Proximal Inferior Vena Cava Research Articles

Influence of tumor thrombus morphology on the surgical complexity in renal cell carcinoma with inferior vena cava tumor thrombus: a single-center, large-sample study from China

BackgroundThe morphology of tumor thrombus varies from person to person and it may affect surgical methods and tumor prognosis. However, studies on the morphology of tumor thrombus are limited. The purpose of our study was to evaluate the impact of tumor thrombus morphology on surgical complexity.MethodsWe retrospectively reviewed the clinical data of 229 patients with renal cell carcinoma combined with inferior vena cava (IVC) tumor thrombus who underwent surgical treatment at Peking University Third Hospital between January 2014 and December 2021. The patients were divided into floating morphology (107 patients) and filled morphology (122 patients) tumor thrombi groups. Chi-square and Mann–Whitney U tests were used for categorical and continuous variables, respectively. Postoperative complications were evaluated using the Clavien–Dindo surgical complication classification method.ResultsPatients with filled morphology tumor thrombus required more surgical techniques than those with floating morphology tumor thrombus, which was reflected in more open surgeries (P < 0.001), more IVC interruptions (P <0.001), lesser use of the delayed occlusion of the proximal inferior vena cava (DOPI) technique (P < 0.001), and a greater need for cut-off of the short hepatic vein (P < 0.001) and liver dissociation (P = 0.001). Filled morphology significantly increased the difficulty of surgery in patients with renal cell carcinoma with tumor thrombus, reflected in longer operation time (P < 0.001), more surgical blood loss (P <0.001), more intra-operative blood transfusion (P < 0.001), and longer postoperative hospital stay (P < 0.001). Filled morphology tumor thrombus also led to more postoperative complications (53% vs. 20%; P < 0.001).ConclusionCompared with floating morphology thrombus, filled morphology thrombus significantly increased the difficulty of surgery in patients with renal cell carcinoma with IVC tumor thrombus.

A novel technique for proximal inferior vena cava control during tumor thrombectomy using the COBRA-OS balloon

A novel technique for proximal inferior vena cava control during tumor thrombectomy using the COBRA-OS balloon

Primary Inferior Vena Cava Leiomyosarcoma Presenting with Proximal Occlusion with Deep Venous Thrombosis and Lower Extremity Edema: Reconstruct vs Ligate Post Resection? A Single Retrospective Case Report

Introduction: Primary leiomyosarcomas of the inferior vena cava (IVC) are rare tumors with a poor prognosis. Curative treatment remains surgical resection with clear margins. Reconstruction vs ligation of the IVC is debatable, especially if the proximal IVC is occluded. This report presents the surgical management of a patient presenting with acutely worsening lower extremity edema and biopsy proven IVC leiomyosarcoma. Methods: This is a retrospective chart review, and the patient was followed up at 2 weeks and at 3 months. Patient provided consent for creation of this case report. Results: The patient’s age at presentation was 67 years and she was of female gender. The IVC leiomyosarcoma had a maximum diameter of 4.8cm, involved the infrarenal IVC only, and the proximal segment was occluded due to bilateral iliofemoral deep venous thrombosis (DVT). She underwent an R0 resection, with immediate reconstruction using 14mm ringed PTFE. Postoperatively, she was noted to have worsening lower extremity edema. The plan was to recanalize her DVTs via endovascular thrombectomy and stenting, however the patient’s edema improved with compression alone. At 2 weeks follow up, her edema had completely resolved. At 3 months follow up, postoperative CT scan showed expected occluded infrarenal IVC graft, and no evidence of recurrent disease. Conclusion: Reconstructing the occluded IVC after resection of the primary IVC leiomyosarcoma gives the patient the option for future endovascular recanalization if there is ongoing lower extremity edema. Further follow up and research is warranted to determine if this provides a feasible long-term solution.

Volumetric Fetal Flow Imaging With Magnetic Resonance Imaging.

Fetal development relies on a complex circulatory network. Accurate assessment of flow distribution is important for understanding pathologies and potential therapies. In this paper, we demonstrate a method for volumetric imaging of fetal flow with magnetic resonance imaging (MRI). Fetal MRI faces challenges: small vascular structures, unpredictable motion, and inadequate traditional cardiac gating methods. Here, orthogonal multislice stacks are acquired with accelerated multidimensional radial phase contrast (PC) MRI. Slices are reconstructed into flow sensitive time-series images with motion correction and image-based cardiac gating. They are then combined into a dynamic volume using slice-to-volume reconstruction (SVR) while resolving interslice spatiotemporal coregistration. Compared to prior methods, this approach achieves higher spatiotemporal resolution ( 1×1×1 mm3, ~30 ms) with reduced scan time - important features for the quantification of flow through small fetal structures. Validation is demonstrated in adults by comparing SVR with 4D radial PCMRI (flow bias and limits of agreement: -1.1 ml/s and [-11.8 9.6] ml/s). Feasibility is demonstrated in late gestation fetuses by comparing SVR with 2D Cartesian PCMRI (flow bias and limits of agreement: -0.9 ml/min/kg and [-39.7 37.8] ml/min/kg). With SVR, we demonstrate complex flow pathways (such as parallel flow streams in the proximal inferior vena cava, preferential shunting of blood from the ductus venosus into the left atrium, and blood from the brain leaving the heart through the main pulmonary artery) for the first time in human fetal circulation. This method allows for comprehensive evaluation of the fetal circulation and enables future studies of fetal physiology.

Robot-Assisted Laparoscopic IVC Treatment Strategy in Retroperitoneal Tumors.

ObjectivesTo show the practice of robot-assisted laparoscopic inferior vena cava (IVC) treatment strategies in patients with retroperitoneal tumors.Patients and MethodsFrom October 2020 to July 2021, 17 patients with retroperitoneal tumors successfully underwent robot-assisted laparoscopic tumor resection with IVC management. The patient details, tumor characteristics, intraoperative data, pathological features and severe complications were assessed. The IVC treatment strategies were divided into 4 ways: ①local resection and primary repair of the IVC; ②IVC ligation; ③ IVC reconstruction by bovine pericardial grafts; and ④ IVC transection and anastomosis.ResultsIn terms of IVC management, 5 cases had conventional total occlusion of the IVC and its branches, 3 cases had delayed occlusion of the proximal IVC technique, 2 cases had IVC resection by Satinsky clamp, 5 cases had IVC ligation, 1 case had IVC reconstruction by bovine pericardial grafts and 1 case had IVC transection and anastomosis. The median operation time was 151 min, and blood loss was 500 ml. There was no severe complication perioperatively. The follow-up time of 17 patients was 8 to 17 months (median: 12 months). No local recurrence or overall death was found during follow-up.ConclusionsThese robot-assisted laparoscopic IVC treatment strategies were considered to be safe and feasible in experienced centers, as well as helpful to completely remove the tumor for better oncological prognosis and restore the blood reflux of IVC as much as possible to ensure fewer postoperative complications.

Inferior Vena Cava (IVC) Resection Without Reconstruction for a Large IVC Leiomyosarcoma

BackgroundRetroperitoneal tumours arising from the inferior vena cava (IVC) are rare tumours often requiring large vessel resection for complete surgical excision. Limited exposure to such tumours often discourages surgeons from offering surgical resection to these patients, depriving them of the only potentially curative modality. We present here the surgical technique for resection of a large IVC sarcoma without IVC reconstruction. MethodsA 53-year-old lady presented with a large retroperitoneal sarcoma encasing the infra-hepatic IVC with tumour thrombus extension into the hepatic cloaca as well as the left renal vein. Surgical resection was planned as the disease remained stable after 2 cycles of neoadjuvant chemotherapy with adriamycin and ifosfamide. ResultsComplete surgical excision of the tumour was achieved by performing a resection of the entire length of infra-hepatic IVC and right kidney, without IVC reconstruction. Left renal vein was divided after careful preservation of a draining collateral. Tumour thrombus was extracted from the hepatic cloaca, and proximal IVC stump closure was achieved with preservation of right hepatic vein insertion. Total blood loss during the procedure was 2300 mL, and the patient recovered without compromise of renal function or development of lower limb oedema. ConclusionIVC resection without reconstruction can be safely performed for large retroperitoneal sarcomas involving major vascular structures. Familiarity with the retroperitoneal, retro-hepatic and supra-hepatic anatomy is paramount to achieving good surgical outcomes.

Pure retroperitoneal laparoscopic radical nephrectomy and thrombectomy with delayed occlusion of the proximal inferior vena cava (DOPI) technique for renal tumor with level II-III venous tumor thrombus

PurposeTo explore the safety and effectiveness of delayed occlusion of the proximal inferior vena cava (DOPI) technique in retroperitoneal laparoscopic radical nephrectomy (LRN) and thrombectomy for renal tumor with level II-III venous tumor thrombus (VTT).Materials and methodsFrom August 2016 to October 2018, a total of 145 patients with renal tumor and VTT were admitted to our centre. Seventy-five patients underwent laparoscopic surgery, and 70 patients underwent open surgery. Among these patients, 17 patients underwent retroperitoneal LRN and thrombectomy with the DOPI technique. Clinical data were collected retrospectively, and a descriptive statistical analysis was conducted.ResultsAll the patients successfully underwent retroperitoneal laparoscopic surgery. The mean operation time was 345.9 ± 182.9 min, the mean estimated blood loss was 466.7 ± 245.5 ml. Postoperative complications occurred in three patients, including two patients of Clavien grading system level IVa and one patient of level II. There were no complications related to carbon dioxide pneumoperitoneum, such as gas embolism, acidosis, and subcutaneous emphysema. During 21 months of median follow-up time, no local recurrence was found, and distant metastasis occurred in four patients. Cancer-specific death occurred in two patients.ConclusionsThe DOPI technique is safe and feasible in the treatment of renal tumor and level II-III VTT. With the DOPI technique, the procedures of dissociating and exposing proximal inferior vena cava are simplified.

Percutaneous Inferior Vena Cava Valve Implantation May Improve Tricuspid Valve Regurgitation and Cardiac Output: Lessons Learned.

Tricuspid valve regurgitation (TR) can be associated with poor prognosis. Transcatheter valve technology was adopted to treat the upstream effects of severe TR by placing a transcatheter valve in the inferior vena cava (IVC). In this study, we report off-label transcatheter valve implantation into the stented IVC in patients with severe TR for compassionate use. From September 2018 to February 2020, 6 inoperable patients with severe TR who failed medical treatment underwent percutaneous caval valve implantation (CAVI). Severity of TR was confirmed by intraoperative transesophageal echocardiography. Z-stents (Cook, Inc., Bloomington, IN, USA) were placed in the proximal IVC, and then a transcatheter valve was deployed in the suprahepatic cava without rapid pacing. Six patients, 2 females and 4 males, with a mean ± SD age of 74.7 ± 8.0 years were included. The procedure was successfully performed in all 6 patients (100%) employing a 29-mm SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA, USA) with supranominal volume. No procedural complication was detected. At 30 days, TR improved from severe to trace in 1 patient, to mild-moderate in 3 patients, and 2 patients remained with severe TR. Among patients with improved TR, left ventricular ejection fraction increased from 47.5% ± 18.5% to 55% ± 20.4% (P = 0.014). No patient had readmission at 30 days. Four patients needed rehospitalization within 6 months. Percutaneous CAVI is feasible and can be considered as a short-term palliative measure in patients with severe TR. CAVI can improve TR and potentially improve cardiac output in selected patients.

123 AI vs Expert: A Comparison of Rapid Visual IVC Collapsibility Assessment between POCUS Experts and a Deep Learning Algorithm

We sought to create a deep learning (DL) algorithm to determine the degree of inferior vena cava (IVC) collapsibility in critically ill patients to enable novice point of care ultrasound (POCUS) providers. We utilized publicly available long short term Memory (LSTM) DL basic architecture which can track temporal changes and relationships in real-time video, to create an algorithm for ultrasound video analysis. The algorithm was trained on public domain IVC ultrasound videos to improve its ability to recognize changes in varied ultrasound video. A total of 220 IVC videos were utilized; 10% of the data was randomly used for cross correlation during training. Data was augmented through video rotation and manipulation to multiply effective training data quantity. After training, the algorithm was tested on the 50 new IVC ultrasound video obtained from public domain sources and not part of the data set used in training or cross validation. Fleiss’ kappa was calculated to compare level of agreement between the three POCUS experts and DL algorithm and POCUS experts. There was very good agreement between the 3 POCUS experts with kappa = 0.87. Agreement between experts and algorithm was good with alpha = 0.73. Our algorithm showed good agreement with POCUS experts in visually estimating degree of IVC collapsibility which has been shown in previously published studies to differentiate fluid responsive from fluid unresponsive septic shock patients. Such an algorithm could be adopted to run in real time on any ultrasound machine with a video output, easing the burden on novice POCUS users by limiting their task to obtaining and maintaining a sagittal proximal IVC view and allowing the AI to make real time determinations.

A Rare Case of Portal Vein Thrombosis due to Protein S deficiency in a patient with Decompensated Cryptogenic CLD with Portal Hypertension, Completely Recanalized by Single Oral Anticoagulant-Rivaroxaban

Venous thromboembolic diseases are a group of heterogeneous diseases with different clinical forms and prognosis. Abdominal venous thrombosis may present either as Budd-Chiari syndrome (BCS) caused by hepatic vein or proximal inferior vena cava (IVC) obstruction or as an extra hepatic portal obstruction (EHPVO) caused by Portal vein thrombosis or mesenteric vein thrombosis. Portal vein thrombosis (PVT) is a rare form of venous thrombosis that affects the hepatic portal vein flow, which can lead to portal hypertension. Treatment of PVT includes anticoagulants, thrombolysis, and insertion of shunts, bypass surgery, and liver transplantation. Single anticoagulation therapy can be associated with a reduction in new thrombotic episodes. Here we experienced a 23 year old young lady with history of recent intrauterine death (IUD) diagnosed as PVT provoked by protein S deficiency with newly diagnosed decompensated cryptogenic chronic liver disease with portal hypertension. PVT was completely recanalized with single oral anticoagulant therapy rivaroxaban as initial low molecular weight heparin, enoxaparin administration caused reversible pancytopenia and there is a concern for bleeding and regular monitoring of INR with warfarin in this patient. Keywords: Portal vein thrombosis; Chronic liver disease; Protein S deficiency; Oral anticoagulant; Portal hypertension; Thrombolysis

Artificial intelligence versus expert: a comparison of rapid visual inferior vena cava collapsibility assessment between POCUS experts and a deep learning algorithm.

ObjectivesWe sought to create a deep learning algorithm to determine the degree of inferior vena cava (IVC) collapsibility in critically ill patients to enable novice point‐of‐care ultrasound (POCUS) providers.MethodsWe used publicly available long short term memory (LSTM) deep learning basic architecture that can track temporal changes and relationships in real‐time video, to create an algorithm for ultrasound video analysis. The algorithm was trained on public domain IVC ultrasound videos to improve its ability to recognize changes in varied ultrasound video. A total of 220 IVC videos were used, 10% of the data was randomly used for cross correlation during training. Data were augmented through video rotation and manipulation to multiply effective training data quantity. After training, the algorithm was tested on the 50 new IVC ultrasound video obtained from public domain sources and not part of the data set used in training or cross validation. Fleiss’ κ was calculated to compare level of agreement between the 3 POCUS experts and between deep learning algorithm and POCUS experts.ResultsThere was very substantial agreement between the 3 POCUS experts with κ = 0.65 (95% CI = 0.49–0.81). Agreement between experts and algorithm was moderate with κ = 0.45 (95% CI = 0.33–0.56).ConclusionsOur algorithm showed good agreement with POCUS experts in visually estimating degree of IVC collapsibility that has been shown in previously published studies to differentiate fluid responsive from fluid unresponsive septic shock patients. Such an algorithm could be adopted to run in real‐time on any ultrasound machine with a video output, easing the burden on novice POCUS users by limiting their task to obtaining and maintaining a sagittal proximal IVC view and allowing the artificial intelligence make real‐time determinations.

459: Sonographically measured inferior vena caval diameter in response to different maternal positions in pregnancy

Placing pregnant patients in left lateral tilt (LLT) position to avoid compression of the inferior vena cava (IVC) has long been standard obstetric practice. The American Heart Association recommends continuous manual left uterine displacement (LUD) instead of LLT position during a maternal cardiac arrest. The relationship between maternal position and proximal filling of the IVC is unknown. The hypothesis is that the maternal IVC diameter would increase in response to LLT and LUD compared to supine position. A pilot prospective observational study was performed on 60 healthy gravidas. 30 patients at 20-24 weeks and 30 patients at 37-41 weeks were recruited. Patients were placed in supine, 30 degree left lateral tilt and supine with left uterine displacement positions. The IVC was visualized by ultrasound using the subxiphoid technique. The primary outcome was IVC diameter at end expiration. Descriptive analysis and student's paired t-test were performed. In the 20-24 weeks cohort, patients in LLT position (77.5 +/- 9.8, p=0.03) and LUD position (77.3 +/-9.5, p=0.04) had a significant decrease in heart rate (bpm) compared to supine position (80.5 +/-8.5). Patients in the LUD position (80.7 +/-7.6, p<0.001) had a significant decrease in MAP compared to supine position (83.7 +/- 7.4). No significant differences were seen in the IVC diameter between all 3 positions.In the 37-41 weeks cohort, there were no significant differences in the MAP, heart rate, and IVC measurement between all 3 positions.In the 20-24 weeks cohort, 48.3%, 30%, 18.3% of patients had their largest IVC diameter in the LUD, LLT, and supine position, respectively. In the 37-41 weeks cohort, 33.3%, 28.3%, 30% of patients had their largest IVC diameter in the LUD, LLT, and supine position, respectively. 1 subject in each cohort experienced symptoms consistent with supine hypotension syndrome in the supine position (3.33%). Sonographically the IVC diameters were not statistically different between all 3 positions. Furthermore, 18% in the 20-24 weeks cohort and 30% in the 37-41 weeks cohort had their largest IVC diameter in the supine position. This observation challenges the universal belief of uterine IVC compression with associating decrease in proximal IVC filling among pregnant cohort. This study suggests that LLT or LUD may not be universally beneficial.

Robot-assisted Retrohepatic Inferior Vena Cava Thrombectomy: First or Second Porta Hepatis as an Important Boundary Landmark

BackgroundRobot-assisted retrohepatic inferior vena cava (IVC) thrombectomy (RA-R-IVCTE) has been reported only for limited series. ObjectiveTo describe in detail the techniques for RA-R-IVCTE with regard to the relationship of a proximal thrombus to either the first porta hepatis (FPH) or second porta hepatis (SPH). Design, setting, and participantsFrom May 2013 to July 2016, 22 patients with R-IVC tumor thrombi were admitted to our hospital. Surgical procedureRA-R-IVCTE was performed using the Rummel tourniquet technique. For a proximal thrombus inferior to the FPH, we ligated some short hepatic veins (SHVs; typically 1–3). For a thrombus between the FPH and SPH, we mobilized the right lobe of the liver from the IVC by ligating additional SHVs. For a thrombus near or above the SPH but below the diaphragm, we mobilized both the right and left lobes of the liver to obtain high proximal control of the suprahepatic and infradiaphragmatic IVC, and simultaneously clamped the FPH. MeasurementsDetailed techniques were described for various scenarios and perioperative outcomes were recorded. Results and limitationsThe median operation time was 285min (interquartile range [IQR] 191–390). Intraoperative estimated blood loss was 1350ml (IQR 1000–2075ml). Some 63.6% of patients required an intraoperative blood transfusion and 68% were transferred to the intensive care unit after surgery. Grade IV complications developed in five cases. Vascular injuries (4 cases) were treated with intraoperative endoscopic sutures. An intestinal fistula was found on postoperative day 7 in one case; treatment with gastrointestinal decompression and drainage resolved the condition by 1 mo. ConclusionsEven though the risks involved are high, RA-R-IVCTE is feasible for selected patients. The FPH/SPH is an important boundary landmark for RA-R-IVCTE. The location of proximal IVC tumor thrombi in relation to the FPH or SPH should determine the technique used. Patient summaryRobot-assisted thrombectomy for retrohepatic inferior vena cava tumor thrombus is feasible in selected patients.

Clinical experience of Mayo 0-IV tumor thrombus treated with radical nephrectomy and inferior vena cava thrombectomy

Objective To investigate the safety and feasibility radical nephrectomy and Mayo 0-Ⅳ venous thrombectomy. Methods The clinical data 52 patients with Mayo 0-Ⅳ tumor thrombus from February 2015 to January 2017 were analyzed retrospectively. Of the 52 patients, 42 were male and 10 were female. The average age was (59.8 ±13.6) years old (2.5 to 84.0 years). The renal vein tumor thrombus or inferior vena cava tumor thrombus was found in all patients, including type 0 thrombus in 12 cases, typeⅠthrombus in 11 cases, type Ⅱthrombus in 15 cases, type Ⅲthrombus in 9 cases, type Ⅳ thrombus in 5 cases (Mayo Medical Center classification). Imaging suggested the right renal tumor in 36 cases and left tumor in 16 cases. The average tumor size was (8.5±2.0) cm(2.0-21.1 cm). There were 2 cases ASA Ⅰ, 40 cases ASA Ⅱ and 10 cases ASA Ⅲ according to the American Society Anesthesiologists (ASA). In laparoscopic radical nephrectomy and Mayo 0 venous thrombectomy, we clamped the vena cava vessel wall nearby the renal vein entrance. The vena cava blood flow was blocked partially. Then we cut the vessel wall arcuately. Mayo Ⅰ tumor thrombus requires the use a non traumatic auricle clamp to control blood flow by the block vena cava above thrombus, vena cava below the renal vein level, and the contralateral renal vein. Right kidney tumors with Mayo Ⅱ could be completed by retroperitoneal surgery. At the time vascular occlusion, the distal inferior vena cava, the left renal vein and the proximal inferior vena cava were interrupted sequentially. For left renal tumors with Mayo Ⅱ, the retroperitoneal approach combined with transperitoneal approach was used. The technique of milking can shrink the tumor thrombus and reduced the difficulty the operation. For Mayo Ⅲ tumor thrombus just at the hepatic vein level, we cut off 3-5 hepatic short veins, and separated inferior vena cava long enough to provide surgical field. For Mayo Ⅲ tumor thrombus much higher than the hepatic vein level, we used open surgeries to free the liver and porta hepatis. We first blocked the distal inferior vena cava, followed by the left renal vein, the hepatic artery and portal vein, at last the proximal inferior vena cava. Mayo Ⅳ tumor thrombus often required a median incision to open the chest and establish an extracorporeal circulation. Results All the 52 surgeries were completed successfully without intraoperative and perioperative mortality. Open radical nephrectomy and inferior vena cava thrombectomy was underwent in 22 cases. Pure laparoscopic surgery was under went in 30 case. Two cases were converted to open surgery. The average surgery time was(333.7±80.1)min(136-694 min). The average blood loss volume was (1339.0±508.1)ml(20-10 000ml). During the operation, the amount suspended red blood cells transfusion was(761.5±394.8)ml(0-10 400ml). 28 cases underwent regional lymph node dissection, and postoperative pathological diagnosis showed lymph metastasis in 4 cases. 24 cases underwent ipsilateral adrenalectomy, and 2 cases showed tumor invasion adrenal gland. 7 cases with right tumors underwent inferior vena cava wall resection because invasion by tumor thrombus. The average postoperative hospitalization all 52 cases was (9.7±4.7) d. Among 27 patients, early postoperative complications occurred in 18 cases (34.6%). There were 1 case Clavien Ⅰ, 12 cases Clavien Ⅱ, 1 case Clavien Ⅲa, 2 cases Clavien Ⅳa and 2 cases Clavien Ⅴ according to modified Clavien classifications.44 cases(84.6%) were followed up for 1 to 22 months with a median 8 months. Postoperative recurrence occurred in 3 cases, and distant metastasis occurred in 9 cases. 9 cases (20.5%) had tumor specific death. Conclusions Our initial clinical results show that radical nephrectomy and inferior vena cava thrombectomy is safe and effective for patients with Mayo 0-Ⅳtumor thrombus, but the wide extension vein tumor thrombus leads to the difficulty operation technique. Sufficient preoperative preparation, rich operative experience and skills can improve the safety operation. Key words: Renal carcinoma; Tumor thrombus; Inferior vena cava

Robotic Radical Left Nephrectomy With Inferior Vena Cava Level III Thrombectomy

We present our robotic approach and technique to manage a large left renal tumor with inferior vena cava (IVC) Level III thrombus. The superior mesenteric artery crossing the left renal vein requires robotic docking from the left, for dissection of the left kidney followed by repositioning and re-docking the robot from the right side for dissection of the right renal vein, distal and proximal IVC, and the remaining left renal vein insertion into the IVC. We present a 53-year-old man with a 10.9-cm left renal mass with IVC level III tumor thrombus. A robotic left radical nephrectomy with lymph node dissection was completed using 4 ports in a midline configuration. The dissection of the left renal vein was taken medially until the superior mesenteric artery. The patient was then repositioned in the right side flank position and the robot was re-docked using the previously placed midline ports. The right renal vein, distal and proximal IVC were then controlled using modified Rummel tourniquets. Operative time was 530 minutes which included patient positioning, robot re-docking. The patient did not require a blood transfusion. Hospital stay was 4 days. Final pathology showed pT3bNoM1 renal cell carcinoma, clear cell type grade 4 with necrosis, and focal rhabdoid features measuring 11 cm. The tumor invaded the renal sinus and the renal vein and was metastatic to the ipsilateral adrenal gland. Margins were negative. Herein we present a successful outcome of a left-sided robotic radical nephrectomy with IVC level III tumor thrombectomy.

Unusual Presentation of Metastatic Hepatocellular Carcinoma in a Previously Healthy Patient With Newly Diagnosed Hepatitis B Infection

Introduction: Early HCC diagnosis is paramount and guides further management. Over 700,000 cases of HCC are reported annually worldwide. In the U.S., about 20% of HCC is due to hepatitis B (HBV). Tumor invasion into the portal vein is reported in about 70% of cases and is more common in tumors larger than 5 cm in diameter. Initial presentation of HCC with tumor thrombus in the heart and extensive involvement of the iliac veins in a patient without previous HCC or signs of decompensated liver disease is rare. A 51-year-old Hispanic man with HBV infection, but otherwise healthy, presented with altered mental status. One month prior, he was diagnosed with HBV and was prescribed tenofovir, but was non-compliant. On physical exam, he had a palpable liver, scleral icterus, and asterixis. Abdominal CT showed cirrhosis, a hyperdense lesion in the dome of the liver (1.7 x 1.2 cm) and an ill-defined liver lesion at the level of the inferior vena cava (IVC). A 3 x 5-cm thrombus was seen in the right atrium, and another thrombus was noted in the iliac veins with partial thrombosis of the proximal IVC. ALT was 785 IU/L, AST 677 IU/L, total bilirubin 5.5 mg/dL. HBeAb was positive, HBeAg negative, HBV DNA level 39,572 IU/mL, and AFP level 7,150 IU/mL, essentially diagnostic of HCC and obviated the need for biopsy of the tumor. He was treated with low molecular weight heparin and tenofovir; however, he died 2 weeks later. HCC invasion into the heart and iliac veins in a previously asymptomatic patient is infrequently encountered. Extensive vascular invasion and tumor thrombi are ominous signs of HCC. Early HBV diagnosis and HCC detection is emphasized.

A Case Study of Duplicated Inferior Vena Cava: An Incidental Finding in an Abdominal Vascular Evaluation

Often during routine studies, vascular technologists are confronted with unusual findings. This case presentation describes finding a duplicated inferior vena cava (IVC) in a 43-year-old man with fatigue, dizziness, and a physical finding of dilated iliac veins. When insonating the mid aorta in transverse view, we noted that the aorta had what appeared to be two IVCs (one IVC on each side of the aorta). As a result of the finding, further assessment took place. The proximal IVC was visualized with color Doppler in longitudinal view and noted to be anterior to the aorta. Further evaluation took place and a second vein appearing to be a duplicated IVC was discovered posterior to the aorta. Duplicated IVC is a rare congenital anomaly that results from persistence of right and left supracardinal veins in embryo. Duplicated IVC needs to be recognized in association with vena cava filter placement and renal anomalies.

Giant myxoma causing heart failure symptoms.

SummaryBackground:Myxomas arising from the eustachian valve are exceedingly rare.Case Report:A 72-year-old Jamaican-Chinese woman was evaluated for worsening dyspnea. The 2-dimensional and real time 3-dimensional transesophageal echocardiogram showed a 75 mm length × 44 mm width, multilobulated, mobile mass arising from the eustachian valve occupying the entire right atrial and right ventricular cavities extending into the coronary sinus, right ventricular outflow tract, and proximal inferior vena cava. The patient underwent successful resection of the mass and replacement of the tricuspid valve. Histopathologic examination confirmed the diagnosis of atrial myxoma.Conclusions:This is the largest myxoma found on a Eustachian valve.

Patient with a Massive Idiopathic Thrombosis in the Inferior Vena Cava

A 50 year-old man with no significant medical history was admitted for dyspnea and left femoral swelling. Contrast-enhanced computed tomography revealed pulmonary thromboembolism (PTE) and a thrombus in the inferior vena cava (IVC). The thrombus extended from the proximal IVC to the left popliteal vein. Therefore, we decided that an IVC filter insertion was difficult to indicate. Urgent IVC and peripheral vein thrombectomy was performed under cardiopulmonary bypass. On postoperative day 1, venous ultrasonography showed residual deep vein thrombosis in the left external iliac-femoral vein and the popliteal vein. The IVC filter insertion was performed to prevent the recurrence of PTE.

Emergency department right atrial pressure and intravascular volume estimation using right ventricular tissue Doppler bedside ultrasonography

Abstract A 41 year old woman with a history of colon cancer metastatic to her lung and liver, presented to the emergency department severely dehydrated. Bedside ultrasonography revealed a tumor mass in her proximal inferior vena cava at the junction of the right atrium obstructing the ability to assess her volume status with inferior vena cava inspiratory collapse. Bedside emergency department cardiac tissue Doppler ultrasonography of the lateral right ventricle and pulse Doppler ultrasonography of the tricuspid valve was used to estimate her right atrial pressure and intravascular volume status.