Intrahepatic Inferior Vena Cava Research Articles

A Rare Cause of Abdominal Pain After Transjugular Intrahepatic Portosystemic Shunt

Question: A 77-year-old woman presented with progressive dyspnea for 4 months. The patient was diagnosed with primary biliary cirrhosis more than 1 years ago and was ever since on ursodeoxycholic acid medication. Recurrent ascites occurred at least 6 months before diagnosis and was responsive to diuretics. Beyond these, she did not experience any onset of gastrointestinal bleeding or hepatic encephalopathy. Laboratory examination indicated the decreased hemoglobin (10.7 g/dL, normal value [nv]: 11.5–15 g/dL), leukocyte (2.85 × 103/μL, nv: [3.5–9.5] × 103/μL), and platelet counts (53 × 103/μL, nv: [100–300] × 103 /μL), increased alkaline phosphatase (195 IU/L, nv: 50–135 IU/L) and glutamyl transpeptidase (149 IU/L, nv: <45 IU/L), and normal aminotransferase and total bilirubin levels. Chest computerized tomography showed a large amount of right-sided pleural effusion. Pleural fluid tests revealed an uncomplicated hepatic hydrothorax with serum-pleural fluid albumin gradient >1.1 g/dL and polymorphonuclear cell count <500 cells/μL. However, the patient did not show significant improvement of symptoms with dietary sodium restriction and adequate-dose diuretics. Considering the existence of hepatic hydrothorax refractory, transjugular intrahepatic portosystemic shunt (TIPS) was performed thereafter. The portal pressure gradient decreased from 18 mm Hg–7 mm Hg after stent implantation. The interventional procedure was uneventful and no complication occurred during the processes. Postoperatively, the patient experienced slight dull pain in the right upper abdomen, and the symptom intensified gradually despite giving analgesic medication in the following 36 hours. Abdominal examination showed tenderness in the right upper quadrant and percussion pain in the liver area. Liver function tests revealed obviously elevated alanine aminotransferase (1147 IU/L, nv: <50 IU/L) and aspartate aminotransferase (1582 IU/L, nv: <40 IU/L), mildly elevated total bilirubin (1.73 mg/dL, nv: 0.29–1.64 mg/dL). Blood routine showed the change of hemoglobin (11.4 g/dL) and leukocyte (6.67 × 103 /μL). Abdominal computerized tomography showed multiple strips of low-density shadows along the blood vessels and scattered low-density nodules in the liver parenchyma (Figure A, white arrowheads). What is the most likely diagnosis? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Abdominal contrast-enhanced computerized tomography (CECT) showed diffuse linear hypodensity around portal vein branches and multiple low-density nodules in the liver, but no obvious enhancement was observed (Figures B and C, white arrowheads). These imaging findings were absent from hepatic vein and intrahepatic inferior vena cava (Figure D). According to the history of hepatic invasive procedure, laboratory findings, and CECT presentation, intrahepatic lymphangiectasia was suspected. After a short course of nonsteroidal anti-inflammatory drug therapy, her symptoms completely resolved and transaminases gradually returned to normal levels. Follow-up CECT scans at 30 days showed complete resolution of the periportal low-density areas (Figures E and F). Intrahepatic lymphangiectasia (IHL), manifested as dilated hepatic lymphatics and related lymphedema, is caused by either increased lymph flow or lymphatic obstruction.1Pupulim L.F. Vilgrain V. Ronot M. et al.Hepatic lymphatics: anatomy and related diseases.Abdom Imaging. 2015; 40: 1997-2011Crossref PubMed Scopus (26) Google Scholar Liver transplantation, blunt abdominal trauma, hepatic malignant neoplasms, and congestive hepatomegaly due to cardiac decompensation are the most common underlying etiology of IHL.2Koslin D.B. Stanley R.J. Berland L.L. et al.Hepatic perivascular lymphedema: CT appearance.AJR Am J Roentgenol. 1988; 150: 111-113Crossref PubMed Google Scholar “Periportal halo,” characterized by hypodense appearance on computed tomography and hyperintense appearance on T2-weighted magnetic resonance images, has important clinical significance in the diagnosis of IHL.3Karcaaltincaba M. Haliloglu M. Akpinar E. et al.Multidetector CT and MRI findings in periportal space pathologies.Eur J Radiol. 2007; 61: 3-10Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Presence of hypodense appearance on both sides of the portal venous system can allow differentiation from biliary dilatation.3Karcaaltincaba M. Haliloglu M. Akpinar E. et al.Multidetector CT and MRI findings in periportal space pathologies.Eur J Radiol. 2007; 61: 3-10Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar In fact, IHL could be an overlooked complication of TIPS that has never been previously reported. Iatrogenic injury during a TIPS procedure may interrupt lymphatic vessels and initiate coagulation at the injury site, and thrombus/microthrombus provisionally compresses and blocks the hepatic lymphatic system. Once the thrombus/microthrombus dissolves, the occluded lymphatics are recanalized and IHL could be spontaneously resolved. In conclusion, IHL is a procedure-related complication of TIPS that should not be neglected. Periportal halo by CECT provides valuable evidence for both diagnosis and differential diagnosis. Further studies with a larger sample size are necessary to investigate the morbidity and natural course of IHL after TIPS.

LBMON138 Leg Tumeo: Is It Neuroendocrine Tumor?

Abstract Introduction Neuroendocrine tumors (NETs) are heterogenous group of epithelial neoplasms often known to produce and secrete peptides and bioamines. The presentation varies from symptomatic functional to non-functional tumors. The functional tumors cause symptoms based on the substance secreted: corticotropin, gastrin, glucagon, insulin, norepinephrine, serotonin, somatostatin, etc. The prognosis ranges from well-differentiated tumors being indolent while the poorly differentiated forms are aggressive. We present a case with an atypical presentation of NET which was noted to secrete an atypical hormone, cortisol. Case Presentation A 55-year-old Caucasian man presented with bilateral lower extremity grade 3 pitting edema for past 2 weeks. His past medical history was significant for hypertension. Lower extremity doppler showed no evidence of deep vein thrombosis. Serum potassium was critically low at 1.9mmol/L. Computed tomography of abdomen and pelvis showed a large mass involving the right hepatic lobe, upper pole of right kidney and hypoattenuated lesions in left hepatic lobe. The intrahepatic inferior vena cava appeared to be severely compressed by the mass. MRI abdomen was suggestive of hepatocellular cancer but alfaprotein levels was normal. Biochemical testing for evaluation of hormonal hypersecretion showed elevated cortisol levels (57.2mcg/dl) and markedly elevated dehydroepiandrosterone sulfate (2641mcg/dl). Serum adrenocorticotrophic hormone and aldosterone levels were within normal limits. Low dose dexamethasone suppression test showed no decline in serum cortisol level reflecting adrenal origin. Urinary evaluation showed elevated cortisol but normal metanephrine and catecholamine levels. With concerns for adrenal carcinoma, right adrenal mass biopsy was performed. The biopsy showed poorly differentiated malignant neoplasm with neuroendocrine features. Tumor cells were positive for synaptophysin (a marker for neuroendocrine differentiation) and CD 138. Soon after, he progressed to multisystem organ failure, tumor lysis syndrome and resorted to comfort care. The patient passed away within a week of diagnosis. Conclusion NETs usually originate in gastrointestinal tract, pancreas, adrenal, lung and rarely genitourinary tract. The incidence of NETs is on the rise with increased detection by imaging. Adrenal NETs, well-known as pheochromocytoma are mostly benign but small cell adrenal neuroendocrine carcinomas are rare and have a grave prognosis. Flushing, diarrhea are the commonest presentations (75-85%) for gastrointestinal NETs and symptoms are based on the substance secreted. This case highlights a case of adrenal neuroendocrine cancer presenting with lower extremity swelling and secreting an uncommon hormone, cortisol. Increasing awareness among the medical fraternity will help with early diagnosis and better outcomes. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Massive adrenocortical carcinoma presenting as peripheral edema: a case report

BackgroundAdrenocortical carcinoma is a rare, but potentially lethal, malignancy that is usually detected as an incidental finding on abdominal imaging studies or owing to hormonal complications. This report recounts an unusual presentation with leg edema due to compression of the inferior vena cava. The dearth of proven effective treatment is also addressed.Case presentationA 65-year-old White male physician presented with severe, bilateral pitting edema that extended from the toes to the thighs. It progressed over several months. He also experienced paroxysmal dyspnea. Evaluation of cardiac, hepatic, and renal function failed to determine a cause. Computed tomography revealed a tumor above the right kidney, with compression of the intrahepatic inferior vena cava and upstream distension. Serum cortisol and dehydroepiandrosterone sulfate concentrations were elevated, 24-hour urinary cortisol level was elevated, and serum adrenocorticotropic hormone and testosterone concentrations were suppressed. A 27-cm tumor, the right lobe of the liver, the right kidney, and 26 lymph nodes were resected. Histological study confirmed the diagnosis of adrenocortical carcinoma. Ki67 proliferation index was 26.7% (worse prognosis associated with index > 10%). Lymph nodes were negative for malignancy, but a separate 2.7-cm tumor was found near the renal hilum. Adjuvant mitotane chemotherapy was prescribed. Serum testosterone concentration returned to normal. High-dose hydrocortisone administration was needed because of adrenal suppression and CYP 3A4 induction by mitotane.ConclusionImaging of the abdomen and pelvis should be conducted in cases of unexplained leg edema. In this case, a large adrenal cancer compressed the vena cava. Iron deficiency followed resection of the large tumor. Advanced stages of adrenocortical carcinoma are associated with poor prognosis. Mitotane chemotherapy is a standard but unproven adjuvant treatment that is associated with many complications, and its induction of hepatic CYP 3A4 enzymes necessitates adjustment of other medications.

Hepatic Necrosis Mimicking Infiltrative Masses in Acute Budd-Chiari Syndrome With Hereditary Protein C Deficiency

ABSTRACTWe report the case of a patient with an unusual acute Budd-Chiari syndrome (BCS). The patient presented with high-grade fever and right upper quadrant pain. Infiltrative lesions at the right hepatic lobe and segment IVB with intrahepatic inferior vena cava and right hepatic vein thrombus appeared on abdominal imaging. Liver biopsy revealed hepatic infarction compatible with acute BCS. Thrombophilia work-up demonstrated low protein C activity with the -1657C/T mutation of the PROC gene. Necrotic liver mass with acute BCS related to congenital protein C deficiency was diagnosed. Patient symptoms and necrotic masses improved after anticoagulant treatment for 4 months.

V13-06 OPEN RIGHT PARTIAL NEPHRECTOMY WITH INFERIOR VENA CAVA THROMBECTOMY FOR RENAL CELL CARCINOMA

You have accessJournal of UrologyCME1 May 2022V13-06 OPEN RIGHT PARTIAL NEPHRECTOMY WITH INFERIOR VENA CAVA THROMBECTOMY FOR RENAL CELL CARCINOMA Ryan Nasseri, Devin Patel, Daniel Holst, Margaret Meagher, and Ithaar Derweesh Ryan NasseriRyan Nasseri More articles by this author , Devin PatelDevin Patel More articles by this author , Daniel HolstDaniel Holst More articles by this author , Margaret MeagherMargaret Meagher More articles by this author , and Ithaar DerweeshIthaar Derweesh More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002646.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We present a case of a 65 year-old female with cT3b renal cell carcinoma (RCC) and inferior vena cava (IVC) tumor thrombus who underwent open right partial nephrectomy (PN) with IVC thrombectomy at our institution. METHODS: 65 year-old female with CKD stage III [baseline estimated Glomerular Filtration Rate (eGFR) 57 ml/min.1.73m2] and active segmental pulmonary emboli (PE) presented with locally advanced RCC with venous tumor extension to the level of the intrahepatic IVC. Patient was deemed to not be optimal surgical candidate due to symptomatic PE and poor performance status (ECOG 2 status) and also had strong indication for nephron preservation. The patient ultimately underwent systemic therapy with 12 cycles of nivolumab and 6 cycles of ipilimumab with shrinkage of primary tumor and regression of tumor thrombus to the infrahepatic IVC. RESULTS: Open right PN with IVC thrombectomy was undertaken. A reverse-hockey stick incision was made. Large and small intestinal medial reflection was conducted with liver mobilization. Cranial and caudal IVC control was obtained as well as control of the contralateral renal vein. IVC clamping and control of the contralateral renal vein in addition to clamping of the main renal artery was conducted, and the tumor and IVC tumor extension were resected en bloc via a venotomy and longitudinal cavotomy, primary closure of which were performed with 6-0 and 3-0 Prolene. Collecting system entries and segmental vessels were closed with 3-0 Monocryl and 4-0 PDS. The cortical defect was then approximated with 0 Chromic suture and hemostatic agents.Final pathology demonstrated pT3b clear cell RCC/ISUP grade 2 with protrusion into IVC. Negative margins for primary tumor and distal caval margins. Postoperative creatinine was 1.01 ng/dL with eGFR of 55 mL/min/1.73m2. No evidence of disease was noted at 3-month radiologic follow up. CONCLUSIONS: PN with IVC thrombectomy may be safely achieved for select patient with imperative indication for nephron sparing surgery. Further investigation of long-term oncologic outcomes and efficacy are requisite. Source of Funding: Stephen Weissman Kidney Cancer Research Fund © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1032 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ryan Nasseri More articles by this author Devin Patel More articles by this author Daniel Holst More articles by this author Margaret Meagher More articles by this author Ithaar Derweesh More articles by this author Expand All Advertisement PDF DownloadLoading ...

Cuffed endotracheal tube as a cardiopulmonary bypass venous return cannula.

Cuffed endotracheal tube as a cardiopulmonary bypass venous return cannula.

Technique and short-term outcomes of surgical treatment in patients with renal cell carcinoma and tumor venous thrombosis: experience of the Urology Clinic, N.N. Blokhin National Medical Research Center of Oncology

Objective: to describe the technique of nephrectomy and thrombectomy used in patients with renal cell carcinoma (RCC) and tumor venous thrombosis of various levels, and to identify risk factors of in-hospital death among operated patients.Materials and methods. This study included 768 patients with RCC and tumor venous thrombosis who have undergone surgical treatment. Median age was 58 years (range: 16-82 years); the male to female ratio was 2.3:1. The symptoms of venous tumor thrombosis were identified in 199 patients (25.9 %). In the majority of patients (n = 509; 66.3 %), the tumor thrombus originated from the right renal vein. The cranial border of the tumor thrombus was located in the perirenal inferior vena cava (IVC) in 219 patients (28.5 %), subhepatic IVC in 201 patients (26.2 %), intrahepatic IVC in 171 patients (22.3 %), and above the diaphragm in 177 patients (23.0 %). We used an individual approach to choose an optimal method of vascular control and to identify indications for circulatory support. Two-thirds of patients (n = 512; 66.7 %) underwent temporary block of the second renal vein; 268 patients (34.9 %) - temporary block of the hepatoduodenal ligament and right heart; 11 patients (3.2 %) were operated on with cardiopulmonary bypass.Results. The median surgery time was 190 ± 63.6 min; median blood loss was 3,000 ± 71.6 mL (≥50 % of circulating blood in 35.1 % of patients). Intraoperative complications were registered in 23 patients (3.0 %); eight patients (1.0 %) died during surgery with 4 of them died due to pulmonary embolism (0.5 %), 3 died due to hemorrhagic shock (0.4 %), and 1 died due to myocardial infarction (0.1 %). One hundred and ninety individuals (25.0 %) developed postoperative complications with Clavien-Dindo grade III-V complications observed in 115 cases (15.1 %). Forty-one patients (5.3 %) died in the early postoperative period. The causes of death included multiple organ dysfunction (n = 21; 2.8 %), pulmonary embolism (n = 7; 0.9 %), sepsis (n = 6; 0.8 %), stroke (n = 4; 0.5 %), myocardial infarction (n = 2; 0.2 %), and RCC progression (n = 1; 0.1 %). We have identified several independent risk factors for in-hospital mortality, including ascites (hazard ratio (HR) 8.3; 95 % confidence interval (CI) 3.2-21.4; p &lt; 0.0001), preoperative pulmonary embolism (HR 3.5; 95 % CI 1.3-9.4; p = 0.013), supradiaphragmatic thrombi (HR 1.5; 95 % CI 1.1-2.0; p = 0.003). The in-hospital mortality rate was 3.5 % (20/575) among patients with no risk factors, 9.8 % (16/163) among those with 1 risk factor, 40.0 % (10/25) among those with 2 risk factors, and 60.0 % (3/5) among those with 3 risk factors (area under the curve (AUC) 0.705; p &lt;0.0001 for all).Conclusion. The incidence of severe complications and postoperative mortality rate in RCC patients with tumor venous thrombosis who have undergone nephrectomy and thrombectomy were 15.1 and 6.4 %, respectively. Risk factors for perioperative mortality included ascites, preoperative pulmonary embolism, and supradiaphragmatic thrombosis.

Four-quadrant transverse abdominis plane block: A relatively new frontier for postoperative analgesia after major abdominal surgery

Four-quadrant transverse abdominis plane block: A relatively new frontier for postoperative analgesia after major abdominal surgery

Interruption of inferior vena cava with azygos continuation in a newborn

We present a male newborn referred to pediatric cardiology due to a heart murmur, whose echocardiographic evaluation showed an intrahepatic inferior vena cava interruption with azygos continuation and two small mesoseptal ventricular septal defects. Although mainly incidental, the early diagnosis of interrupted inferior vena cava can be crucial to avoid complications of invasive vascular procedures.

MP53: A feasibility analysis for successful completion of IVC ultrasound in hypotensive emergency department patients

Introduction: Determining fluid status prior to resuscitation provides a more accurate guide for appropriate fluid administration in the setting of undifferentiated hypotension. Emergency Department (ED) point of care ultrasound (PoCUS) has been proposed as a potential non-invasive, rapid, repeatable investigation to ascertain inferior vena cava (IVC) characteristics. Our goal was to determine the feasibility of using PoCUS to measure IVC size and collapsibility. Methods: This was a planned secondary analysis of data from a prospective multicentre international study investigating PoCUS in ED patients with undifferentiated hypotension. We prospectively collected data on IVC size and collapsibility using a standard data collection form in 6 centres. The primary outcome was the proportion of patients with a clinically useful (determinate) scan defined as a clearly visible intrahepatic IVC, measurable for size and collapse. Descriptive statistics are provided. Results: A total of 138 scans were attempted on 138 patients; 45.7% were women and the median age was 58 years old. Overall, one hundred twenty-nine scans (93.5%; 95% CI 87.9 to 96.7%) were determinate. 131 (94.9%; 89.7 to 97.7%) were determinate for IVC size, and 131 (94.9%; 89.7 to 97.7%) were determinate for collapsibility. Conclusion: In this analysis of 138 ED patients with undifferentiated hypotension, the vast majority of PoCUS scans to investigate IVC characteristics were determinate. Future work should include analysis of the value of IVC size and collapsibility in determining fluid status in this group.

Inferior Vena Cava Reconstruction in Symptomatic Patients Using Palmaz Stents: A Retrospective Single-Center Experience

The use of stents for treating central venous occlusion is well described. Limited evidence exists related to Palmaz balloon-expandable stent use in inferior vena cava (IVC) reconstruction. We analyzed patency and complication rates after IVC reconstruction using Palmaz stents. From 2002 to 2019, 37 patients (mean age: 51year) underwent IVC reconstruction with 68 Palmaz stents. Indications were symptomatic chronic venous obstruction in the infrarenal (n=25) and intrahepatic (n=12) IVC. Demographic, operative, and imaging data were evaluated. Clinical data, abdominal CT, and/or duplex ultrasound were used to determine patency at follow-up. Restoration of caval patency was achieved in all patients, with complications in 2/37 (5.4%) patients (thrombus formation within the stent; stent embolization eight days after placement). Follow-up data were available for 27 patients. Primary patency was maintained through last follow-up in 19/27 (70%) patients (mean: 1.1year), with successful stent redilation performed in 6 patients. Mean duration of primary-assisted patency (n=5) was 1.2year. Late lumen loss was (n=13) was 40% during a mean time to follow-up of 2.0years. Primary patency in patients with occlusion secondary to malignancy was 109day (range: 1 day-1.0year), whereas primary patency in patients with occlusion from other etiologies was 1.1year (range: 2day-5.9year). The Kaplan-Meier analysis demonstrated primary and primary-assisted patency of 66% and 84%, respectively, at 24 and 48 months. Palmaz balloon-expandable stents for IVC reconstruction is feasible and effective for symptomatic IVC occlusion. Risk of stent migration was low.

Sinusoidal obstruction syndrome: A systematic review of etiologies, clinical symptoms, and magnetic resonance imaging features.

BACKGROUNDSinusoidal obstruction syndrome (SOS) is a kind of rare liver disease which is characterized by damage to small hepatic vessels, affecting particularly the sinusoidal endothelium. Due to the special etiology and high mortality, early diagnosis of SOS is significant for clinical survival and prognosis.AIMTo generalize the common etiologies and clinical symptoms of SOS and summarize the characteristic magnetic resonance imaging (MRI) features so as to provide more valuable information for early diagnosis of SOS.METHODWe searched PubMed, Web of science, Wanfang Data, China Knowledge Resource Integrated, VIP, and Cochrane Library databases without a limiting period and the types of articles. The search process mainly revolved around the etiologies, common clinical symptoms, and MRI imaging features of SOS. Ultimately, 29 full articles were included in this review and 222 articles were excluded.RESULTSEleven case reports included 13 patients. The etiologies of these patients including chemotherapy (5/13), medicinal herbs containing pyrrolidine alkaloids (PAs, e.g. Tusanqi) (4/13), hematopoietic stem cell transplantation (HSCT) (2/13), drug toxicity (6-thioguanine) (1/13), and “poppers”, a recreational drug used during anal intercourse (1/13). Eighteen case series including 497 patients, and SOS in 465 (93.6%) patients was caused by PAs. Ascites, abdominal pain and swelling, jaundice were the most common clinical symptoms. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), gamma-glutamyl transpeptidase (GGT), total bilirubin (TBil), direct bilirubin (DBil), and prothrombin time (PT) had varying degrees of elevation. Heterogeneous signals on T1 weighted imaging/T2 weighted imaging (T1WI/T2WI), heterogeneous enhancement of liver parenchyma, ascites, hepatomegaly, narrowing and blurring of intrahepatic inferior vena cava and three main hepatic veins, edema around the portal vein, and gallbladder wall edema were the most common MRI imaging features of SOS.CONCLUSIONIn the West, SOS was mostly secondary to HSCT. Some SOS developed in the process of chemotherapy for hepatic metastatic tumor. A few SOS were caused by toxicity of certain drugs. In the East, Tusanqi was a major cause of SOS. Ascites, abdominal pain and swelling, jaundice were the common clinical symptoms. Elevations of ALT, AST, GGT, ALP, TBil, and DBil could be used as predictors of liver function damage. Numerous characteristic MRI imaging features could provide more valuable information for early diagnosis of SOS.

Inferior Vena Cava Rupture Caused by Balloon Angioplasty During the Treatment of Budd-Chiari Syndrome.

Percutaneous transluminal balloon angioplasty (PTA) is the main treatment option for Budd-Chiari syndrome (BCS) with inferior vena cava (IVC) obstruction. However, IVC rupture caused by PTA has never been reported. Between August 2004 and December 2016, a consecutive cohort of 617 BCS patients with obstructed IVC who underwent PTA with or without stent placement were reviewed retrospectively to identify IVC rupture. Pre- and post-procedural imaging data, clinical and procedural technical data were analyzed. Of the 617 BCS patients, five patients had IVC rupture caused by PTA (0.81%). Four of these patients had retroperitoneal, intra-hepatic IVC rupture without extravasation into abdominal cavity which was successfully managed conservatively. One patient had supra-hepatic IVC rupture into the pericardial cavity which was surgically treated. IVC rupture is a rare complication of PTA treatment of BCS and most commonly located at the intra-hepatic IVC caused by oversized balloons which does not require additional treatment.

'IVC contrast level: a sign of cardiovascular dysfunction'.

Contrast blood level in intrahepatic inferior vena cava (IVC) on arterial contrast-enhanced CT images is referred to as IVC layering or IVC contrast level sign. This sign is important to recognize as it has dismal prognosis and requires immediate attention. The causes described in literature include cardiogenic shock, cardiac arrest and cardiac tamponade. We hereby present three cases depicting IVC contrast level sign.

Intravascular Cement Leak after Vertebroplasty Treated with Stent Graft Placement in the Inferior Vena Cava

A 75-year-old man presented with a large amount of cement extravasation into the inferior vena cava (IVC) after undergoing L4-S1 surgical fusion with vertebroplasty for prostate cancer metastases. Cement extended from L4 to the suprarenal IVC (Fig 1). Given the risk for embolization, a decision was made to intervene. The brittle consistency of set cement raised concern for fracture and embolization during snaring maneuvers. It was decided to stabilize this cement column and exclude it from the flow lumen. Under general anesthesia, a 3-pronged approach was used. Through a 16-F internal jugular vein sheath, a Coda balloon (Cook, Inc, Bloomington, Indiana) was positioned in the suprahepatic IVC and inflated for flow interruption and embolic protection; the acute drop in preload was mitigated by aggressive fluid resuscitation with pressor support. A second Coda balloon positioned from the right groin was used to displace and compact the cement into the infrarenal IVC, allowing for deployment of a 32 mm × 57 mm Endurant II aortic extension stent graft (Medtronic, Minneapolis, Minneapolis) caudal to the renal veins, placed from a left groin access (Figs 2, 3). This stabilized most of the cement, excluding it from the flow lumen (Fig 4). Inadvertent embolization of a small piece of cement to the left lung occurred without clinical consequences (Fig 5). The patient was discharged on aspirin and clopidogrel. Six-month clinical follow-up was uneventful. The patient had no further embolization or IVC thrombosis on 1-month follow-up computed tomography (CT) (Fig 6). Figure 2Fluoroscopy image demonstrates undeployed stent graft placed from left femoral access (short arrow), positioned just caudal to lowest (right) renal vein—marked by wire placed from jugular approach (black arrow). The large cement piece extended from the level of L5 up to intrahepatic IVC (white arrows). Note an additional guide wire that had been advanced from a right common femoral vein access (asterisk). View Large Image Figure Viewer Download Hi-res image Figure 3A Coda balloon (black arrow) placed from the jugular access was inflated in the suprarenal IVC to interrupt blood flow and minimize embolization risk. A second Coda balloon placed from a right femoral access was inflated above the cement piece and pulled down to displace cement (white arrows) caudal to the ostia of the renal veins. Note a small fragment of cement that inadvertently broke off (short arrow), which was seen only retrospectively. View Large Image Figure Viewer Download Hi-res image Figure 4The stent graft was deployed in the infrarenal IVC while trapping most of the cement against the vein wall (white arrow). A wire placed from jugular access into the right renal vein courses through the uncovered portion of the stent graft (black arrow), designed for suprarenal fixation. View Large Image Figure Viewer Download Hi-res image Figure 5Fluoroscopy of the chest demonstrates a small cement fragment in the left lung (arrow) owing to embolization. View Large Image Figure Viewer Download Hi-res image Figure 6Coronal oblique multiplanar reformat from contrast-enhanced CT performed 1 month after procedure confirms exclusion of cement from the IVC lumen by the stent graft (white arrow) and patency of IVC and right renal vein draining through the uncovered portion of the stent graft (short arrow). The left renal vein was also patent, draining above the stent graft (not shown). Hyperdensities to the left of the IVC correspond to aortic atherosclerotic plaques (asterisk). View Large Image Figure Viewer Download Hi-res image

Giant Hepatic Hemangioma: An Incidental Finding Causing Pulmonary Embolism

Hepatic hemangiomas are typically discovered as incidental findings.1 We present a patient with pulmonary embolism (PE) likely due to IVC thrombosis caused by a giant hepatic hemangioma. Diagnosing IVC thrombosis is a difficult task and often requires a high index of suspicion as early recognition can help decrease the risk of PE through appropriate intervention. A 44-year old female with no significant past history presented to the ER with a six-month history of chest pain, leg heaviness, abdominal fullness, and dyspnea. A few weeks ago, she was evaluated for lower extremity (LE) DVT which was negative. On admission she was hemodynamically stable with a benign physical exam. She had no recent surgery, prolonged immobilization, prior venous thromboembolic event, or family history of a hypercoagulable disorder. D-dimer was elevated, however, other labs were unremarkable and a repeat ultrasound (US) to assess for LE DVT was negative. PE was diagnosed by CTA of the chest. A 7.4 x 7.5 x 8.7 cm giant hemangioma (incidentally diagnosed earlier that year) was also evident. As she could not tolerate an MRI, CT abdomen with portal venous phasing was obtained. It showed complete compression of the intrahepatic inferior vena cava (IVC) and portal vein abutment. She was started on anticoagulation and referred to specialists. Giant hepatic hemangiomas may present with a constellation of symptoms depending on size, location, and compression of adjacent structures.1 PE attributable to giant hepatic hemangiomas has been reported in the past. IVC thrombosis can lead to PE in 30% of the population with 2.6% - 4.0% of patients with LE DVT having IVC thrombosis.2 Presenting as a diagnostic challenge due to nonspecific symptoms, insidious course, and physician unfamiliarity, IVC thrombosis is often diagnosed when clot migration has already occurred.2 Mechanisms for IVC thrombosis include sluggish flow caused by IVC compression from a mass, migration of thrombi from a hemangioma into the IVC, and prothrombotic factors.1,2 Individuals with DVT and one or more high-risk features (Table I) for IVC thrombosis should undergo initial screening with an IVC duplex US with anticoagulation as the mainstay of treatment in IVC thrombosis.2 Although this patient's clinical presentation made diagnosing IVC thrombosis a challenge, recognizing that it can result in PE is of paramount importance as early detection and treatment can decrease the risk of PE.2379_A Figure 1. Computed tomography with IV contrast of the abdomen, axial image of liver demonstrates 7.4 x 7.5 x 8.7 cm lesion with evidence of globular discontinuous enhancement on portal venous phase (red arrow) compatible with giant cavernous hemangioma. The lesion causes mass effect on the intrahepatic portion of the inferior vena cava with evidence of complete compression (yellow arrowhead).2379_B Figure 2. Table adapted from: 2. Mohamad, Alkhouli, Mohammad Morad, et al. “Inferior Vena Cava Thrombosis.” JACC: Cardiovascular Interventions [Online], Volume 9, Issue 7, Pages 629-643

4:21 PM Abstract No. 370 Transfemoral transcaval core-needle liver biopsy: safety and efficacy in over 200 cases

To investigate the safety, efficacy, and outcomes of transfemoral transcaval (TFTC) core-needle liver biopsies. We previously published our results of the first 66 patients using TFTC as an alternative to transjugular liver biopsy, where hepatic tissue is directly obtained through the intrahepatic inferior vena cava via a femoral venous approach. In this retrospective study, the medical, surgical, and radiological records of patients who underwent transvenous liver biopsies at a single institution between February 2014 and August 2017 was performed. This is a follow-up study where we present the outcomes and complications of over 200 patients. Procedural complications were classified according to the Society of Interventional Radiology guidelines. 204 total TFTC liver biopsies (61.5% male; mean age 51.1 ± 15.5 years) accounted for 75.0% (204/272) of the transvenous liver biopsies. Technical success was achieved in 98.5% (201/204) of cases. Histopathologic diagnoses were made in 198 cases (97.1%). Fragmented or limited samples in which a pathological diagnosis was still made occurred in 6 cases (3.0%). Complications occurred in 4 cases (1.9%). There was one case with a small subhepatic hematoma, not requiring any transfusion and one case with delayed bleeding at the femoral puncture site requiring a blood transfusion that was successfully treated with a figure eight stitch. Venous pressure measurements were requested in 171 cases and were successfully obtained in all. TFTC core-needle liver biopsy is a safe and highly effective method of obtaining hepatic tissue samples and venous pressure measurements.

Role of Transesophageal Echocardiography in General Anesthesia

Transesophageal echocardiography (TEE), a relatively non-invasive method, is an ideal intraoperative monitoring tool. In this review, we evaluated all potential applications of TEE in general anesthesia. The uses of intraoperative TEE have expanded over the years. TEE’s main application is in the intraoperative assessment and monitoring of the cardiac function. Its impact in clinical decision making has been demonstrated in non-cardiac surgery in the operating room and as a rescue in case of hemodynamic instability and cardiac arrest. TEE may also provide more complete quantitative hemodynamic monitoring of intracardiac pressures as the pulmonary artery catheter. Newer intraoperative TEE application includes imaging of extra-cardiac structures such as the kidney, the intrahepatic inferior vena cava, the lungs, the pleura space, and the epidural space. Several scanning protocols have been proposed ranging from a focused to a comprehensive cardiac assessment. Current guidelines for intraoperative use of TEE include basic and advanced TEE exam. Intraoperative TEE is a very powerful tool in the hands of the TEE trained anesthesiologist. It has a positive safety profile but requires a significant initial manpower and financial investment. While less expensive equipment has become available, specific training is necessary and requires a significant time commitment.

Urologic Oncologic SurveyRobotic level III inferior vena cava tumor thrombectomy: Initial series. Gill IS, Metcalfe C, Abreu A, Duddalwar V, Chopra S, Cunningham M, Thangathurai D, Ukimura O, Satkunasivam R, Hung A, Papalia R, Aron M, Desai M, Gallucci M. J Urol. 2015 Oct;194(4):929–938. [Epub 2015 Apr 6]. doi: 10.1016/j.juro.2015.03.119.

PurposeLevel III inferior vena cava tumor thrombectomy for renal cancer is one of the most challenging open urologic surgeries. We present the initial series of completely intracorporeal robotic level III inferior vena cava tumor thrombectomy. Materials and methodsNine patients underwent robotic level III inferior vena cava thrombectomy and 7 patients underwent level II thrombectomy. The entire operation (high intrahepatic inferior vena cava control, caval exclusion, tumor thrombectomy, inferior vena cava repair, radical nephrectomy, and retroperitoneal lymphadenectomy) was performed exclusively robotically. To minimize the chances of intraoperative inferior vena cava thrombus embolization, an “inferior vena cava-first, kidney-last” robotic technique was developed. Data were accrued prospectively. ResultsAll 16 robotic procedures were successful, without open conversion or mortality. For level III cases (9), median primary kidney (right 6, left 3) cancer size was 8.5cm (range: 5.3–10.8) and inferior vena cava thrombus length was 5.7cm (range: 4–7). Median operative time was 4.9 hours (range: 4.5–6.3), estimated blood loss was 375ml (range: 200–7,000), and hospital stay was 4.5 days. All surgical margins were negative. There were no intraoperative complications and 1 postoperative complication (Clavien 3b). At a median 7 months of follow-up (range: 1–18) all patients are alive. Compared to level II thrombi the level III cohort trended toward greater inferior vena cava thrombus length (3.3 vs 5.7cm), operative time (4.5 vs 4.9h) and blood loss (290 vs 375ml). ConclusionsWith appropriate patient selection, surgical planning and robotic experience, completely intracorporeal robotic level III inferior vena cava thrombectomy is feasible and can be performed efficiently. Larger experience, longer follow-up and comparison with open surgery are needed to confirm these initial outcomes.

A rare case of unprovoked venous thromboembolism manifestation in a young patient with antithrombin Type IIB deficiency combined with inferior vena cava anomaly from Lithuania.

A 12-year-old previously healthy boy of Romani origin presented with a swollen, painful left leg and fever. Imaging revealed signs of inferior vena cava (IVC) thrombosis, the presence of interrupted intrahepatic IVC with azygos continuation and bilateral iliofemoral thrombosis with enlargement of the azygous and hemiazygos venous system. In addition, right pleural effusion and signs of bilateral renal pericortical cysts, possibly caused by retroperitoneal lymphangiectasia, were disclosed. Thrombophilia screening involving protein C, Protein S, Antithrombin (chromogenic assays based on the inhibition of FIIa and FXa, antigen concentration), APC resistance, prothrombin mutation and Lupus anticoagulants was performed using standard laboratory methods. Genetic analysis of the SERPINC1 gene was done by direct sequencing. Thrombophilia screening showed isolated decreased AT activity at 21% (RR 80-120%). AT levels were retested and remained decreased (33-36%) on two consecutive occasions. SERPINC1 gene analysis revealed a previously described homozygous mutation (Budapest III) causing type IIB deficiency (c.391C>T; p.Leu131Phe). A family study confirmed the same mutation in both parents and three siblings. The patient improved significantly following warfarin therapy and over the past 2.5 years did not experience new thromboembolism. This case represents a rare combination of two risk factors provoking manifestation of spontaneous venous thromboembolism at a young age requiring permanent anticoagulant therapy.