Subdiaphragmatic Inferior Vena Cava Research Articles

Totally implanted central venous access devices inserted by the femoral route: A narrative review and the proposal of a novel approach, the FICC-port.

Femoral ports are used in patients with indication to a totally implanted venous access device but with contraindication to chest-ports and brachial ports because of obstruction of the superior vena cava. In the last three decades, femoral ports have been implanted almost exclusively by cannulation of the common femoral vein at the groin, while the position of the tip has been assessed by X-ray. We report our experience with a new approach to femoral ports, which includes recent methods and techniques developed in the last few years. These novel femoral ports, which we call "FICC-ports," are characterized by (a) long femoral 5 Fr polyurethane catheter inserted by ultrasound-guided puncture of the superficial femoral vein at mid-thigh; (b) intraprocedural location of the tip in the sub-diaphragmatic inferior vena cava, using ultrasound visualization by the transhepatic and/or the subcostal view; (c) low-profile or very low-profile reservoir implanted above the quadriceps muscle, at mid-thigh. In the last 3 years, we have implanted 47 FICC-ports in young adults with mediastinal lymphoma compressing the superior vena cava. We had no immediate/early complication, and only three late complications (one kinking of the catheter in the subcutaneous tissue; one tip migration with secondary venous thrombosis; one persistent withdrawal occlusion due to fibroblastic sleeve). If there is indication to a femoral port, the implantation of a "FICC-port"-as described above-is to be strongly considered in terms of safety, effectiveness, and cost-effectiveness: no immediate-early complications, minimal late complications, no X-ray exposure, low invasiveness, low cost.

Ultrasound based tip location of femorally inserted central catheters into the inferior vena cava: A comparison between the transhepatic and the subcostal view.

Intraprocedural catheter tip location is currently recommended. Intracavitary EGC and ultrasound are the preferred methods of tip location for catheters with their tip in the superior vena cava or in the right atrium. Though, the best method of intraprocedural tip location for catheters with their tip in the inferior vena cava is still uncertain. One possibility is to visualize the subdiaphragmatic inferior vena cava by ultrasound, using either the transhepatic or the subxiphoid view. In this prospective study, we compared two different ultrasound windows for the visualization of the inferior vena cava (transhepatic vs subxiphoid) for the purpose of localizing the catheter tip during the insertion of femorally inserted central catheters. We studied 249 consecutive insertions of central catheters via the superficial femoral vein. Intraprocedural location of the catheter tip was performed by ultrasound, using both transhepatic and subxiphoid view. Visualization of the inferior vena cava was possible only in 81 cases (32.5%) with the subxiphoid view, but it was always possible in all 249 cases with the transhepatic view. The catheter tip was localized in 15 patients out of 81 with the subxiphoid view (18.5%); the transhepatic view allowed the visualization of the tip in all 249 patients. The applicability of the subxiphoid window has several limitations, both in terms of visualization of the inferior vena cava and localization of the catheter tip. The transhepatic view should be the preferred method for intraprocedural ultrasound localization of the catheter tip in the inferior vena cava.

Applicability and feasibility of intraprocedural tip location of femorally inserted central catheters by transhepatic ultrasound visualization of the inferior vena cava in adult patients.

The ideal intraprocedural method for tip location during insertion of femorally inserted central catheters (FICCs) is still a matter of debate. When the catheter tip is meant to be in the right atrium or in the supradiaphragmatic inferior vena cava (IVC), tip location by either intracavitary electrocardiography or transthoracic echocardiography may be accurate and easy to perform. When the catheter tip is planned to be placed in the subdiaphragmatic IVC, fluoroscopy-though inaccurate and unsafe-has been regarded as the only option for intraprocedural tip location. We have investigated prospectively the applicability and feasibility of transhepatic ultrasound as intraprocedural method for assessing the location of the catheter tip in the subdiaphragmatic tract of IVC, during FICC insertion. We enrolled 169 consecutive patients undergoing FICC insertion by ultrasound guided puncture of the superficial femoral vein. In 165 out of 169 patients, the subdiaphragmatic IVC was visualized by the transhepatic ultrasound view. In all cases of IVC visualization, the catheter tip could be identified by ultrasound, either directly (direct evidence of the tip inside the vein) or indirectly (enhanced visualization of the tip after "bubble test"). There was no immediate or early complication, and very few late complications. The intraprocedural method of tip location of FICCs by transhepatic ultrasound was applicable in 97.6% of cases and feasible in 100%. When the position of the catheter tip is planned to be in the subdiaphragmatic IVC, this method of tip location is accurate, safe, and inexpensive, and should be considered as an alternative to fluoroscopy.

Determinants of outcomes after resection of renal cell carcinoma with venous involvement

To determine the outcomes and to identify prognostic variables determining mortality and recurrence after surgery for renal cell cancer (RCC) with venous involvement. Retrospective evaluation of the medical records of 132 patients with RCC and tumor thrombi treated at Johns Hopkins Hospital (1997-2008) was done. Kaplan-Meier analysis was used to determine survivals. Uni- and multivariate Cox proportional analysis was done to identify predictors for recurrence, all-cause mortality (ACM) and cancer-specific mortality (CSM). Mean follow-up was 30.3 (0.03-159.5) months. Sixty-four (48.5%) patients had renal vein thrombus (Group 1), 55 (41.7%) had subdiaphragmatic inferior vena cava (IVC) tumor thrombus (Group 2), while 13 (9.8%) had involvement of IVC above diaphragm or atrial extension (Group 3). IVC thrombus was more common from the right-sided tumors. Patients with higher thrombus levels had more blood loss and complicated and longer hospital stay. Thrombus level was not found to be a predictor of recurrence, ACM and CSM. One- and three-year recurrence-free survivals for non-metastatic patients were 69 and 53%. Tumor size (p=0.015), grade (p=0.007) and venous wall invasion (p=0.027) were predictors for recurrence. Five-year overall survival was 48, 35 and 13% for 3 groups, respectively. Presence of distant metastasis (p=0.032), size (p=0.002), histology (p=0.020) and grade (p=0.013) were predictors of ACM. Five-year cancer-specific survival was 65, 43 and 36 for 3 groups, respectively. Tumor size (p=0.001) and distant metastasis at presentation (p=0.025) were the predictors of CSM. Tumor thrombus level does not predict recurrence or mortality in RCC with venous involvement. Survival is determined by inherent aggressiveness of the cancer manifested by tumor size, grade and distant metastasis at presentation.

Multi-slice spiral CT multiplanar reconstruction findings of localized fat collection adjaction to the subdiaphragmatic inferior vena cava

Objective To discusses the MSCT multiplanar reconstruction manifestation (MPR) of localized fat collection adjaction to subdiaphragmatic inferior vena cava (IVCfat).Methods The thoracic and abdominal MSCT scan data of 8246 patients were browsed,45 patients with presumed IVCfat on axial CT scans were further studied prospectively with MSCT MPR.The predisposing position of IVCfat and its relationship with IVC were observed.It was divided into two kinds of intraluminal type and extraluminal type according to the angle of IVCfat with respect of the wall of IVC.The other 50 patients without IVCfat were randomly selected as the control group.The sagittal inclination angle (SIA) and diameter ratio (DR) between supra- and sub-diaphragmatic IVC between the two groups were compared by using t test.Results The detection rate was 0.55％ (45/8246).Of which hepatic vein lacuna 8 patients,subdiaphragmatic gap medial to IVC 28 patients and IVC groove 9 patients.The shape of IVCfat showed mainly for the round,oval and crescents on axial CT scans,of 15 patients intraluminal type,4 showed target signs .The shape of IVCfat showed mainly for half-moon at MPR.The SIA and DR at IVCfat group were 21.62° ± 8.42°and 2.01 ±0.84 respectively,at control group were 16.75° ±7.82°(t =1.594,P ＞0.05) and 1.31 ±0.28(t =2.341,P ＜ 0.05 ) respectively.Conclusion The round,oval or half of limited fat density shadow adjaction to subdiaphragmatic inferior vena cava which similar to in the lumen is the characteristic performance of IVCfat,it may be an anatomical variation. Key words: Vena cava,inferior; Fat; Tomography, X-ray computed

Agenesis of the ductus venosus: three-dimensional power Doppler reconstruction

The ductus venosus (DV) is an important fetal vascular structure that connects the umbilical venous system to the inferior vena cava (IVC) near its insertion point into the right atrium1. It allows 20–30% of the umbilical blood to bypass the liver in utero and reach the heart rapidly, thus increasing the flow of well-oxygenated blood to the cephalic and coronary circulation. The DV therefore plays a key role in increasing the shunt of oxygenated blood to the heart and decreasing placental return during hypoxemia and hypovolemia1,2. For several years, improvements in ultrasound techniques, such as two-dimensional (2D) and threedimensional (3D) ultrasound reconstruction, have made it possible to identify numerous malformations that were previously undetectable antenatally, including agenesis of the DV3, which is associated with various morphological and cytogenetic abnormalities. Examination of the DV has been used in referral centers to refine diagnoses involving cardiac, extracardiac and chromosomal anomalies2 as well as in first-trimester screening for Down syndrome in the high-risk population4. The DV pulsatility index for veins can be used as a continuous variable, in combination with nuchal translucency (NT) measurement, to increase specificity in the identification of congenital heart defects5. We report here the case of a 31-year-old primigravida, referred at 35 weeks of gestation to our prenatal center after the abnormal finding at third-trimester ultrasound of a highly dilated IVC (4.1 mm) and umbilical vein. Firstand second-trimester findings had been unremarkable. Combined marker screening in the first trimester indicated a 1/554 risk for Down syndrome, with NT on the 60th percentile. The only morphological abnormalities found during the third-trimester examination were the dilated IVC and umbilical vein. Suspecting agenesis of the DV, we performed a color Doppler ultrasound examination. Looking for an abnormal course or flow in the umbilical vein, we found that it was connected directly to the IVC and the flow velocity was high. To clarify the situation, 3D volume datasets were acquired with transverse and sagittal sweeps over the abdominal region. The umbilical vein and IVC were reconstructed using the glass-body rendering (angiographic) mode to optimize examination of these vessels. To highlight their abnormal connection, we then used the Magicut postprocessing application (Figure 1). This 3D power Doppler reconstruction demonstrated the anomalous course of the dilated umbilical vein, which was connected directly to the dilated subdiaphragmatic IVC and bypassed the liver. Fetal echocardiography showed substantial disproportion in the diameters of the IVC and superior vena cava at the points of insertion into the heart: 4.1 mm vs 1.2 mm. No features of cardiac decompensation or morphological abnormality were seen. The patient was offered amniocentesis for karyotype determination because agenesis of the DV is associated with a high rate (17%) of chromosomal abnormalities2; the karyotype was normal. The remainder of the pregnancy and delivery were uneventful, and the child appeared healthy. Little is known about the consequences and clinical implications of agenesis of the DV6. This anomaly affects approximately 6/1000 fetuses in a high-risk population. The few reports in the literature of an absent DV are associated with three different abnormal patterns: the umbilical vein may bypass the liver and then connect to the subdiaphragmatic IVC or to the iliac or renal veins, it may connect directly to the right or left atrium, or it may connect directly to the portal vein without giving rise to the DV2,7. DV agenesis is associated with congenital morphological abnormalities in approximately 65% of cases and with cytogenetic abnormalities in 17%2,8. The cardiac anomalies associated with DV agenesis, which occur in 48% of cases, include atrial and ventricular septal defects, tricuspid atresia, double outlet right ventricle, pulmonary atresia and transposition of the great arteries7,9. Other common associated anomalies involve the gastrointestinal system (duodenal atresia and tracheoesophageal fistula), the genitourinary system (bilateral hydronephrosis and ectopic kidney) and the musculoskeletal system

Outcome of operation in patients with adrenocortical cancer invading the inferior vena cava—a European Society of Endocrine Surgeons (ESES) survey

Most patients with adrenocortical cancer (ACC) continue to present with advanced disease. Invasion into the inferior vena cava (IVC) defines stage III disease and the management of such patients raises additional difficulties. A multicentre survey was organized by emailing a standardized proforma to members of the European Society of Endocrine Surgery (ESES). Anonymised retrospective clinical data were collected. Replies were received from 18 centres in nine countries. ACC with IVC invasion was encountered in 38 patients (18F:20M, age 15-84years, median 54years). There were 16 nonfunctioning tumours and 22 functioning tumours predominantly right-sided (26R:12L) and measuring 18-255mm (median 115mm). Fourteen patients had metastatic disease at presentation. Tumour thrombus extended in the prehepatic IVC (n = 21), subdiaphragmatic IVC (n = 6) or into the SVC/right atrium (n = 3). Open adrenalectomy was associated with resection of surrounding viscera in 24 patients (nephrectomy n = 16, liver resection n = 14, splenectomy n = 3, Whipple procedure n = 2). IVC was controlled locally (n = 27), at suprahepatic levels (n = 6) or necessitated cardiac bypass (n = 5). Complete resection (R0, n = 20) was achieved in the majority of patients, with a minority having microscopic persistent disease (R1, n = 7) or macroscopic residual disease (R2, n = 4). Perioperative 30-day mortality was 13% (n = 5). Postoperative Mitotane was used in 23 patients and chemotherapy in eight patients. Twenty-five patients died 2-61months after their operation (median 5months). Currently, 13 patients are alive at 2-58months (median 16months) with known metastatic disease (n = 7) or with no signs of distant disease (n = 6). This dataset is limited by the lack of a denominator as it remains unknown how many other patients with ACC presenting with IVC invasion did not undergo surgery. The relatively low perioperative mortality and the long disease-free survival achieved by some patients should encourage surgeons with adequate experience to offer surgical treatment to patients presenting with advanced adrenocortical cancers.

Prognostic Value of Renal Vein and Inferior Vena Cava Involvement in Renal Cell Carcinoma

BackgroundThe prognostic significance of venous tumor thrombus extension in patients with renal cell carcinoma (RCC) is a matter of many controversies in the current literature. ObjectiveTo evaluate the prognostic role of inferior vena cava (IVC) involvement in a large series of pT3b and pT3c RCCs. Design, setting, and participantsA total of 1192 patients from 13 European institutions underwent a radical nephrectomy for pT3b and pT3c RCC between 1982 and 2003. The patients were evaluated in a retrospective manner. Age, gender, clinical symptoms, Eastern Cooperative Oncology Group (ECOG) performance status, TNM stage, tumor size, adrenal invasion, perinephric fat invasion, histological type, and Fuhrman grade were reviewed. The log-rank and Cox uni- and multivariate regression analyses were used to evaluate prognostic factors for overall survival. MeasurementsOverall survival and prognostic factors for overall survival in patients with RCC extending to the renal vein (RV) or to the IVC. Results and limitationsThe median follow-up was 61.4 mo (56.3–66.5 mo). The mean age was 63.2 yr. The mean tumor size was 8.9cm. Group 1 (Gr 1) included 933 patients with a renal vein tumor thrombus (78.3%), Group 2 (Gr 2) included 196 patients with a subdiaphragmatic IVC tumor thrombus (16.4%), and Group 3 (Gr 3) included 63 patients with a supradiaphragmatic IVC tumor thrombus (5.3%). Median survival was 52 mo for Gr 1, 25.8 mo for Gr 2, and 18 mo for Gr 3. In univariate analysis, Gr 1 had a significantly better overall survival than Gr 2 (p<0.001) and Gr 3 (p≤0.001). No significant difference in survival was noted between Gr 2 and Gr 3 (p=0.613). Prognostic factors for overall survival in univariate analysis were clinical symptoms (p<0.001), tumor size (p<0.001), perinephric fat invasion (p<0.001), Fuhrman grade (p<0.001), histological type (p=0.021), lymph node invasion (p<0.001), and distant metastasis (p<0.001). Independent prognostic factors in multivariate analysis were tumor size (p=0.013), perinephric fat invasion (p=0.003), lymph node invasion (p<0.001), distant metastasis (p<0.001), and IVC invasion (p=0.008). ConclusionsThe level of tumor thrombus in the IVC does not significantly affect long-term overall survival in patients with renal cell carcinoma. The overall survival was statistically different for patients with a tumor thrombus in the RV compared to those with IVC involvement. This has to be considered for the next revision of the TNM system, and the pT3b and pT3c stages have to be redesigned.

Endoluminal occlusion of the inferior vena cava in renal cell carcinoma with retro‐ or suprahepatic caval thrombus

To evaluate endoluminal occlusion of the inferior vena cava (IVC) during surgical treatment of renal cell carcinoma (RCC) with either retrohepatic (level II) or suprahepatic (level III) caval tumour thrombus. From January 2000 to February 2005, 31 patients with renal vein/IVC involvement (T3b/c) of 278 who had a radical nephrectomy, were selected for review. Of these 31, 13 consecutive patients with RCC presenting a thrombus level II or III were prospectively treated with endoluminal occlusion of the free IVC cranial to the thrombus, to avoid dissection of the suprahepatic IVC or the subdiaphragmatic IVC. The occlusion balloon was positioned using transoesophageal echocardiography (TEE) control through a cavotomy at the ostium of the renal vein. Thrombectomy and radical nephrectomy were then performed. The operative duration, peri-operative bleeding, and complications during and after surgery were assessed. Overall patient survival time, disease-free survival and development of metastasis were calculated. Caval thrombectomy was successful in all patients. The IVC needed to be replaced with an expanded polytetrafluoroethylene graft in three patients and a patch closure after lateral cavectomy was used in four. There was no case of air embolism. One case of asymptomatic tumour migration was detected during the procedure by TEE. The mean (sd) and median (range) operative duration was 170 (29) and 170 (120-210) min, and the mean number of units of packed red cells transfused during hospitalization was 5 (5) and 3 (0-16). There was no peri-operative mortality. The complications were one splenectomy and one early thrombosis of the IVC. The mean (range) follow-up was 22.1 (2-50) months. Distant metastases occurred in seven patients; there was no local or IVC tumour recurrence. Four patients died from metastatic progression and six are alive with no progression. Endoluminal occlusion of the IVC with TEE monitoring for level II and III thrombus avoided a suprahepatic or subdiaphragmatic approach to the IVC. This technique caused no major complications and was very reliable, due to TEE monitoring. Segmental resection and reconstruction of the IVC could also be used for adherent thrombi.

Effect of portal hypertension caused by chronic high venous pressure on small-intestinal sugar absorption

The effect of portal hypertension and chronic high venous pressure on the absorption of the small intestine was examined by constricting the suprahepatic and subdiaphragmatic inferior vena cava in rats. A group of rats with the constricted suprahepatic and subdiaphragmatic inferior vena cava comprised group 1 ( n = 9) and another group of rats with only laparotomy comprised group 2 ( n = 9). Two months after the operation, sugar absorption and other parameters were measured. The blood pressures of the infrahepatic inferior vena cava and the portal vein 8 wk after the operation in group 1 were significantly higher than those in group 2. The results of d-xylose absorption tests showed that the amount of excreted d-xylose in urine in group 1 was significantly lower than that of group 2, but the d-xylose everted sac test showed no significant differences between the two groups. The glucose everted sac test showed that the amount of glucose absorption in group 1 was significantly lower than that in group 2. These findings suggest that chronic high venous pressure caused by constriction of suprahepatic inferior vena cava may lead to sugar malabsorption. We conclude that portal hypertension with high venous pressure below the diaphragm can lead to sugar malabsorption in the intestine.

Pericaval fat collection that mimics thrombosis of the inferior vena cava: demonstration with use of multi-directional reformation CT.

To evaluate the causes for localized fat collection that seemed to be within the subdiaphragmatic inferior vena cava (IVC) on axial computed tomographic (CT) scans. Six consecutive patients with presumed intracaval fat collection at routine abdominal CT (n = 2) or thin-section CT of the lung (n = 4) were studied prospectively with helical CT. Three patients had chronic liver diseases. Multi-directional, two-dimensional, reformatted images were obtained from the helical CT data for identification of the relation between the IVC and fat collection. Six patients without intracaval fat collection were studied as control subjects. On axial CT scans, the fat collection had a round or oval shape (in four of six patients) and was located posteromedial to the IVC (in four of six patients). On coronal reformatted images, the fat collection was outside the IVC between the diaphragm and subdiaphragmatic IVC, which was contiguous to the fat around the subdiaphragmatic esophagus. In the fat collection group, the IVC angled toward the right and narrowed to half in diameter as it passed down to the diaphragm. In the control group, the IVC was straight, although the diameter decreased similarly. A localized fat collection adjacent to the subdiaphragmatic IVC that mimics intracaval fat on axial CT scans is due to acute angulation of the IVC, which is probably a result of anatomic variation, chronic liver disease, or both.

Treatment of Budd-Chiari syndrome due to inferior vena cava occlusion by combined portal and vena caval decompression

This study concerns Budd-Chiari syndrome (BCS) caused by occlusion of the subdiaphragmatic inferior vena cava (IVC). It describes the experimental and clinical evaluation of the treatment of this disorder by one-stage combined portal and vena caval decompression with a direct side-to-side portacaval shunt (PCS) and a caval-atrial shunt (CAS) graft. BCS was produced in rats by gradual occlusion of the suprahepatic IVC with an ameroid constrictor. When ascites and portal hypertension were established, 12 control rats survived a sham thoracolaparotomy, 16 rats survived a mesoatrial shunt, and 16 rats survived combined PCS and CAS graft. All control rats re-formed ascites and died within 2 months. Nine of 16 rats with mesoatrial shunt developed graft thrombosis, re-formed ascites, and died within 2 months. In contrast, only 2 of 16 rats that underwent combined PCS and CAS developed graft thrombosis, re-formed ascites, and died. Liver biopsies showed reversal of severe pathologic changes in rats with patent grafts. Clinical evaluation of combined PCS and CAS using a 20-mm ring-reinforced Gore-Tex graft has been undertaken in five patients with BCS and ascites, hepatosplenomegaly, intense hepatic congestion on biopsy, and angiography showing occlusion of both the IVC and hepatic veins. All five patients are alive and well 6 months to 7.5 years postoperatively with patent grafts, no ascites or need for diuretics, no encephalopathy, normal liver function, and reversal of liver pathology. It is concluded that combined PCS and CAS create a high-flow shunt that decompresses both the portal system and IVC, has a low incidence of graft thrombosis, has been consistently effective in relieving BCS caused by IVC occlusion, and appears to be superior to mesoatrial shunt.

Classification of Hepatic Venous Outflow Obstruction: Ambiguous Terminology of the Budd-Chiari Syndrome

Severe hepatic venous outflow obstruction and its manifestations often are recorded under the label "Budd-Chiari syndrome." Unfortunately, this label is ambiguous; it does not clearly identify the site of the lesion (hepatic veins versus inferior vena cava), its morphologic features (thrombotic versus nonthrombotic), or its cause. In the literature, implied or expressed definitions vary. Use of a standardized topographic and pathogenetic classification of hepatic venous outflow obstruction would enable investigators to group patients with comparable conditions, as required for therapeutic trials, prognostic evaluations, and studies of pathogenetic pathways. Review of our own cases revealed that hepatic venous outflow obstruction involving large hepatic veins is usually thrombotic and that isolated obstruction of the inferior vena cava or of small hepatic veins is usually nonthrombotic. Application of such a classification seems feasible and may yield useful results.

Blood flow through vasa vasorum in arteries and veins: effects of luminal PO2.

We have examined effects of chronic reduction of intraluminal PO2 on blood flow through vasa vasorum, by comparing large arteries and veins, and effects of acute hypoxia on flow through vasa. Microspheres were used to measure flow in anesthetized dogs. Values obtained with different sizes of microspheres suggest that spheres 9 and 15 micron in diam, but not 50 micron, are appropriate for measurement of blood flow through vasa vasorum. Flow [expressed as ml X min-1 X 100 g-1 (SE)] through medial vasa was similar in the aorta (9.0 +/- 2.1) and pulmonary artery (9.3 +/- 1.1) although, on the basis of wall thickness and number of lamellae, one would predict much higher levels of flow to aortic media. Two veins that we studied have a thick muscular wall. Both veins had high levels of flow through medial vasa: 33 +/- 4.4 to the subdiaphragmatic inferior vena cava and 18 +/- 5.4 to the portal vein. Two other veins are apparently conduit vessels, with dense connective tissue and minimal smooth muscle. Both veins had minimal flow through medial vasa: 2.4 +/- 1.0 to superior vena cava, and 1.9 +/- 0.8 to supradiaphragmatic inferior vena cava. Thus, because flow through vasa differs greatly in different veins, structure of the vessel (as well as intraluminal PO2) is an important determinant of flow through vasa. Acute hypoxia increased conductance of medial vasa vasorum of arteries and veins when neurohumoral constrictor effects were blocked by phenoxybenzamine.(ABSTRACT TRUNCATED AT 250 WORDS)