Vein Thrombus Research Articles

Follicular Thyroid Carcinoma Metastasis to the Internal Jugular Vein Demonstrated by 131I SPECT/CT

Cervical uptake detected by 131I whole body scintigraphy (131I-WBS) may be due to thyroid remnants or loco-regional metastases. We describe a patient with follicular carcinoma submitted to total thyroidectomy. 131I-WBS showed left cervical linear uptake and focal areas of uptake in the abdomen and pelvis. SPECT/CT images demonstrated a potential thrombus in the left jugular vein (confirmed by doppler neck ultrasound and MRI) as well as bone metastases. The patient was submitted to thrombectomy and histopathology confirmed metastasis of follicular carcinoma.

V73 Radical nephrectomy in a horseshoe kidney with endo caval trombosis: Infra hepatic caval vein control with Piggy back technique

Introduction: Renal cell carcinoma with vascular invasion of vena cava is still a great challenge for uro-oncologists. The surgical approach to this clinical scenario is even more challenging when coupled with anatomical anomalies, like horseshoe kidney and the presence of abnormal vessels. Materials and Methods: In this video, we will show a case of a large left renal tumor in a horseshoe kidney with double renal vein and endo-caval thrombus that reaches the suprahepatic veins (T2b— third level). The video describes, step by step, the piggy-back surgical technique, which allows to completely expose the inferior infrahepatic vena cava, splitting it from the liver that remains connected just to the three suprahepatic veins. This technique, borrowed from the liver transplant, allows, without increasing the risk of intraoperative complications and maintaining a high oncologic efficacy, to have an excellent vascular control that, in cases like the presented one, may avoid recourse to the use of extracorporeal circulation and allows urological equipe to complete the operation, without the aid of cardiac surgeons. Moreover, the video shows how it is possible, on a horseshoe kidney, the presence of abnormal vessels, whose arterial component has to be preserved to maintain a proper blood flow in the residual renal parenchyma. Results: The postoperative course was uneventful, underlining the reliability of the chosen surgical approach. The patient died after 10 months from cardiopulmonary failure. Conclusions: The video shows how it is possible to surgically approach an advanced left kidney cancer on a horseshoe kidney with abnormal vessels and an associated endo-caval thrombus that VID-2014-0035-ver9-Veneziano_1P.3d 07/26/14 8:32pm Page 1

Ultrasound Guided Fine-Needle Aspiration Cytology (FNAC) of Portal Vein Thrombus: A Novel Diagnostic and Staging Technique for Occult Hepatocellular Carcinoma

Introduction: The diagnosis of Hepatocellular Carcinoma (HCC) is usually established using noninvasive radiological imaging and tumor markers. The stage at diagnosis is a critical factor in the treatment, course and prognosis of HCC. Patients with Tumor Portal vein thrombus (PVT) are considered to have an advanced disease and are only offered palliative therapy. Therefore, every possible attempt should be made to accurately stage HCC. Fine-needle aspiration cytology (FNAC) of PVT is an effective procedure for diagnosing and staging HCC. We present a case where we used Ultrasound (USG) guided FNAC of a PVT to successfully diagnose and stage HCC in the absence of a well-defined liver mass on imaging. Case report: A 43-year-old Hepatitis B surface antigen positive male presented with a 3-month history of fatigue, jaundice and fever. On examination he had hepatomegaly. His liver function tests were elevated, but his alpha-fetoprotein was normal. USG and Computed Tomography (CT) showed a thrombus in the portal vein but failed to show a well-defined liver lesion. FNAC was taken from the PVT, which was positive for malignancy. He was offered palliative chemotherapy and a steroid for his pyrexia. He is on follow-up. Conclusion: FNAC is a safe, quick, easy and economical technique to diagnose and stage HCC in the presence of portal vein thrombus, especially in patients where the tumor is occult on imaging. It also affords an accurate method to differentiate between malignant and nonmalignant PVT, thereby aiding appropriate therapeutic decision making.

Paraneoplastic internal jugular vein thrombosis leading to diagnosis of bilateral ovarian ependymoma.

Ovarian ependymomas are extremely rare tumors of the ovary. We present a case of a 67-year-old lady presented to us with swelling in the right side of neck for 2 months followed by pelvic pain, lower abdominal distention, and weight loss for 1 month. Her coagulation profile, blood chemistry, lipid profile, and tumor markers were within normal limits. Neck Doppler ultrasonography revealed thrombus in the right internal jugular vein and CT scan of the abdomen showed bilateral ovarian masses. Patient was subjected to debulking surgery for suspected ovarian cancer and microscopy revealed a highly cellular tumor composed of small cells with hyperchromatic, round-to-oval nuclei with scanty cytoplasm, and perivascular pseudorosettes. Diagnosis was confirmed by immunophenotype showing strong positivity to glial fibrillary acidic protein, estrogen receptors, and progesterone receptors. Patient was successfully managed with anticoagulants, adjuvant chemotherapy with BEP regimen, and letrozole. After ruling out other common conditions for thrombosis in this age group, this seems to be a paraneoplastic presentation of ovarian malignancy that preceded the diagnosis of ependymoma by 2 months. To the best of our knowledge this is the first case report in the world literature as “paraneoplastic internal jugular vein thrombosis leading to diagnosis of bilateral ovarian ependymoma.”

Synchronous adrenal metastasis and an inferior vena cava tumor thrombus from an ovarian carcinoma

A 60-year-old woman presented with synchronous adrenal metastasis and an inferior vena cava tumor thrombus in the adrenal vein that developed from an ovarian carcinoma. The patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and right adrenalectomy with caval tumor thrombectomy for treatment. Microscopic examination revealed a clear cell ovarian carcinoma and a metastatic adrenal tumor. The patient is clinically free of disease after 6 years of follow-up. There have been no reports of synchronous adrenal metastasis with an inferior vena cava thrombus that developed from an ovarian carcinoma. As several reports have described the long-term survival after adrenalectomy for the treatment of isolated adrenal metastasis, clinicians should be aware of this potential occurrence so that patients can be appropriately treated.

Incidental finding of organized thrombus in right inferior pulmonary vein extending in left atrium in the patient scheduled for esophagectomy: What should an anesthesiologist look for?

Incidental finding of organized thrombus in right inferior pulmonary vein extending in left atrium in the patient scheduled for esophagectomy: What should an anesthesiologist look for?

CT-guided radiofrequency ablation following high-dose chemotherapy of a liver-metastasizing pancreatoblastoma with tumor thrombus in the portal vein

Pancreatoblastoma is a rare neoplasm encountered most commonly in infants and young children. Unresectable or metastatic tumors have a poor prognosis despite adjuvant chemotherapy or radiotherapy. We report the successful use of CT-guided radiofrequency ablation subsequent to intensive chemotherapy in an 8-year-old girl with liver-metastasizing pancreatoblastoma and with right and segment 4 portal vein tumor thrombosis. She has been in remission for 3years.

Abstract 54: Peptidylarginine Deiminase 4-dependent Generation of Neutrophil Extracellular Traps is Crucial for Deep Vein Thrombosis in Mice

Introduction Histone hypercitrullination by the enzyme peptidylarginine deiminase 4 (PAD4) leads to nuclear chromatin decondensation that is needed for neutrophil extracellular trap (NET) formation. NETs consist of chromatin and granule proteins that are released into the extracellular environment. NETs were shown to be involved in thrombosis by promoting coagulation and platelet adhesion and were identified in the thrombus scaffold in animal models of deep vein thrombosis (DVT). Objective Whether NETs are involved in the pathogenesis of DVT or whether they are merely a consequence of neutrophil recruitment to the thrombus is unknown. We hypothesized that NET formation would be impaired in PAD4-deficient mice during deep vein thrombosis and that this may affect thrombus formation and/or stability. Methods PAD4-deficient mice are incapable of citrullinating histones and therefore fail to decondense chromatin during NETosis. We performed the inferior vena cava stenosis model of DVT in wild-type or PAD4-/- mice. Intravital microscopy was done to assess leukocyte vessel wall interaction in PAD4 deficiency. Results We induced NET formation in isolated peripheral blood mouse neutrophils with ionomycin and found that PAD4-/- neutrophils had a complete inability to produce NETs (WT, 20.65±2.61% NETs; PAD4-/-, not detected. n=4). Leukocyte-endothelial interactions in PAD4-/- mice were not impaired upon induction of systemic Weibel-Palade body release (WT, 55.2±11.8; PAD4-/-, 62.0±17.5 cells/min, n=5-6). In the DVT model, while a majority (9/10) of wild-type mice formed a thrombus 48 hours after stenosis, only 1 of 11 PAD4-/- mice formed a thrombus. Thrombus formation could be rescued by infusions of isolated WT bone marrow neutrophils into PAD4-/- mice, and extracellular H3Cit+ areas were seen within these thrombi. This data suggests that neutrophil PAD4 was essential for thrombus formation in deep veins. Conclusion NETs comprise a crucial part of the pathologic thrombus scaffold, and here we report that the lack of NETs inhibits pathological thrombosis. Chromatin decondensation initiated by PAD4 in neutrophils is a key player in the formation of deep vein thrombi and targeting neutrophil histone modification could be a new way to prevent DVT.

Abstract 483: Clot Degradation Assay for the Analysis of Vascular Bed Fibrinolytic Reactivity

Introduction Pulmonary emboli cause significant morbidities and risk of mortality to affected patients, yet the mechanism behind their formation is still elusive. A greater understanding of clot formation and fibrinolysis in the pulmonary artery (PA) and iliac vein (IV) vascular beds has become an important area of research in order to find better therapeutics for the treatment of deep vein thrombi and pulmonary emboli. The aim of this study was to develop a novel in vitro clot degradation assay for the comparison of fibrinolytic reactivity of different vascular beds. Methods Thrombin was added to fibrinogen at 37 ° C for 24 hours and the resulting fibrin clot was centrifuged, dried and weighed. Human PA and IV endothelial cells were incubated for 24 hours and cellular extract and media samples were collected and evaluated for their ability to degrade fibrin clots in the presence of plasminogen. Fibrinolysis, stimulated by plasmin formed by endothelial cell derived plasminogen activator, was measured as percent clot degradation by weight. Results Fibrinogen and thrombin dose responses were completed to find the appropriate concentrations of each to use for clot formation: fibrinogen (6.04x10 -6 M) and thrombin (0.0005 NIH units). To validate the clot degradation assay, a uPA dose response was conducted from 150fM to 15nM uPA and demonstrated that each ten-fold increase in uPA concentration corresponded to an average of 14% degradation (p<0.05, n=3) up to 72.5% degradation in the presence of 15 nM uPA. While PA cell extracts showed no effect on clot degradation, IV cell extracts increased degradation by 30%. However, when clots were exposed to PA media there was a 14% increase in clot degradation (p<0.05, n=3), whereas the corresponding IV media samples had no effect on clot weight. Conclusions This study demonstrates the development of a novel and reproducible methodology to examine fibrinolytic reactivity in cell culture samples. Endothelial cells from the pulmonary artery circulation exhibit greater ability to extrinsically degrade fibrin clots when compared to endothelial cells from the iliac venous bed which may explain, in part, why more clots are found in the deep veins and not the pulmonary vasculature.

Experimental study of radiofrequency ablation of liver in swine

To explore the feasibility and efficacy of multiple-radiofrequency ablation (RFA) in swine liver. One swine undergone percutaneous and intra-operative RFA for three times in succession (an interval of 5 days) guided by real-time ultrasound. Then 6 ablated lesions formed. The outcome of RFA and the change of tissues adjacent to ablated lesions (biliary, liver vascular and abdominal wall) were observed by trans-abdominal ultrasonography (US), contrast enhanced ultrasound (CEUS), intra-operative ultrasound (IOUS) and contrast enhanced computed tomography (CT). Bile duct dilatation was found beside primary porta hepatis on US, CT, IOUS after RFA. There was no thrombus in liver vein through the ablated lesion with electrodes parallel to primary porta hepatis. Two ablated lesions were incompletely fused together. Small thermal injury was observed on abdominal wall after an injection of saline into subcapsular gap. Subcapsular hepatic tissue around ablation lesion changed into coagulative necrosis from hyperemia with elapsing time. Carbonizing granule formed during RFA on the top of intro-operative radio-frequency electrode easily caused bleeding along the withdrawing passage. Gelfoam was helpful to stop bleeding during intro-operative RFA. Occluding blood flow into liver definitely enlarged ablated area with the same amount of RFA energy. Multiple-RFA is feasible and efficacious for patients with RFA indication. But the complications of RFA increase if the ablation areas are adjacent to such organs as bile duct, stomach, intestine and diaphragm, etc.

Lung carcinoid with pulmonary vein and left atrial neoplastic thrombus

Lung carcinoid with pulmonary vein and left atrial neoplastic thrombus

Robotic Partial Nephrectomy for Renal Cell Carcinomas With Venous Tumor Thrombus

To describe the first report of robotic partial nephrectomies (RPNs) for renal cell carcinoma (RCC) with venous tumor thrombus (VTT). Partial nephrectomy for RCC extending into the renal vein has been described in limited fashion, but such a complex procedure has not previously been reported in minimally-invasive fashion. We demonstrate the feasibility of robotic nephron-sparing surgery despite vein thrombi and the results of the initial four highly-selected patients to have undergone this novel procedure. Two patients underwent RPN for RCC with VTT involving intraparenchymal vein branches, and 2 others had VTT involving the main renal vein. Mean patient age was 65 years (range 50-74 years). Mean tumor size was 7.75 cm (range 4.3-12.8 cm) with mean RENAL (radius, exophytic/endophytic, nearness to collecting system, anterior/posterior, and location) nephrometry score of 9.75 (range 8-12). Mean warm ischemia time was 24.2 minutes (range 19-27 minutes) and mean estimated blood loss was 168.8 mL (range 100-300 mL). No patients required transfusion, and there were no intraoperative complications. No patients required conversion to open or standard laparoscopic surgery. All 4 patients were discharged home on the first postoperative day. A single postoperative complication occurred in 1 patient who was readmitted with an ileus that resolved spontaneously. All patients had negative surgical margins. Two patients developed metastatic disease on surveillance imaging. RPN in patients with VTT is safe and feasible in selected patients. Given the risk of metastatic disease in patients with pathologic stage T3a RCC, the role of nephron sparing requires furtherevaluation such that radical nephrectomy remains the standard of care.

Intraluminal Soft-Tissue Mass versus Pedunculated Thrombus of Internal Jugular Vein in a Neonate

Introduction —A 2 month old baby boy presented to the vascular lab for evaluation of left sided neck swelling. This case study details the use of duplex ultrasound in the evaluation and diagnosis of left internal jugular vein thrombus a rare condition in infants. Case Report —The patient had a CT scan which showed marked distention of the left jugular vein, as well as an intraluminal mass measuring approximately 2.3 × 1.8 × 2.7 cm. The study was interpreted as an intraluminal mass. Subsequent upper extremity duplex imaging was ordered for correlation. By duplex exam the patient was noted to have a 2–3 cm partially obstructing filling defect within the left jugular vein consistent with a pudunculated thrombus not excluding other etiologies. The patient was referred to a larger institution for further imaging. This confirmed the diagnosis of a pudunculated thrombus in the internal jugular vein. Conclusion —The incidence of internal jugular vein thrombus is unknown due to the limited number of studies available in this area.

A report of renal artery embolization for hematuria facilitating neoadjuvant chemotherapy in an unresectable malignant renal rhabdoid tumor

Malignant rhabdoid tumor (MRT) of the kidney is a rare pediatric tumor characterized by its aggressive nature and chemoresistance. Our patient had MRT of the right kidney with tumor thrombus in the renal vein, inferior vena cava, and right atrium. He developed transfusion-resistant hematuria. This was successfully controlled with right renal artery embolization allowing completion of his neoadjuvant chemotherapy. He then underwent complete resection of the tumor and thrombus avoiding cardiopulmonary bypass.

Inferior vena cava thrombosis in a pediatric patient of amebic liver abscess

Amebic liver abscess (ALA) in pediatric age group is rare. We describe a successful thrombectomy and open drainage of a large left lobe ALA associated with thrombus in the hepatic veins and inferior vena cava extending into the right atrium in a 6-year-old boy.

Living donor liver transplantation to a survivor of liver resection for hepatocellular carcinoma with major portal vein invasion.

We present a case of living donor liver transplantation to a 3-year disease-free survivor of liver resection for hepatocellular carcinoma (HCC) with major portal vein invasion. A 48-year-old man had HCC in the right lobe with a portal venous tumor thrombus extending into the left portal vein. An extended right lobectomy with thrombectomy was performed to remove the thrombus. Three years after liver resection, the patient experienced liver failure, with massive ascites and jaundice due to the formation of a thrombus in the main and left portal veins. During the 3 years after liver resection, no metastasis or recurrence of HCC had been detected, and tumor markers had been within normal ranges. The portal venous thrombus did not show any arterial enhancement under contrast-enhanced computed tomography, suggesting that the co-existence of any HCC component in the portal venous thrombus may have been negative. Based on these findings, living donor liver transplantation was performed using a right lobe graft from the patient's son. The patient is alive at 87 months after the transplantation, with no evidence of HCC recurrence.

Hydatid cyst of liver complicated with Budd-Chiari syndrome and portal vein thrombosis

Hydatid cyst of liver complicated with Budd-Chiari syndrome and portal vein thrombosis

Testicular orphan nuclear receptor 4-associated protein 16 promotes non-small cell lung carcinoma by activating estrogen receptor β and blocking testicular orphan nuclear receptor 2

The possible involvement of estrogen receptors (ERs) and testicular orphan nuclear receptors (TRs) in human non-small cell lung carcinoma (NSCLC) has been suggested, but their precise roles and their relationship remain largely unknown. This study aimed to investigate whether TR4-associated protein 16 (TRA16) regulates the ERβ and TR2 pathways and could be a potential target in NSCLC. We used tissue microarrays including NSCLC tissues (n=154) and negative controls (n=14) to examine the expression of TRA16 and ERβ, and in vitro reporter gene assays, the mammalian two-hybrid method and immunoprecipitation in Cos-1 cells to investigate the relationships among TRA16, ERβ and TR2. We found that TRA16 was highly expressed in approximately 90% of the NSCLC tissues examined. TRA16 overexpression was significantly associated with TNM stage, tumor size, lymph node metastasis, tumor thrombus in vein, tumor differentiation and prognosis of NSCLC patients, in which TRA16 was shown to be an independent prognostic factor. Introduction of TRA16 into Cos-1 cells enhanced cell proliferation. Co-expression of TRA16 and ERβ in Cos-1 cells using different reporter gene systems and mammalian two-hybrid approaches revealed that TRA16 enhanced ERβ-mediated transcriptional activity. By adopting similar approaches, and immunoprecipitation and immunocytofluorescence assays, we found that TRA16 also interacted with TR2, and blocked the TR2 inhibitory effect on ERβ. Our findings demonstrate that TRA16 could be a promising diagnostic and prognostic biomarker in NSCLC, and promotes cancer cell growth through activation of the ERβ pathway by interacting with ERβ and TR2.

Novel Percutaneous Radiofrequency Ablation of Portal Vein Tumor Thrombus: Safety and Feasibility

We report our experience of the safety of partial recanalization of the portal vein using a novel endovascular radiofrequency (RF) catheter for portal vein tumor thrombosis. Six patients with liver cancer and tumor thrombus in the portal vein underwent percutaneous intravascular radiofrequency ablation (RFA) using an endovascular bipolar RF device. A 0.035-inch guidewire was introduced into a tributary of the portal vein and through which a 5G guide catheter was introduced into the main portal vein. After manipulation of the guide catheter over the thrombus under digital subtraction angiography, the endovascular RF device was inserted and activated around the thrombus. There were no observed technique specific complications, such as hemorrhage, vessel perforation, or infection. Post-RFA portography showed partial recanalization of portal vein. RFA of portal vein tumor thrombus in patients with hepatocellular carcinoma is technically feasible and warrants further investigation to assess efficacy compared with current recanalization techniques.

Splenic vein aneurysm: a rare clinical entity

A 52-year-old man presented with complaints of generalized malaise along with pain in left hypochondrium and diarrhea. The color Doppler and subsequent contrast enhanced CT scan revealed changes of portal hypertension and saccular dilatation of splenic vein along with partial thrombus in portal vein and superior mesenteric vein.