Thrombus Extension Research Articles

PD07-09 ADRENOCORTICAL CARCINOMA WITH VENOUS TUMOR INVASION. IS THERE A ROLE FOR MINI-INVASIVE SURGERY?

You have accessJournal of UrologyAdrenal (PD07)1 Sep 2021PD07-09 ADRENOCORTICAL CARCINOMA WITH VENOUS TUMOR INVASION. IS THERE A ROLE FOR MINI-INVASIVE SURGERY? Alberto Olivero, Kan Liu, Enrico Checcucci, Lei Liu, Lulin Ma, Guoliang Wang, Guglielmo Mantica, Stefano Tappero, Daniele Amparore, Michele Sica, Cristian Fiori, Quingbo Huang, Shaoxi Niu, Baojun Wang, Xin Ma, Xiaofei Hou, Francesco Porpiglia, Carlo Terrone, and Xu Zhang Alberto OliveroAlberto Olivero More articles by this author , Kan LiuKan Liu More articles by this author , Enrico CheccucciEnrico Checcucci More articles by this author , Lei LiuLei Liu More articles by this author , Lulin MaLulin Ma More articles by this author , Guoliang WangGuoliang Wang More articles by this author , Guglielmo ManticaGuglielmo Mantica More articles by this author , Stefano TapperoStefano Tappero More articles by this author , Daniele AmparoreDaniele Amparore More articles by this author , Michele SicaMichele Sica More articles by this author , Cristian FioriCristian Fiori More articles by this author , Quingbo HuangQuingbo Huang More articles by this author , Shaoxi NiuShaoxi Niu More articles by this author , Baojun WangBaojun Wang More articles by this author , Xin MaXin Ma More articles by this author , Xiaofei HouXiaofei Hou More articles by this author , Francesco PorpigliaFrancesco Porpiglia More articles by this author , Carlo TerroneCarlo Terrone More articles by this author , and Xu ZhangXu Zhang More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001975.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Venous invasion(VI) from adrenocortical carcinoma(ACC) is a rare presentation of a very rare malignancy and is a poor prognostic feature. There is limited evidence in the treatment of advanced adrenal carcinoma using a mini-invasive(MI) approach. This study aims is to investigate early oncologic outcomes in patients with ACC with VI accordingly to the surgical approach applied. METHODS: We conducted a retrospective analysis of 4 international referral centers databases, including all the patients undergoing Adrenalectomy for ACC with VI from 2007 to March 2020. Patients’ demographics, lesion characteristics, perioperative, pathology, and oncological data were analyzed. From the preoperative imaging, we classified the thrombus invasion in 4 levels: 1 Adrenal vein invasion; 2 Renal vein invasion; 3 infra-hepatic IVC; 4 retro-hepatic IVC. We divided our patients into 2 groups: patients undergone open surgery and patients treated with MI surgery. A Kaplan–Meier plot was used to describe the disease-free(DFS) and overall survival(OS) between the groups. RESULTS: We identified 20 patients with a median follow-up of 12 months. Nine were male with a median age of 51 years. Nine patients (45%) presented a right disease. The median tumor size was 110 mm. ENSAT stage was II in 4 patients, III in 13 patients, and IV in 3 patients. Tumor thrombus extended in the adrenal vein(n=5), renal vein(n=1), infra-hepatic IVC(n=9) or into the retro-hepatic IVC(n=5). Ten patients were treated with MI approach (5 robotic and 5 laparoscopic). A worse disease was reported in the open group. The two groups did not differ in terms of surgical margins, surgical time, blood losses, complications, and length of stay. Accordingly to the more aggressive disease, the prognosis was worse in the open group. Full patients’ characteristics and outcomes are reported in the Table.Kaplan-Meier analysis indicated a difference in OS for the patients stratified by ENSAT stage (p=0.011), we also reported a difference in DFS for patient stratified for thrombus extension(p=0.004) and ENSAT stage(p <0.001). CONCLUSIONS: The DFS of patients with VI from ACC is influenced by the staging and the extension of the venous invasion; the OS is influenced by the staging. The MI approach seems to be feasible and safe in selected patients without influence oncological outcomes. Source of Funding: - © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e108-e109 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alberto Olivero More articles by this author Kan Liu More articles by this author Enrico Checcucci More articles by this author Lei Liu More articles by this author Lulin Ma More articles by this author Guoliang Wang More articles by this author Guglielmo Mantica More articles by this author Stefano Tappero More articles by this author Daniele Amparore More articles by this author Michele Sica More articles by this author Cristian Fiori More articles by this author Quingbo Huang More articles by this author Shaoxi Niu More articles by this author Baojun Wang More articles by this author Xin Ma More articles by this author Xiaofei Hou More articles by this author Francesco Porpiglia More articles by this author Carlo Terrone More articles by this author Xu Zhang More articles by this author Expand All Advertisement Loading ...

Endovenous microfoam ablation of below knee superficial truncal veins is safe and effective in patients with prior saphenous treatment across a wide range of CEAP classes

ObjectivePatients requiring thermal or chemical ablation of below knee (BK) truncal veins often have their proximal saphenous veins treated initially and comprise a study population with multilevel, refractory chronic venous insufficiency. The study objective was to assess the outcomes after microfoam ablation of BK truncal and tributary veins in patients with a history of proximal great saphenous vein (GSV) ablation or stripping. MethodsA retrospective review of a prospectively maintained database was performed. All the patients who had undergone endovenous chemical ablation with commercially manufactured polidocanol microfoam for symptomatic BK truncal vein reflux after a previous saphenous ablation or stripping were identified. The patients had undergone duplex ultrasound scanning 48 to 72 hours after the procedure; those who had not adhered to the recommended follow-up protocol were excluded. The demographic data, CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, venous clinical severity score (VCSS), procedure details, adverse thrombotic events, and follow-up data were abstracted. ResultsBetween April 2018 and April 2021, 201 limbs were treated for symptomatic superficial truncal vein reflux with microfoam ablation. Of the 201 limbs, 68 in 49 patients met the inclusion criteria for the present study. The veins treated included the BK GSV (n = 45) and small saphenous vein (n = 23). The median follow-up was 97 days (range, 33-457 days) for the entire cohort. Most patients (63%) had a preoperative CEAP classification of C4 to C6. The median preoperative VCSS was 12.5. All the limbs that had undergone microfoam ablation in this cohort had a previously treated proximal ipsilateral GSV, with either thermal ablation or stripping. The median postoperative VCSS after BK treatment decreased to 10 (P < .001). The closure rate at the last follow-up was 96%. The overall symptomatic relief was 78% at the last follow-up. The absolute ulcer healing rate during the study period was 64% (16 of 25 ulcers had healed). One patient had developed thrombus extension into the popliteal vein, which resolved with anticoagulation therapy. One asymptomatic patient had developed nonocclusive thrombus in a gastrocnemius vein after small saphenous vein ablation. Because she was asymptomatic, anticoagulation therapy was not prescribed. Postoperative pain, phlebitis, and swelling were reported in 12%, 12%, and 2% of patients, respectively, and all had resolved at the last follow-up visit. Three limbs treated with chronic oral anticoagulant agents had had recanalized truncal veins during the study period after initial closure. No pulmonary emboli or neurologic adverse events were reported. No symptoms of saphenous or sural nerve injury had occurred. ConclusionsEndovenous chemical ablation with commercially manufactured polidocanol microfoam of BK truncal veins is a safe and effective treatment for patients with severe, refractory chronic venous insufficiency and prior saphenous interventions. This technique results in excellent overall closure rates and symptomatic relief with low adverse venous thrombotic events, across a wide range of CEAP classes.

Risk of Deep Venous Thrombosis With the Use of Foamed Sclerosant for Symptomatic Superficial Venous Insufficiency

Thrombus extension from the superficial to the deep system during thermal ablation is well-described; however, treatment paradigms remain controversial. There is limited published data on the incidence of deep venous thrombosis (DVT) when utilizing foamed sclerosant for the treatment of superficial and perforator venous reflux. The purpose of this study is to report outcomes with foam sclerotherapy at our institution. We also aimed to compare the incidence of DVT with precompounded or physician compounded foam sclerotherapy.

Vena Cava Tumor Thrombus Associated With Renal Angiomyolipoma in a Jehovah's Witness Patient

We present a case of a young premenopausal female patient who was found to have a left-sided renal mass consistent with angiomyolipoma (AML) with Mayo Level IIIa vena caval tumor thrombus. The patient is of Jehovah's witness faith and would not accept blood transfusion. The following case report discusses workup and treatment for AML with tumor thrombus extension, as well as pre-operative optimization and intra-operative techniques during nephrectomy and thrombectomy to minimize blood loss in a patient unaccepting of blood transfusion.

Radical nephrectomy and vena caval thrombectomy with the use of cardiopulmonary bypass and hypothermic circulatory arrest: Experience at a large tertiary institution

Objective: This study aimed to review the experience at a large regional tertiary centre of open radical nephrectomy (RN) with vena caval thrombectomy with cardiopulmonary bypass (CPB) and hypothermic circulatory arrest (HCA) for the management of renal masses. Method: Data on patients with renal masses who had undergone RN and vena caval thrombectomy with CPB and HCA had been prospectively collected at two centres over a 19-year period (2000–2019). Twenty-three consecutive patients were identified and retrospectively analysed for operative and tumour characteristics and for postoperative outcome. Kaplan–Meier survival analysis was performed to compare patient outcomes based on tumour characteristics. Results: Median operating time was 358 minutes (interquartile range (IQR)=94 minutes), median bypass time was 117 minutes (IQR=28.5 minutes) and median circulation arrest time was 25 minutes (IQR=18.5 minutes). The median hospital length of stay was 11 days (IQR=5.3 days). Total complication rate was 52% ( n=12), consisting of four minor and eight major complications (Clavien–Dindo score &gt;IIIa), including one intraoperative death. The overall five-year survival rate was 73% (11/15), with a median follow-up time of 53.1 months. Eleven (48%) patients were surgically cured, with a median follow-up time of 60.1 months (IQR=71.8 months). Disease recurrence was seen in eight (35%) patients, of whom four died. Patients who died survived for a median of 46.5 months. Median survival after the diagnosis of metastatic disease was seven months. Conclusions: We report the largest Australian cohort of RN with vena caval thrombectomy with CPB and HCA. We demonstrate outcomes comparable to major overseas centres, with an overall five-year survival rate of 73%. This suggests that even patients with extensive venal caval thrombus from renal masses can experience long-term survival benefit from RN and venal caval thrombectomy. Level of evidence: Level 3.

Catheter-Directed Thrombolysis for Acute Deep Vein Thrombosis: Experience from a Canadian Thrombosis Referral Centre

BACKGROUNDConventional management strategies for DVT with parenteral and/or oral anticoagulants are effective in the prevention of thrombus extension and embolization but do not actively eliminate thrombus. This poses ongoing risk of injury to the venous valves and consequently development of the post-thrombotic syndrome (PTS). Catheter-directed thrombolysis (CDT) involves the local delivery of a low dose of thrombolytic agent directly to the venous thrombus, resulting in acute reduction in clot burden while limiting the systemic thrombolytic effect.Recommendations from clinical practice guidelines differ dramatically on the use of CDT for lower limb DVTs. Results from recent prospective randomized control trials suggest that those individuals who derive benefit must be carefully selected. We describe the clinical features and outcomes of patients who received CDT for lower limb DVT management at a major referral centre for thromboembolic disease. Additionally, cross-sectional follow-up of these patients was performed to estimate the incidence and severity of PTS.METHODSWe conducted a retrospective cohort analysis on all adult patients who had undergone CDT for lower limb DVT management at St. Joseph's Healthcare Hamilton (SJHH), ON, Canada. Retrospective data were collected through use of electronic and chart-based medical records. The presence and severity of PTS was measured using the Villalta scale.RESULTSFrom 2011 to 2016, 15 patients underwent CDT at SJHH (Table 1).12/15 patients were female. Average patient age was 43.2 years (range 20 to 86 years). All patients had risk factors for venous thromboembolism (VTE); 7/15 patients had 2 risk factors. The most commonly identified transient risk factor was use of the oral contraception pill (5/15). May Thurner syndrome (5/15) was the most common permanent VTE risk factor. All patients were deemed to be at low risk of bleeding (platelets > 100,000, INR < 1.6, no known bleeding diathesis).All patients had DVTs that were iliofemoral in location; 2/15 presented with phlegmasia cerulea dolens. The average time between DVT diagnosis to CDT was 6.5 days. Prophylactic IVC filters were inserted prior to CDT in 3/15 patients. Pharmacomechanical thrombolysis with angioplasty was the most common form of CDT (6/15 patients).Complications from CDT were seen in 8/15 patients (Table 2). Recurrent VTE (3/15) and neurologic deficits in the affected leg (3/15) were the most common complications. There were no deaths attributable to CDT. All patients were managed with anticoagulant therapy post-procedure. The type and duration of anticoagulation was variable (Table 2). The Villalta score was calculated for 6/15 patients. Mild PTS was seen in 4/6 patients; 2/6 did not have PTS (average Villalta score 5.83).CONCLUSIONSCatheter-directed thrombolysis appears to be a well-tolerated treatment option for iliofemoral DVT. Complications were seen in 53% of patients and were frequently mild and self-resolving. The results of our study suggest that patients under 45 years of age who receive prompt thrombolysis, within 7-14 days of DVT diagnosis, are most likely to derive benefit from CDT. The clinical characteristics of patients described here are largely in accordance with those recommended by the 2016 CHEST guidelines.Due to the limited sample size in our study, it is unclear if CDT is beneficial in reducing rates of PTS. Additional studies are needed to clarify potential risks and benefits of this treatment approach. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

P0628 - Radical nephrectomy and caval thrombectomy with heart beating technique for renal cell cancer with tumor thrombus extension into inferior vena cava and right atrium: A less invasive multidisciplinary approach

P0628 - Radical nephrectomy and caval thrombectomy with heart beating technique for renal cell cancer with tumor thrombus extension into inferior vena cava and right atrium: A less invasive multidisciplinary approach

A Cardiac Approach to Wilms Tumor with Tumor Thrombus Extension to the Right Atrium Without Cardiopulmonary Bypass: A 5-Year Follow-up

Introduction: Wilms tumor is the most common kidney cancer in children, but Wilms's tumors that extend by direct intravascular spread into the right side of the heart are rare and at this stage, they require the cardiac surgeons’ intervention. Case Presentation: The patient was a 2-year-old girl who was hospitalized due to fever and abdominal pain that had started 2 weeks before admission. Patient’s full abdominal exams revealed a large mass in the right kidney with a thrombus tumor in the entire inferior vena cava which was extended into the right atrium. Patient completed 8 weeks of neoadjuvant chemotherapy. After chemotherapy no changes was noted in renal mass and tumor thrombus. As, the thrombosis in the atrium was loose and there was a high risk of pulmonary embolism, emergency surgery was needed. Two pediatric and cardiac teams, simultaneously performed the surgery without cardiopulmonary bypass and cardiac arrest. Both kidney mass and the thrombus tumor were completely removed. Patient followed up for 5 years after surgery and no surgical complications, tumor recurrence, or metastasis were observed during that period. Conclusions: Although surgical intervention and tumor resection leads to good prognosis, multimodality management and multidisciplinary approach gives the best results.

Should Deferred Stenting Still Be Considered in ST-Elevation Myocardial Infarction with High Thrombus Burden?

Patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) may demonstrate distal microvascular embolization of thrombotic materials. We retrospectively examined 20 cases displaying extensive thrombus in the infarct-related artery (IRA), treated either with a two-step procedure, with interim tirofiban infusion, or immediate stent implantation. Distal embolization tended to be more common in the latter strategy, but, overall, the outcome was comparable. Thus, a two-staged procedure may be considered in selected cases of primary PCI associated with high thrombus burden.

Biochemical Endothelial Injury and Platelets Activation Detectionin Endovenous Laser Ablation of Varicose Veins

Background: Thrombus formation and extension to femoral or popliteal veins and pulmonary embolism may be though as a complication of EVLT in varicose veins treatment we aimed to study the thermal energy effect of the procedure under standardized conditions on biochemical markers of platelets and endothelium activities. Patients and methods: 25 patients admitted to vascular surgery dept. of Alexandria armed forces hospital with varicose veins and GSV. reflux and all treated by endovenous laser ablation during: 1/1/2018_12/31/2018. Venous blood samples were taken from iliofemoral and antecubital veins, before during and one day after surgery of P-selectin, soluble thrombomodulin, fibrin degradation products and D-dime Results: There was no immediate rise of P-selectin and s TM in neither iliofemoral nor antecubital veins, where FDPs D-dimer was significantly elevated post operatively in the two regions. Conclusion: 1480 pulsed mode diode laser doesn’t induce measurable endothelial and platelets activation in iliofemoral region during endovenous ablation of varicose veins.

Pituitary Lymphoma Presenting as Diabetes Insipidus

Introduction: Primary CNS lymphomas are rare accounting for 1-3% of CNS neoplasms. They lack specific clinical or radiological features and are diagnosed histologically. We describe a case of Primary CNS lymphoma involving pituitary gland presenting with confusion and diabetes insipidus. Case: 74-year-old presented with anorexia, weight loss, visual hallucinations and acute confusion. Initial evaluation revealed hypernatremia (148 mmol/L), an old cerebral infarct and new extensive thrombus in aorta and lower limb deep vein thrombosis. During hospital stay, he sustained a fall and a CT head showed a new high attenuation change around the temporal horn and left temporal lobe. MRI head was done to characterize the lesion but because of confusion and irritability, this was inconclusive. Patient continued to have hypernatremia with serum sodium ranging from 148 - 154 mmol/L (135-145 mmol/L) that failed to improve after rehydration. He continued to have negative fluid balance and urine output >2.5 litres a day with dilute urine and urine osmolarity of 134 mosm/L. Due to confusion, we were unable to conduct a water deprivation test. Anterior pituitary profile was consistent with secondary hypothyroidism (TSH was 0.09 (0.02-6.00), Free T4 8.2 (8.0-18.0) and (Free T3 was 2.8 (3.0- 4.8)), and secondary hypogonadism (Testosterone 0.9 nmol/L (6.1-27.1), FSH 1.0 IU/L and LH was <0.2 IU/L). Hypothalamic- adrenal axis was intact as cortisol showed adequate increment after corticotropin stimulation (Cortisol at 0 min 386 nmol/L, 30 minutes 584 nmol/L and 60 minutes 640 nmol/L). Further CT Head with contrast was carried out in view of new findings of hypopituitarism that showed smooth hyperattenuating pituitary gland that was consistent with diabetes insipidus and intense contrast enhancement seen in the periventricular regions and the caudate and dentate nuclei bilaterally. Based on clinical and radiological picture, diagnosis of CNS lymphoma and diabetes insipidus was made and commenced on desmopressin nasal spray. We were unable to perform brain biopsy or quantify the response to desmopressin due to rapid deterioration of patient who died 9 weeks after his initial presentation. An autopsy was carried out and histopathology of pituitary yielded normal anterior pituitary but posterior pituitary was completely infiltrated by Non-Hodgkin’s Lymphoma of Diffuse large B cell type that was also infiltrating parts of the cerebellum, temporal cortex and the basal ganglia hence proving diagnosis of Primary CNS lymphoma. Conclusion: Sudden onset of DI with pathological appearance of posterior pituitary and equivocal/non diagnostic CNS imaging should raise the suspicion of CNS lymphoma. Although diagnosis is histopathological, early detection with high index of suspicion and treatment and lead to better outcomes.

“The Way to a Man’s Heart” - Adrenocortical Carcinoma With Vascular Invasion Into the Right Atrium and Ventricle

Abstract Background: Adrenocortical carcinoma (ACC) is a rare aggressive malignant neoplasm which may present with intravascular extension into the inferior vena cava (IVC) and rarely into the right atrium (RA). Clinical Case: 62-year-old male with no prior known significant medical history presented to ED with 2-day history of mild hematuria with 3-week history of headache. Vital signs were normal other than blood pressure of 198/88 while physical exam was unremarkable. Headache subsided and blood pressure improved to 130/60 range after IV labetalol administration. CT abdomen and pelvis with contrast revealed a large right suprarenal mass extending into the right hepatic vein, IVC, and RA. The right adrenal gland was not visualized while the left adrenal gland and bilateral kidneys were normal. MRI chest, heart and abdomen with contrast showed heterogeneously enhancing lobulated right adrenal mass measuring 11.4 x 11 x 14 cm (AP, transverse, CC, respectively) with extensive tumor thrombus invading the right hepatic vein, IVC, RA and notably protruding into the right ventricle (RV) through the tricuspid valve during diastole. Technitium-99m MDP whole body scan did not show any uptake suspicious for metastases. Pre-op lab assessment showed mildly abnormal 1 mg dexamethasone suppression test but no evidence of ACTH suppression, elevated catecholamines or excess adrenal steroidogenesis. He underwent combined cardiothoracic and abdominal surgery on cardiopulmonary bypass with resection of adrenal mass, removal of thrombus from IVC, RA, RV and patch angioplasty of IVC with bovine pericardium. Pathology report was consistent with ACC (AJCC stage III). On 1 month postoperative follow-up, patient is clinically doing well with plans to start mitotane with addition of etoposide/doxorubicin/cisplatin (EDP) chemotherapy. Conclusion: ACC is a rare, highly aggressive malignancy which may produce extensive intravascular invasion. It may rarely extend to the RA and even rarer into the RV; with 42 and 1 reported cases, respectively. No study has conclusively found that vascular extension of ACC is a poor prognostic factor, hence surgical management is the primary strategy including cases with RA/RV involvement. There is lack of data and consensus regarding adjuvant or palliative medical therapy. However, in phase II trials combination of EDP chemotherapy and mitotane have shown response rates ranging from 11% to 54%. Reference: Alghulayqah, Abdulaziz, et al. “Long-term recurrence-free survival of adrenocortical cancer extending into the inferior vena cava and right atrium: Case report and literature review.” Medicine 96.18 (2017).

Role of the Laparoscopic Approach for Complex Urologic Surgery in the Era of Robotics.

(1) Introduction: The advent of robotic surgery led to the assumption that laparoscopic surgery would be replaced entirely. However, the high costs of robotic surgery limit its availability. The aim of the current study was to assess the feasibility of the 3D laparoscopic approach for the most complex urological procedures. (2) Materials and methods: We included in the current study all patients who had undergone complex 3D laparoscopic procedures in our department since January 2017, including radical nephrectomy (LRN) using a dual combined approach (19 patients), radical nephroureterectomy (LRNU) with bladder cuff excision (13 patients), and radical cystectomy (LRC) with intracorporeal urinary diversion (ICUD) (21 patients). (3) Results: The mean operative time was 345/230/478 min, the complications rate was 26%/30.76%/23.8% and positive surgical margins were encountered in 3/1/1 patients for the combined approach of LRN/LRNU/LRC with ICUD, respectively. A single patient was converted to open surgery during LRN due to extension of the vena cava thrombus above the hepatic veins. After LRC, sepsis was the most common complication and 8 patients were readmitted at a mean of 15.5 days after discharge. (4) Conclusions: In the era of robotic surgery, laparoscopy remains a plausible alternative for most complex oncological cases.

Pulmonary Embolism and Wilms’ Tumor. Can It Be Any Worse? Case Report

It is common for Wilms tumor to invade the inferior vena cava and right atrium, but a massive pulmonary embolism is rare. This case report describes an 8-year-old male patient who presented to an outpatient clinic with mild pain associated with subjective fever for 1 week. A left renal mass with extension of an inferior vena cava thrombus was seen on abdominal computed tomography, suggesting a Wilms tumor. An exploratory laparotomy biopsy was scheduled, but not completed because the patient’s health suddenly deteriorated, and he died despite high-quality cardiopulmonary resuscitation. A massive pulmonary embolism was found to cause a sudden and fatal cardiac arrest.&#x0D;

Thrombus Extension after Great Saphenous Vein Mechanochemical Ablation

BackgroundThe objective of this study is to examine factors associated with thrombus extension after early experience with mechanochemical ablation, which combines mechanical damage to the venous endothelium with infusion of a sclerosant. MethodsA retrospective review was performed of patients who underwent mechanochemical ablation to treat saphenous vein insufficiency in the thigh including the saphenofemoral junction. Data abstracted included patient demographics, procedural details, and postprocedural outcomes. Thrombus extension was determined by postprocedural duplex ultrasound and classified as flush closure with the femoral vein and any extension of thrombus into the femoral vein. ResultsSeventy-three patients met inclusion criteria. The mean age of the population was 60, 17.8% were female, and the mean body mass index (BMI) was 30.7. Seven (9.6%) patients who underwent mechanochemical ablation experienced saphenous vein closure flush with the femoral vein. Eleven (15%) patients experience extension of thrombus to less than 50% of the diameter of the femoral vein and one patient experienced complete thrombosis of the femoral vein. There was no significant difference in age, sex, or comprehensive classification system for chronic venous disorders between the group with thrombus extension and the group without, with the exception of BMI. The mean BMI in the group with thrombus extension was 26.8 vs. 32 in the group without (P = 0.02). There was no significant difference between the 2 groups in sclerosant volume used, distance between catheter tip and SFJ, and mean diameter of GSV in the thigh. ConclusionsIn this cohort, the incidence of thrombus extension into the femoral vein with mechanochemical ablation was high relative to rates of thrombus extension associated with reported rates of thermal ablation. Further investigation with larger cohorts, and standardized reporting is required to characterize the true rate of thrombus extension after mechanochemical ablation and identify maneuvers which may prevent thrombus extension.

Heparin-Induced Thrombocytopenia and Thrombosis with Axillary Impella 5.5 as Bridge-to-Transplant

IntroductionA patient presenting with biventricular failure was managed with Impella 5.5 as BTT. His course was complicated by HITT causing device failure, and he successfully underwent heart transplant (HTx) after plasmapheresis.Case ReportA 44-year-old man with DM, HTN, and HLD was transferred to our center in cardiogenic shock. Coronary angiography revealed slow flow without obstruction. TTE showed biventricular dysfunction with LVEF 10%. Impella CP was placed, and on transfer the device was exchanged for a surgically placed axillary Impella 5.5. Filling pressures and RV function improved with diuresis. Platelets decreased from 230 (1000/uL) to 96 by hospital day 10, and a PF4 antibody was sent (Fig 1A). The next day, Impella purge pressure doubled and purge flow decreased, concerning for device thrombosis. The PF4 antibody returned positive, suggesting HITT. Heparin was stopped and argatroban administered systemically and through the purge. Pump power and hemodynamics were maintained. While awaiting results of a serotonin release assay, a suitable donor was identified. The risks and benefits of HTx included risk of cardiopulmonary bypass with heparin-PF4 antibodies, risk of Impella exchange, and risk of imminent device failure and stroke. Preliminary SRA was positive. The patient underwent two sessions of plasmapheresis and was transplanted on day 13. In the OR, there was extensive thrombus encasing the device (B). The driveline was transected proximally, and the distal catheter was removed with the native heart to decrease risk of embolization. After HTx, the patient was placed on argatroban and transitioned to apixaban.SummaryWe describe using Impella 5.5 as BTT in severe biventricular failure, where RV function improved with LV unloading. The case is notable for TCS failure due to HITT despite only modest thrombocytopenia (nadir 86,000), and for proceeding with HTx after plasmapheresis rather than Impella exchange. The patient was anticoagulated for a month post-HTx and is doing well. A patient presenting with biventricular failure was managed with Impella 5.5 as BTT. His course was complicated by HITT causing device failure, and he successfully underwent heart transplant (HTx) after plasmapheresis. A 44-year-old man with DM, HTN, and HLD was transferred to our center in cardiogenic shock. Coronary angiography revealed slow flow without obstruction. TTE showed biventricular dysfunction with LVEF 10%. Impella CP was placed, and on transfer the device was exchanged for a surgically placed axillary Impella 5.5. Filling pressures and RV function improved with diuresis. Platelets decreased from 230 (1000/uL) to 96 by hospital day 10, and a PF4 antibody was sent (Fig 1A). The next day, Impella purge pressure doubled and purge flow decreased, concerning for device thrombosis. The PF4 antibody returned positive, suggesting HITT. Heparin was stopped and argatroban administered systemically and through the purge. Pump power and hemodynamics were maintained. While awaiting results of a serotonin release assay, a suitable donor was identified. The risks and benefits of HTx included risk of cardiopulmonary bypass with heparin-PF4 antibodies, risk of Impella exchange, and risk of imminent device failure and stroke. Preliminary SRA was positive. The patient underwent two sessions of plasmapheresis and was transplanted on day 13. In the OR, there was extensive thrombus encasing the device (B). The driveline was transected proximally, and the distal catheter was removed with the native heart to decrease risk of embolization. After HTx, the patient was placed on argatroban and transitioned to apixaban. We describe using Impella 5.5 as BTT in severe biventricular failure, where RV function improved with LV unloading. The case is notable for TCS failure due to HITT despite only modest thrombocytopenia (nadir 86,000), and for proceeding with HTx after plasmapheresis rather than Impella exchange. The patient was anticoagulated for a month post-HTx and is doing well.

Management of locally advanced renal cell carcinoma

: With the increased use of cross-sectional imaging, renal masses are increasingly detected when they are still clinically localized. However, a large portion of patients still have locally advanced or metastatic disease at the time of diagnosis. This includes both locally invasive disease as well as vena caval thrombus extension. Currently, surgical management offers the only chance of cure for tumors with direct invasion into adjacent structures and vena caval thrombus. This chapter will discuss this management including the surgical approach and techniques in these procedures, which can sometimes require a multidisciplinary approach and even bypass. Though surgical management might present the only chance for cure, frail patients might not be suitable candidates therefore not benefit from invasive intervention. The role of cytoreductive nephrectomy in metastatic disease is uncertain in the immunotherapy era, though it may offer benefit to some patients with good-risk features. This chapter will discuss the treatment of locally advanced renal cell carcinoma, risk assessment to reduce unnecessary morbidity and mortality, the role of lymph node dissection, caval thrombectomy, renal mass biopsy, and the changing landscape with the advent of targeted therapy and immunotherapy.

NAXIVA: A phase II neoadjuvant study of axitinib for reducing extent of venous tumor thrombus in clear cell renal cell cancer (RCC) with venous invasion.

275 Background: Venous tumor thrombus (VTT) extension occurs in 4-15% cases of renal cell cancer (RCC). The Mayo classification distinguishes 4 levels of VTT extension between the renal vein and supradiaphragmatic inferior vena cava (IVC). Although surgery is performed with curative intent, mortality is high (5-15%) with complications increasing with the level of the VTT. 5-year survival rates are poor; ~40-65% in non-metastatic RCC. It is hypothesised that neoadjuvant targeted therapy could downstage the VTT reducing the extent of surgery, leading to reduced surgical morbidity and mortality, and increased survival. However, level I or II evidence is lacking. NAXIVA provides the first level II evidence in this patient group, assessing the response of VTT to axitinib. Extensive translational sampling will provide in depth interrogation of VTT (using genomics, proteomics, immunophenotyping and metabolomics) to examine the role of the tumor microenvironment of VTT and response to axitinib. Methods: NAXIVA was a single arm, single agent, multi-center phase 2 feasibility study of axitinib in patients with both metastatic and non-metastatic clear cell RCC prior to nephrectomy and thrombectomy. A Simon two stage minimax design was adopted and the trial designed for adequate power to distinguish a &lt;5% from a &gt;25% improvement in the Mayo VTT level. 21 patients were recruited over a 24 month period between 15/Dec/2017 and 06/Jan/2020 at 5 sites across the UK. Patients were treated with 8 weeks of axitinib (starting dose 5mg bd, increasing to 10mg bd as tolerated) prior to planned surgery. The primary endpoint was the percentage of evaluable patients with an improvement in VTT according to the Mayo classification (assessed using MRI abdomen scans at screening and week 9, prior to surgery. Secondary endpoints were percentage change in surgical approach, percentage change in VTT height, response rate (by RECIST) and evaluation of surgical morbidity assessed by Clavien-Dindo classification. Results: The percentage of evaluable patients with an improvement in VTT according to the Mayo classification was 26.58% [80% CI: 15.76%, 39.74%] (6 of 21 evaluable patients). 35.29% (6 of 17 patients who progressed to surgery) had a change in surgical approach to a less invasive option. There was a median percentage reduction in VTT height of 21.49% (SD=27.60%). The response rate (by RECIST) in the evaluable population was 61.90% SD, 14.29% PR, 9.52% PD. In terms of surgical morbidity 11.76% (2 of 17 patients who progressed to surgery) experienced a Clavien-Dindo 3 or greater complication (0 CD3, 1 CD4, 1 CD5). Conclusions: NAXIVA provides unique prospective data on the feasibility of neoadjuvant axitinib administration to down stage IVC VTT and reduce the extent of surgery. Work is ongoing to establish predictors of response. Clinical trial information: NCT03494816 .

Current Trends in Management of Renal Cell Carcinoma with Venous Thrombus Extension.

To review the evidence regarding the current trends in surgical management of renal cell carcinoma (RCC) with inferior vena cava (IVC) thrombosis. Recent published series have shown the role of minimally invasive surgery in IVC thrombectomy. This review article evaluates the present RCC with venous extent literature to assess the role of open and minimally invasive surgery in this scenario. Robotic urological surgery has shown to have known benefits in radical prostatectomy, partial nephrectomy, and pyeloplasty. Recent published series showed feasibility of robotic IVC thrombectomy even for level IV cases. With growing number of robot-assisted and laparoscopic surgeries worldwide, there is a current tendency to treat this complex and challenging pathology with a minimally invasive approach, without compromising oncological outcomes.

Large Biventricular Thrombosis in Acute Myocardial Infarction Assessed at CT Scan

Background: Ventricular thrombosis represents a not uncommon complication of Acute Myocardial Infarction (AMI) and Left Ventricular (LV) thrombosis may complicate large anterior ST-elevation myocardial infarction with anteroapical aneurysm. Right ventricular thrombosis is a more rare complication of inferior infarction. Transthoracic echocardiogram is routinely performed in patients with AMI to assess left ventricular function and the occurrence of thrombotic complications. However, other imaging techniques are occasionally required to more clearly evaluate thrombus extent and endocardial border line. Methods: We report a case of biventricular thrombosis firstly found at echocardiograph examination; the exact extension of biventricular thrombosis, however, was more clearly defined at CT scan. Results: In case of large ventricular thrombosis, CT scan may be useful in the exact definition of thrombus extension when cardiac magnetic resonance is not feasible. Conclusion: When transthoracic ultrasonography does not allow adequate characterization of the thrombus and cardiac magnetic resonance is not feasible, CT scan can provide additional definition of cardiac walls and the extent of the thrombus.