ASD) with continuous left-to-

Characteristics and prognosis of interrupted inferior vena cava with azygous continuation

Objective: To explore the clinical characteristics of interrupted of the inferior vena cava with azygous continuation and the prognosis. Methods: Retrospective analysis of 21 fetuses diagnosed with interrupted inferior vena cava with azygous continuation among 28 567 pregnant women who underwent routine ultrasound scan. The clinical data, ultrasonographic features, genetic information and prognosis were collected. Results: Interrupted of the inferior vena cava with azygous continuation occurred in 21(0.07%, 21/28 567) of 28 567 patients. Three fetuses (14%, 3/21) complicated with heart and extracardiac malformations, including endocardiac cushion defect, single atrium and single ventricle, double superior vena cava, dextrocardia, asplenia syndrome, visceral heterotaxy, duodenal atresia; six fetuses (29%, 6/21) were associated with cardiac anomalies, such as hypoplastic left heart syndrome, double outlet right ventricle, pulmonary stenosis, ventricular septal defect, persistent left superior vena cava, endocardiac cushion defect and transposition of the great arteries; six cases (29%, 6/21) were only combined with extracardiac malformations, includingasplenia syndrome, visceral heterotaxy, duodenal atresia. Three fetuses (14%, 3/21) were nonorganic abnormalities included thickening of the right ventricle wall, fetal bradycardia, pericardial effusion, hydrops abdominis, increased peak systolic velocity/end diastolic velocity and single umbilical artery. Three fetuses (14%, 3/21) were isolated interrupted inferior vena cava with azygous continuation, but without other anomalies and 2 of them had normal fetal karyotype. Five cases (24%, 5/21) were successfully vaginal delivery, 1 case (5%, 1/21) had cesarean section. After 12-40 months follow-up, we didn't obeserve obviously abnormality, nor any chromosomal abnormality. Ten patients (48%, 10/21) opted for termination of the pregnancy and the autopsies were not done. Five cases (24%, 5/21) were lost to follow up. Conclusions: Interrupted inferior vena cava with azygous continuation are associated with cardiovascular and extracardiac anomalies, cardiac malformation and visceral heterotaxy are the most common anomalies. Visceral heterotaxy should be considered and fetal karyotype should be suggested. In the cases of isolated interrupted inferior vena cava with azygous continuation and normal karyotype, the outcome is favorable.

Atypical perioperative management for duodenal obstruction in an infant with heterotaxy syndrome: a case report

BackgroundHeterotaxy syndrome (HS) is characterized by a wide variety of cardiac and extra-cardiac malformations, including pulmonary valve stenosis, interruption of the inferior vena cava, total anomalous pulmonary venous connection (TAPVC), asplenia, polysplenia, intestinal malrotation, and preduodenal portal vein (PDPV). We report the case of a heterotaxic infant with an infracardiac TAPVC and preduodenal portal vein who experienced repetitive hemodynamic instability during urgent laparotomy for duodenal obstruction.Case presentationA 3-day-old boy with HS was planned to undergo urgent laparotomy for duodenal atresia. Echocardiogram showed an interrupted inferior vena cava, single right ventricle, pulmonary valve stenosis, and infracardiac TAPVC. On exploratory laparotomy, intestinal malrotation characterized by Ladd’s band was found. During further exploration, repetitive severe hypotension and hypoxia occurred. Thorough examination revealed a greatly dilated PDPV crossing over and compressing the proximal duodenum externally. Finally, we considered the possibility that surgical manipulation directly compressed the dilated PDPV into which the TAPVC had pulmonary venous drainage, leading to repetitive pulmonary venous obstruction (PVO). Computed tomography, which was examined after laparotomy, indicated that the vertical vein from pulmonary venous confluence drained into the portal vein.ConclusionPDPV is a rare anomaly associated with HS. In case of intestinal malrotation and duodenal obstruction in HS with infracardiac TAPVC, both the presence of PDPV and the possibility of pulmonary venous drainage into the PDPV should be considered by pediatric surgeons and anesthesiologists performing laparotomy to avoid catastrophic PVO.

Transjugular closure of secundum atrial septal defect in a patient with interrupted inferior vena cava

In this case, we report a successful closure of secundum atrial septal defect in a 32-year-old female patient with an interrupted inferior vena cava (IVC). Interrupted IVC was detected coincidentally during right heart catheterization. The defect was successfully closed through transjugular vein approach as an alternative to surgery.

The Road Less Travelled: Cavo-Tricuspid Isthmus Ablation from a Superior Approach

Background: Cavo-tricuspid isthmus (CTI) catheter ablation is an established and effective treatment for typical atrial flutter, usually performed via a femoral approach. Unusual anatomical abnormalities such as inferior vena cava (IVC) interruption necessitate alternative approaches. Access via the superior approach has been described in the literature but not locally.