Suprahepatic Inferior Vena Cava Research Articles

Hepatic Venous and Inferior Vena Cava Morphology No Longer a Barrier to Living Donor Liver Transplantation for Budd-Chiari Syndrome: Surgical Techniques and Outcomes.

Living donor liver transplantation (LDLT) for Budd-Chiari syndrome (BCS) has been reported with<10 inferior vena cava (IVC) replacements with vascular/synthetic graft. The goal of this study was to review outcomes of LDLT for BCS at our center, with an emphasis on surgical techniques and postoperative anticoagulation therapy. Between October 2011 and December 2015, a total of 1027 LDLTs were performed. Nine of these patients had BCS. We analyzed their etiologies, operative details, postoperative complications, and outcomes. The indication was chronic liver disease for all patients. Two patients required retrohepatic IVC replacement with a polytetrafluoroethylene graft due to severe adhesions and thrombosis, respectively. One patient required V-Y plasty for suprahepatic IVC narrowing. Five patients had portal venous thrombosis, 3 treated by thrombectomy, and 1 by renoportal anastomosis. The mean follow-up time was 18 ± 16 months. Only 1 early death occurred due to sepsis. The anticoagulation therapy involved heparin infusion from postoperative day 1, conversion to low-molecular-weight-heparin on postoperative days 3 to 6, followed by warfarin (postoperative days 9-16 to maintain an international normalized ratio of 2-3 long term), along with low-dose aspirin for 6 months. There was no recurrence of thrombosis. LDLT for BCS is well documented in literature. Prevention of recurrent thrombosis depends on meticulous surgical technique, perfect and wide outflow anastomoses, and a strict anticoagulation protocol. A synthetic (polytetrafluoroethylene) graft for IVC interposition is a safe and feasible option for reconstruction with good results. Low-dose aspirin with low-molecular-weight-heparin later converted to warfarin provides excellent results and prevents recurrence of thrombosis.

Percutaneous Transluminal Angioplasty for Complete Membranous Obstruction of Suprahepatic Inferior Vena Cava: Long-Term Results.

To determine the long-term results of percutaneous transluminal angioplasty (PTA) for a complete membranous obstruction of the suprahepatic inferior vena cava. Patients (n=65) who were referred to the interventional unit for PTA for a complete membranous obstruction of the suprahepatic inferior vena cava between January 2006 and October 2014 were included in the study. Thirty-two patients (18 males, 14 females, mean age 35±10.7, range 20-42years) were treated. The patients presented with symptoms of ascites (88%), pleural effusion (53%), varicose veins (94%), hepatomegaly (97%), abdominal pain (84%), and splenomegaly (40%). Transjugular liver access set and re-entry catheter were used to puncture and traverse the obstruction from the jugular side. PTA balloon dilations were performed. The mean follow-up period was 65.6±24.5months. The objective was to evaluate technical success, complications, primary patency, and clinical improvement in the symptoms of the patients. The technical success rate was 94%. In two patients, obstruction could not be traversed. These patients underwent cavoatrial graft bypass surgery. There were no procedure-related complications. Clinical improvements were achieved in all patients within 3months. The primary patency rate at 4years was 90%. There was no primary assisted patency. There was no need for metallic stent deployment in the cohort. The secondary patency rate at 4years was 100%. Percutaneous transluminal angioplasty for a complete membranous obstruction of the suprahepatic inferior vena cava is safe and effective, and the long-term results are excellent.

Use of Caval Subtraction 2D Phase-Contrast MR Imaging to Measure Total Liver and Hepatic Arterial Blood Flow: Preclinical Validation and Initial Clinical Translation.

Purpose To validate caval subtraction two-dimensional (2D) phase-contrast magnetic resonance (MR) imaging measurements of total liver blood flow (TLBF) and hepatic arterial fraction in an animal model and evaluate consistency and reproducibility in humans. Materials and Methods Approval from the institutional ethical committee for animal care and research ethics was obtained. Fifteen Sprague-Dawley rats underwent 2D phase-contrast MR imaging of the portal vein (PV) and infrahepatic and suprahepatic inferior vena cava (IVC). TLBF and hepatic arterial flow were estimated by subtracting infrahepatic from suprahepatic IVC flow and PV flow from estimated TLBF, respectively. Direct PV transit-time ultrasonography (US) and fluorescent microsphere measurements of hepatic arterial fraction were the standards of reference. Thereafter, consistency of caval subtraction phase-contrast MR imaging-derived TLBF and hepatic arterial flow was assessed in 13 volunteers (mean age, 28.3 years ± 1.4) against directly measured phase-contrast MR imaging PV and proper hepatic arterial inflow; reproducibility was measured after 7 days. Bland-Altman analysis of agreement and coefficient of variation comparisons were undertaken. Results There was good agreement between PV flow measured with phase-contrast MR imaging and that measured with transit-time US (mean difference, -3.5 mL/min/100 g; 95% limits of agreement [LOA], ±61.3 mL/min/100 g). Hepatic arterial fraction obtained with caval subtraction agreed well with those with fluorescent microspheres (mean difference, 4.2%; 95% LOA, ±20.5%). Good consistency was demonstrated between TLBF in humans measured with caval subtraction and direct inflow phase-contrast MR imaging (mean difference, -1.3 mL/min/100 g; 95% LOA, ±23.1 mL/min/100 g). TLBF reproducibility at 7 days was similar between the two methods (95% LOA, ±31.6 mL/min/100 g vs ±29.6 mL/min/100 g). Conclusion Caval subtraction phase-contrast MR imaging is a simple and clinically viable method for measuring TLBF and hepatic arterial flow. Online supplemental material is available for this article.

Establishment of liver transplantation model with improved two-cuff in rat

Objective To build rat orthotopic liver transplantation model and use this model as an experimental animal model for further research about liver transplantation. Methods Based on the classic two-cuff technique, a variety of skills were integrated,such as abdominal aorta perfusion first before ligation, suprahepatic inferior vena cava single continuous suture, preoperative and postoperative rehydration, hepatic portal vein and infrahepatic vena cava blocked by mosquito's haemostatic forceps. At last, the postoperative survival rates of 2 days and 2 weeks were recorded. Results Donors' operation time was (35±2) min, cuffing time was (7.0±1.5) min, receptors' operation time was (80±15) min, anhepatic phase was (21±3) min. The 2-day survival rate was 92 % (46/50) and 2-week survival rate was 86 % (43/50). Conclusion To some extent,the improved methods can not only reduce the difficulty of orthotopic liver transplantation operation, but also to create a uniform, stable and reliable orthotopic liver transplantation model. Key words: Liver tansplantation; Rats; Animal model

Technical and Anatomic Factors Influencing the Success of Inferior Vena Caval Stent Placement for Malignant Obstruction

PurposeTo evaluate the outcomes of inferior vena cava (IVC) stent placement for malignant obstruction and to identify anatomic and procedural factors influencing technical and clinical success. Materials and MethodsA total of 57 patients (37 male, 20 female; age range, 22–86 y) underwent 62 IVC stent placement procedures using 97 stents (47 Wallstents, 15 S.M.A.R.T. stents, 18 Wallflex stents, 17 others) from 2005 to 2016 for malignant IVC obstruction caused by hepatic metastases (n = 22; 39%), primary hepatic malignancy (n = 16; 28%), retroperitoneal metastases (n = 16; 28%), or other primary malignancy (n = 5; 9%). Presenting symptoms included lower-extremity edema (n = 54; 95%), ascites (n = 28; 50%), and perineal edema (n = 14; 25%). Sixteen percent (n = 10) and 10% (n = 6) of the procedures involved tumor and bland thrombus, respectively. ResultsStent placements resulted in 100% venographic patency and significantly decreased pressure gradients (P < .0001). Lower-extremity swelling, perineal swelling, and abdominal distension improved within 7 days in 83% (35 of 42), 100% (9 of 9), and 40% (6 of 15) of patients, respectively, and at 30 days after the procedure in 86% (25 of 29), 89% (8 of 9), and 80% (4 of 5) of patients, respectively. Increased pre- and post–stent placement pressure gradients were associated with worse outcomes. A 4% stent misplacement rate (4 of 97) was related to the use of Wallstents with caudal stent tapering, asymmetric deployment superior to the obstruction, suprahepatic IVC involvement, and decreased stent adherence to the IVC wall as a result of local mechanical factors. ConclusionsStent placement is reliable, rapid, and durable in improving malignant IVC syndrome. Understanding of technical and anatomic factors can improve accuracy and avoid complications of stent misplacement.

Suprahepatic inferior vena cava avulsion repair with total hepatic isolation using cardiopulmonary bypass. The end of the shrock shunt?

Suprahepatic inferior vena cava avulsion repair with total hepatic isolation using cardiopulmonary bypass. The end of the shrock shunt?

Association of factor V Leiden, Janus kinase 2, prothrombin, and MTHFR mutations with primary Budd-Chiari syndrome in Egyptian patients.

Budd-Chiari syndrome (BCS) is defined as obstruction of hepatic venous outflow anywhere from the small hepatic veins to the suprahepatic inferior vena cava. The pathogenesis of BCS is still not fully understood. This study aimed to evaluate the association of factor V Leiden (FVL), Janus kinase 2 (JAK2), prothrombin, and methylene tetrahydrofolate reductase (MTHFR) mutations with primary BCS. The study was carried out on 35 patients with primary BCS and 15 age and gender matched healthy individuals as a control group. Genotyping of FVL, prothrombin, and MTHFR mutations was determined by GENEQUALITY AB-THROMBO TYPE kit based on the reverse hybridization principle. JAK2 mutation was determined by polymerase chain reaction-restriction fragment length polymorphism. There was a statistically significant difference between patients and controls regarding FVL, MTHFR C677T, and MTHFR A1298C mutations with odds ratio of 1.83, 2.0, and 1.79, respectively. Hetero MTHFR C677T, hetero FVL, and hetero MTHFR A1298C were the most common etiological factors being responsible for 57.1, 42.9, and 42.9% of primary BCS cases, respectively. It could be concluded that BCS is a multifactorial disease; in the current study, MTHFR C677T mutation was the most common cause of disease. Identification of one cause of BCS should not eliminate investigations for detection of other etiological factors.

Membranous obstruction of hepatic Inferior Vena Cava: A rare finding in the workup of ascites and oedema

44 years old Caucasian female presented with new-onset ascites with extremity edema and work up indicated absence of hepatic, cardiac or hematologic diseases. Imaging suggested Budd-Chiari (Image 1), abdominal venography demonstrated a blunt occlusion of the Inferior Vena Cava (IVC) prior to junction with suprahepatic IVC (Image 2). Attempts to cannulate thick web-like segment with a Kumpe and Cobra style catheter over flexible Glidewire by femoral approach were unsuccessful. It was thus decided to position an endovascular snare at the level of the occlusion via jugular approach, a Kumpe catheter was advanced after carefully piercing the occlusion with the back end of a stiff Glidewire which was then snared successfully. Sequential balloon dilatation was then performed using 8/10/12, and 14 mm catheters. Post-completion venography showed no restriction to IVC flow and disappearance of collaterals (Image 2). She was started on anticoagulation with resolution of ascites and edema subsequently. Hepatic IVC obstruction remains a rare cause of hepatic outflow obstruction, and development of IVC collaterals may delay presentation. The diagnosis and prompt treatment can prevent development of advanced liver disease and portal hypertension. Endovascular treatment without stent placement has diverse long-term outcomes data, however is shown to be safe and well tolerated with no immediate technical complications i.e. embolization, bleeding, infection, or hematoma. Patients mostly require anticoagulation to prevent IVC thrombosis.

Hepatic venous outflow obstruction in piggyback liver transplantation: single centre experience.

Hepatic venous outflow obstruction (HVOO) is a rare but serious complication in liver transplantation (LT). We conducted a retrospective analysis of HVOO with venography and gradient measurement in consecutive LT from a single centre. Five hundred and six LTs were performed in 486 patients with a median age of 49 years (range 3 months to 71 years). Nineteen (3.8%) cases of HVOO were identified. Diagnosis was confirmed at a median of 26 days post-LT (1-2312). The incidence fell from 5.5% in the first 253 LT, to 2.0% in the second 253 (P = 0.03). Seventeen were due to narrowing at the anastomosis and two cases were due to thrombosis. In adult patients, reconstruction of the supra-hepatic donor inferior vena cava (IVC) onto two veins versus modified 2-3 hepatic veins did not alter the likelihood of HVOO. 17/19 cases were managed successfully by stenting or venoplasty. Two paediatric patients with early onset HVOO had attempted surgical thrombectomy, one was successful and the other required retransplantation. The incidence of HVOO appears to fall with increasing experience and does not appear to be related to the number of veins the donor IVC is anastomosed to in adult recipients.

The fate of human platelets exposed to porcine renal endothelium: a single-pass model of platelet uptake in domestic and genetically modified porcine organs

BackgroundThrombocytopenia may represent a significant challenge to the clinical application of solid-organ xenotransplantation. When studied in a pig-to-primate model, consumptive coagulopathy has challenged renal xenografts. New strategies of genetic manipulation have altered porcine carbohydrate profiles to significantly reduce human antibody binding to pig cells. As this process continues to eliminate immunologic barriers to clinical xenotransplantation, the relationship between human platelets and pig organs must be considered. MethodsGenetically modified pigs that were created by the CRISPR/Cas9 system with α-1,3-galactosyltransferase (GGTA1)−/− or GGTA1−/− cytidine monophosphate-N-acetylneuraminic acid hydroxylase−/− phenotype, as well as domestic pigs, were used in this study. Autologous porcine platelets were isolated from donor animal blood collection, and human platelets were obtained from a blood bank. Platelets were fluorescently labeled and in a single-pass model, human, or autologous platelets were perfused through porcine organs at a constant concentration and controlled temperature. Platelet uptake was measured by sampling venous output and measuring sample florescence against input florescence. In vitro study of the interaction between human platelets and porcine endothelial cells was accomplished by immunohistochemical stain and confocal microscopy. ResultsDifferences between human and autologous platelet loss through the porcine kidney were not significant in any genetic background tested (WT P = 0.15, GGTA1−/−P = 0.12, GGTA1−/− cytidine monophosphate-N-acetylneuraminic acid hydroxylase−/−P = 0.25). The unmodified porcine liver consumed human platelets in a single-pass model of platelet perfusion in fewer than 10 min. WT suprahepatic inferior vena cava fluoresce reached a maximum of 76% of input fluoresce within the human platelet cohort and was significantly lower than the autologous platelet control cohort (P = 0.001). Confocal microscopic analysis did not demonstrate a significant association between human platelets and porcine renal endothelial cells compared with porcine liver endothelial positive controls. ConclusionsOur results suggest that in the absence of immunologic injury, human platelets respond in a variable fashion to organ-specific porcine endothelial surfaces. Human platelets are not removed from circulation by exposure to porcine renal endothelium but are removed by unmodified porcine hepatic endothelium. Kidneys possessing genetic modifications currently relevant to clinical xenotransplantation failed to consume human platelets in an isolated single-pass model. Human platelets did not exhibit significant binding to renal endothelial cells by in vitro assay.

Comparison of Methods for the Reconstruction of the Hepatic Artery in Mouse Orthotopic Liver Transplantation.

BackgroundThe mouse model of arterialized orthotopic liver transplantation (AOLT) has played an important role in biomedical research. The available methods of sutured anastomosis for reconstruction of the hepatic artery are complicated, resulting in a high incidence of complications and failure. Therefore, we developed and evaluated a new model of AOLT in mice.Materials and methodsMale inbred C57BL/6 mice were used in this study. A continuous suture approach was applied to connect the suprahepatic inferior vena cava (SHVC). The portal vein and infrahepatic inferior vena cava (IHVC) were connected according to the "two-cuff" method. The common bile duct was connected by a biliary stent. We used the stent (G3 group) or aortic trunk (G2 group) to reconstruct the hepatic artery. The patency of the hepatic artery was verified by transecting the artery near the graft after one week. The survival rate of the recipients and serum alanine aminotransferase (ALT) levels, hepatic pathologic alterations, apoptosis and necrosis were observed at one week postoperatively.ResultsThe patency of the hepatic artery was verified in eight of ten mice in G3 and in six of ten mice in G2. The 7-day survival rate, extents of necrosis and apoptosis, and TGF-β levels were not significantly different among the three groups (P>0.05). However, the serum ALT levels and operation time were markedly lower in G3 compared with G2 or G1 (both P<0.05).ConclusionsReconstruction of the hepatic artery using a stent can be performed quickly with a high rate of patency. This model simplifies hepatic artery anastomosis and should be promoted in the field of biomedical research.

Reply

Potential conflict of interest: Nothing to report. Author names in bold designate shared co‐first authorship. We thank Dr. Qi et al. for their positive comments about our special article in Hepatology.1 Beyond the contents discussed in our paper, these authors mentioned the discrepancy and similarity in diagnosis and treatment of Budd‐Chiari syndrome (BCS) between Western countries and China. In particular, Qi et al. suggested that the difference in clinical characteristics and etiology may be associated with the choice of suitable treatment options for BCS. To better recognize how the discrepancy influences the outcome of disease progression and treatment efficacy, there is an urgent need to strengthen translational study on liver diseases including BCS between China and Western countries. Budd‐Chiari syndrome is a rare, heterogeneous, and potentially fatal disease associated with the occlusion of hepatic veins and/or the suprahepatic inferior vena cava.2 There is a distinct geographic variation in BCS incidence between Asia and Western countries, being only lower than 1 to 2 per million inhabitants in Western countries.3 Over the past decades BCS has been frequently reported in China; however, national data on incidence and prevalence of BCS in the Chinese population are not available. The literature reports that BCS is more frequent in Henan, Shandong, Jiangsu, and Anhui Provinces in the Yellow River valley compared to other regions in China.5 The clinical characteristics and etiology of BCS patients in China are similar to those of patients in India and Nepal but significantly different from those of Western patients.3 Idiopathic forms, combined membranous occlusion of the inferior vena cava and the hepatic veins, and higher incidence of hepatocellular carcinoma are typical features of most Chinese BCS patients.5 In addition, selection of treatment modalities for BCS patients is different between China and Western countries.3 Chinese patients with BCS are usually treated using percutaneous transluminal angioplasty and have a similar good clinical outcome to Western patients, who often are treated with transjugular intrahepatic portosystemic shunt plus long‐term anticoagulants.9 As an update, there have been around 3000 articles on BCS in China, but the real prevalence might be higher than estimated due to increased awareness and improved diagnostic methods in China. However, duplicate publications about BCS in China both in English‐language journals and in Chinese‐language journals are relatively common.11 We should pay more attention to this situation in meta‐analyses and systemic reviews of this syndrome.

Living-Donor Liver Transplantation for Budd-Chiari Syndrome—Resection and Reconstruction of the Suprahepatic Inferior Vena Cava With the Use of Cadaveric Aortic Allograft: Case Report

BackgroundLiving-donor liver transplantation with inferior vena cava resection and reconstruction is rarely indicated for Budd-Chiari syndrome. The aim of this case presentation was to present and discuss the inferior vena cava reconstruction with the use of cadaveric aortic allograft after resection of the suprahepatic inferior vena cava in a patient with Budd-Chiari syndrome who was treated with living-donor liver transplantation. Case ReportA 29-year-old male patient with end-stage liver disease and suprahepatic inferior vena cava obstruction was referred to our center. He was scheduled for living-donor liver transplantation. The suprahepatic inferior vena cava was resected and reconstruction was achieved by means of interposition of the cadaveric aortic allograft between the right atrium and inferior vena cava. Postoperative course was uneventful. DiscussionLiver transplantation and vena cava reconstruction is indicated in some patients with end-stage liver disease and Budd-Chiari syndrome. Limitations in cadaveric organ donation may be compensated for with the use of living-donor liver. In this condition, various aspects of inferior vena cava reconstruction may be discussed. ConclusionsBudd-Chiari syndrome due to suprahepatic inferior vena cava obstruction close to the right atrium may be treated with vascular reconstruction with the use of a cadaveric aortic allograft.

Preoperative multivariable prognostic models for prediction of survival and major complications following surgical resection of renal cell carcinoma with suprahepatic caval tumor thrombus

ObjectiveSurgical resection for renal cell carcinoma (RCC) with suprahepatic inferior vena cava tumor thrombus is associated with significant morbidity, yet there are currently no tools for preoperative prognostic evaluation. Our goal was to develop a preoperative multivariable model for prediction of survival and risk of major complications in patients with suprahepatic thrombi. MethodsWe identified patients who underwent surgery for RCC with suprahepatic tumor thrombus extension from 2000 to 2013 at 4 tertiary centers. A Cox proportional hazard model was used for analysis of overall survival (OS) and logistic regression was used for major complications within 90 days of surgery (Clavien≥3A). Nomograms were internally calibrated by bootstrap resampling method. ResultsA total of 49 patients with level III thrombus and 83 patients with level IV thrombus were identified. During median follow-up of 24.5 months, 80 patients (60.6%) died and 46 patients (34.8%) experienced major complication. Independent prognostic factors for OS included distant metastases at presentation (hazard ratio = 2.52, P = 0.002) and Eastern Cooperative Oncology Group (ECOG) performance status (hazard ratio = 1.84, P<0.0001). Variables associated with increased risk of major complications on univariate analysis included preoperative systemic symptoms, level IV thrombus, and elevated preoperative alkaline phosphatase and aspartate transaminase levels; however, only systemic symptoms (odds ratio = 8.45, P<0.0001) was an independent prognostic factor. Preoperative nomograms achieved a concordance index of 0.72 for OS and 0.83 for major complications. ConclusionsWe have developed and internally validated multivariable preoperative models for the prediction of survival and major complications in patients with RCC who have a suprahepatic inferior vena cava thrombus. If externally validated, these tools may aid in patient selection for surgical intervention.

Use of Cardiac Magnetic Resonance Imaging Based Measurements of Inferior Vena Cava Cross-Sectional Area in the Diagnosis of Pericardial Constriction

PurposeTo evaluate the value of cardiac magnetic resonance imaging (MRI)–based measurements of inferior vena cava (IVC) cross-sectional area in the diagnosis of pericardial constriction. MethodsPatients who had undergone cardiac MRI for evaluation of clinically suspected pericardial constriction were identified retrospectively. The diagnosis of pericardial constriction was established by clinical history, echocardiography, cardiac catheterization, intraoperative findings, and/or histopathology. Cross-sectional areas of the suprahepatic IVC and descending aorta were measured on a single axial steady-state free-precession (SSFP) image at the level of the esophageal hiatus in end-systole. Logistic regression and receiver-operating curve (ROC) analyses were performed. ResultsThirty-six patients were included; 50% (n = 18) had pericardial constriction. Mean age was 53.9 ± 15.3 years, and 72% (n = 26) were male. IVC area, ratio of IVC to aortic area, pericardial thickness, and presence of respirophasic septal shift were all significantly different between patients with constriction and those without (P < .001 for all). IVC to aortic area ratio had the highest odds ratio for the prediction of constriction (1070, 95% confidence interval [8.0-143051], P = .005). ROC analysis illustrated that IVC to aortic area ratio discriminated between those with and without constriction with an area under the curve of 0.96 (95% confidence interval [0.91-1.00]). ConclusionsIn patients referred for cardiac MRI assessment of suspected pericardial constriction, measurement of suprahepatic IVC cross-sectional area may be useful in confirming the diagnosis of constriction when used in combination with other imaging findings, including pericardial thickness and respirophasic septal shift.

PD35-11 PREOPERATIVE MULTIVARIABLE PROGNOSTIC MODELS FOR PREDICTION OF SURVIVAL AND MAJOR COMPLICATIONS FOLLOWING SURGICAL RESECTION OF RENAL CELL CARCINOMA WITH SUPRAHEPATIC CAVAL TUMOR THROMBUS

Objective: Surgical resection for renal cell carcinoma (RCC) with suprahepatic inferior vena cava tumor thrombus is associated with significant morbidity, yet there are currently no tools for preoperative prognostic evaluation. Our goal was to develop a preoperative multivariable model for prediction of survival and risk of major complications in patients with suprahepatic thrombi. Methods: We identified patients who underwent surgery for RCC with suprahepatic tumor thrombus extension from 2000 to 2013 at 4 tertiary centers. A Cox proportional hazard model was used for analysis of overall survival (OS) and logistic regression was used for major complications within 90 days of surgery (Clavien Z3A). Nomograms were internally calibrated by bootstrap resampling method. Results: A total of 49 patients with level III thrombus and 83 patients with level IV thrombus were identified. During median follow-up of 24.5 months, 80 patients (60.6%) died and 46 patients (34.8%) experienced major complication. Independent prognostic factors for OS included distant metastases at presentation (hazard ratio 1⁄4 2.52, P 1⁄4 0.002) and Eastern Cooperative Oncology Group (ECOG) performance status (hazard ratio 1⁄4 1.84, P o 0.0001). Variables associated with increased risk of major complications on univariate analysis included preoperative systemic symptoms, level IV thrombus, and elevated preoperative alkaline phosphatase and aspartate transaminase levels; however, only systemic symptoms (odds ratio 1⁄4 8.45, P o 0.0001) was an independent prognostic factor. Preoperative nomograms achieved a concordance index of 0.72 for OS and 0.83 for major complications. Conclusions: We have developed and internally validated multivariable preoperative models for the prediction of survival and major complications in patients with RCC who have a suprahepatic inferior vena cava thrombus. If externally validated, these tools may aid in patient selection for surgical intervention. r 2015 Elsevier Inc. All rights reserved.

Difficulty in Diagnosis of Leiomyosarcoma of Infrahepatic Inferior Vena Cava

Background: Leiomyosarcomas of inferior vena cava (IVC) are rare tumors that mostly are proposed as a primary malignancy of the IVC. The optimal treatment is completely resects the malignant lesion with preservation of venous return. According to the treated experience of one patient in our hospital, we present our opinions as below. Methods and Results: A 61-year-old woman underwent successful surgical treatment for a leiomyosarcoma with the method of infrahepatic inferior vena cava (IVC). A large tumor that was demonstrated in the Spiegel lobe liver with IVC tumor thrombus was imagined by tomography and magnetic resonance. The tumor was found from IVC, which was performed by suprahepatic and infrahepatic IVC occlusion with Satinskys clamp in the operation. The patient underwent a combined operation which is en bloc resection of the IVC tumor and lobotomy of the left lateral section of liver. Pathological examination confirmed that is primary leiomyosarcoma of the IVC. The patient had a normal live for nearly one year and no recurrence. Conclusion: It is difficult to distinguish leiomyosarcoma from a hepatic tumor. About two thirds of these patients were confirmed as the diagnosis of leiomyosarcomas only after laparotomy. The misdiagnosis to be considered as tumor arising from segment I of the liver with IVC tumor thrombus was lead to the tumor to predominant intra-luminal growth. Radical surgical en bloc resection is the mainly treatment for IVC leiomyosarcomas. Using suprahepatic IVC and infrahepatic IVC occlusion with Satinsky clamp, surgical management of an infrahepatic IVC leiomyosarcoma is a simple vascular surgical techniques.

Ante-situm resection: a novel approach to avoid extracorporeal circulation using a transient portacaval shunt

Hepatic tumours located at the hepatocaval confluence or compromising the inferior vena cava (IVC) are not often resectable using conventional techniques. To overcome this problem, different surgical procedures have been described. Ex-vivo resection techniques provide excellent accessibility to tumours placed around the IVC that otherwise would be unresectable. These ex-vivo techniques include in-situ, ante-situm and ex-situ resections. The in-situ technique performs hypothermic perfusion of the liver, with cross-clamping but without sectioning of the vena cava and the hepatic pedicle. The ante-situm approach also includes hypothermic perfusion, with cross-clamping of the major vessels and division of the suprahepatic IVC for complete exposure of the liver, preserving the hepatic artery and biliary tree. And finally, the ex-situ technique requires cross-clamping and division of the major vessels for complete removal of the liver, allowing a bench procedure before re-implantation of the organ. The two main problems regarding ex-vivo procedures are the low hepatic tolerance to warm ischaemia and the splanchnic congestion secondary to vascular exclusion. Hypothermic hepatic perfusion and veno-venous bypasses, frequently used in classic ex-vivo resections, are two well-known strategies to avoid these complications. This report describes a novel technique of ante-situm resection using an in-vivo veno-venous bypass between the portal vein and the IVC with a cadaveric venous graft in a patient with IVC replacement. Case

Suprahepatic Inferior Vena Cava and Internal Jugular Vein Thrombosis: A Rare Complication Of Pancreatitis: Case Report

Vascular thrombosis of portal veins and splenic vein due to pancreatitis has been described. Involvement of suprahepatic inferior vena and internal jugular vein is a rare complication of acute pancreatitis. Here we report a case of suprahepatic inferior vena cava thrombosis and internal jugular vein thrombosis in an alcoholic patient presented with acute pancreatitis.

Refractory Hypoxemia in a 23-Year-Old Patient With Budd-Chiari Syndrome

Antiphospholipid syndrome is an autoimmune disorder characterized by a hypercoagulable state, leading to arterial and venous thrombosis. We present a 23-year-old patient, suspected of having Budd-Chiari syndrome due to antiphospholipid syndrome, who developed severe and progressive hypoxemia, requiring prolonged mechanical ventilation. After a detailed but unsuccessful workup, a contrast CT scan revealed an occluded superior vena cava and azygos vein-superior vena cava junction and massive right-to-left shunting through a network of systemic to pulmonary venous collaterals. Restoring normal blood flow from the azygos vein into the right atrium by stenting the azygos-superior vena cava junction resolved the hypoxemia immediately. Within the same procedure, the hepatic outflow obstruction was successfully treated by stenting a severe stenosis of the suprahepatic inferior vena cava caused by calcified thrombus.