Vena Cava Research Articles

Robotic ureteroureterostomy for correction of a retrocaval ureter

Introduction: Retrocaval ureter is a rare condition identified in the adult patient usually revealing dilation of the proximal ureter as it passes posterior to the inferior vena cava. The presentation can vary from incidental radiographic findings to declining renal function secondary to hydronephrosis. Management of a retrocaval ureter typically involves surgery in patients who have symptoms or deterioration in renal function. Case Report: This case report explores the diagnosis and treatment of a retrocaval ureter in a 34-year-old male who was referred to Urology after the detection of right-sided hydronephrosis on computed tomography (CT). Further management included a confirmatory CT, diuretic renogram, and retrograde pyelogram before definitive treatment with robotic ureteroureterostomy. Conclusion: This case report explores the surgical steps to a robotic-assisted ureteroureterostomy to treat a retrocaval ureter that resulted in significant hydronephrosis and flank pain.

Feasibility and Clinical Efficacy of Focal Pulsed Field Ablation in Patients With Non-Pulmonary Vein Triggered Atrial Arrhythmia From the Superior Caval Vein.

In patients with atrial arrhythmias originating from the superior vena cava (SVC), the use of radiofrequency energy to isolate the SVC is associated with a significant risk of injury both to the phrenic nerve and the sinus node. Pulsed field ablation (PFA) may overcome the disadvantages of thermal energy and improve both ablation efficacy and safety. We report the feasibility, safety, and clinical efficacy of focal monopolar PFA in patients with the origin of their atrial arrhythmia in the SVC. Nine patients (7 men, age 66 ± 8 years) with SVC-induced paroxysmal AF (n = 3), persistent AF (n = 5), or frequent premature atrial beats (n = 1) underwent SVC isolation using focal monopolar PFA. Acute circumferential SVC isolation was achieved in all cases, using 22 Ampere (A) or 25 A in areas with or without phrenic capture, respectively. The safety profile was excellent: two patients had transient sinus arrest and two had transient phrenic nerve stunning. Sinus node and phrenic nerve function recovered during the procedure, and no permanent damage was observed at follow-up. Coronary vasospasm occurred (and quickly resolved after injection of nitroglycerin) in one patient during additional ablation of a focal atrial tachycardia at the coronary sinus ostium. Kidney function remained stable before and after ablation in all patients. In this patient cohort with SVC-triggered atrial arrhythmia, isolation using focal monopolar PFA was feasible, effective, and safe. No permanent injury to the phrenic nerve or sinus node was observed.

Effect of different sealing caps on the backflow of short-term dialysis catheters: A bench study.

Needle-free connectors (NFCs) are recommended as closure systems for peripheral and central vascular catheters to reduce needlestick injuries and infections, while potentially reducing blood reflux. However, their performance in short-term dialysis catheters has never been evaluated. The aim of this study was to evaluate the backflow associated with two NFCs (Neutron™ and Tego™) compared to the standard closure. In this bench study, the physiological blood pressure of the superior vena cava was simulated. Expert operators performed three sealing sequences for each combination of connector and lumens of the catheter, with and without closing the clamp. After that, the backflow was measured in millimeters using a high-precision digital caliper. No combination of caps, lumens, or clamping sequences eliminated the backflow. No differences were observed between standard caps and NFCs in both lumens, apart from the Tego™/No clamp combination in the proximal lumen that showed higher backflow (standard cap 15 [11; 17] mm vs Tego™ 23 [19; 25] mm, p < 0.001). Clamping reduced backflow in both the proximal (13 [11; 17] mm vs 20 [13; 25] mm) and distal lumens (12 [11; 16] mm vs 14 [12; 17] mm). No differences were found between standard caps and NFCs in the distal lumen, regardless of clamping. Proximal lumen consistently exhibited larger backflow (14 [12; 22] mm) compared to distal lumens (13 [11; 17] mm, p = 0.005). NFCs do not seem to introduce any advantage on backflow reduction as compared to a standard cap combined with lumen and clamping. Our data suggest that clamping should become standard practice when NFCs are used in the management of short-term dialysis catheters.

A nomogram model to predict non-retrieval of short-term retrievable inferior vena cava filters

ObjectiveTo develop and validate a nomogram for predicting non-retrieval of the short-term retrievable inferior vena cava (IVC) filters.MethodsIn this study, univariate and multivariate logistic regression analyses were performed to identify predictive factors of short-term retrievable filter (Aegisy or OptEase) non-retrieval, and a nomogram was then established based on these factors. The nomogram was created based on data from a training cohort and validated based on data from a validation cohort. The predictive value of the nomogram was estimated using area under the curve (AUC) and calibration curve analysis (Hosmer-Lemeshow test).ResultsA total of 1,321 patients who had undergone placement of short-term retrievable filters (Aegisy or OptEase) were included in the analysis. The overall retrieval rate was 68.7%. Age, proximal and distal deep vein thrombosis (DVT) vs. distal DVT, active cancer, history of long-term immobilization, VTE was detected in the intensive care unit, active/recurrent bleeding, IVC thrombosis, and history of venous thromboembolism were independent predictive risk factors for non-retrieval of filters. Interventional therapy for DVT, acute fracture, and interval of ≥14 days between filter placement and patient discharge were independent protective factors for non-retrieval of filters. The nomogram based on these factors demonstrated good ability to predict the non-retrieval of filters (training cohort AUC = 0.870; validation cohort AUC = 0.813.ConclusionThis nomogram demonstrated strong predictive accuracy and discrimination capability. This model may help clinicians identify patients who are not candidates for short-term retrievable filter placement and help clinicians make timely, individualized decisions in filter choice strategies.

Case report: Paraganglioma masquerading as angiosarcoma: diagnostic‐dilemma in vascular tumors

Paragangliomas originating from blood vessels are exceptionally rare, presenting diagnostic challenges due to their histological resemblance to other vascular neoplasms. We present a case study of a 60-year-old woman with underlying hypertension and dyslipidemia with obesity, initially diagnosed with angiosarcoma based on imaging and histological characteristics viewed via CT-guided biopsy. Intraoperative exploration revealed a lobulated tumor located between the inferior vena cava (IVC) and aorta measuring 7 cm × 8 cm, during which the patient developed transient hemodynamic instabilities. Histopathological examination and immunohistochemical staining using neuroendocrine markers (chromogranin, synaptophysin, S-100 protein, and CD-56) later confirmed the tumor as a retroperitoneal paraganglioma. Retroperitoneal paraganglioma was initially misdiagnosed as angiosarcoma due to the overlapping imaging characteristics between the two tumors. This highlights the importance of raising suspicion on the possibility of retroperitoneal paraganglioma when imaging examination indicates angiosarcoma and to incorporate histopathological examination and immunohistochemistry in the diagnosis to avoid misdiagnosis.

Endovascular management of central venous catheter induced superior vena cava syndrome.

This case series describes the endovascular management of three patients with catheter-associated superior vena cava (SVC) syndrome. SVC syndrome can result from malignant (60%) or benign (40%) etiologies. The most common causes of benign SVC syndrome are indwelling central venous catheters (CVCs) with 1%-3% and 0.2%-3.3% of patients being affected. In all cases, a mechanical thrombectomy device was used to evacuate the chronic and acute thrombus, followed by a balloon angioplasty and stenting of the SVC. Anterograde flow and rapid symptom resolution was achieved following the procedure. No peri- or postprocedural complications occurred. These cases demonstrate the feasibility of endovascular management of catheter-associated SVC syndrome.

Anomalous inferior vena cava unmasked 48 years later: a rare case of hypoxaemia in an adult with repaired atrial septal defect

Anomalous inferior vena cava unmasked 48 years later: a rare case of hypoxaemia in an adult with repaired atrial septal defect

Normothermic cardiopulmonary bypass and beating heart surgery for renal cell cancer with tumor thrombus extension into inferior vena cava and right atrium: a less invasive strategy.

Management of renal cell carcinoma (RCC) with inferior vena cava (IVC) extension is one of the greatest challenges in urology. The gold standard treatment includes extracorporeal circulation and deep hypothermic circulatory arrest (DHCA). However, this surgical treatment has an impact on survival and prognosis. We aim to present a less invasive surgical approach for the treatment of level III and IV IVC thrombi in RCC. We identified all patients undergoing radical nephrectomy and thrombectomy at our Institution between 2016 and 2020. Patients with level IV thrombi were treated with a combined thoracic and abdominal procedure: beating heart surgery with normothermic cardiopulmonary bypass (CPB) was used for thrombus retrieval. Level III thrombi were approached exclusively through an abdominal access. We identified 12 patients treated with radical nephrectomy and thrombectomy among 243 patients undergoing radical nephrectomy for RCC. Mean age was 69.3 years, most patients were in T3c clinical stage, without lymph-node involvement (75%) and no metastases (66.7%); 58.3% of patients had Mayo III thrombus classification. Median intensive care unit stay was 2 days and total in-hospital stay 10.5 days. In-hospital mortality was 0%, with a 66.6% survival rate at 2 years. Beating heart surgery with normothermic CPB can be considered a less invasive method for radical resection of Mayo level IV IVC thrombi. This surgical approach is safe and feasible, with good in-hospital and short-term outcomes.

METHOD FOR RECONSTRUCTION OF TOTAL PORTOSYSTEMIC SHUNTS INTO A SELECTIVE SHUNT IN CHILDREN

Today, in children with portal hypertension (PH), the most radical treatment method is vascular shunt surgery, and for a number of reasons, splenorenal shunts (SRS), which are total portosystemic shunts (PSS), are predominantly used in practice. However, with them, the total discharge of portal blood into the inferior vena cava (IVC) leads to complications such as pulmonary arterial hypertension (PAH), decreased liver portal perfusion (LPP), liver failure (LF) and hepatic encephalopathy (HE). An alternative to SRS is the distal splenorenal shunt (DSRS), which is a selective shunt and maintains PPP, reducing the risk of developing these complications. However, in practice its use is limited due to the high incidence of anastomotic thrombosis and ascites in the early postoperative period. Prevention of all the above-mentioned complications of pSS continues to be an urgent problem in modern pediatric surgery. However, we have proposed a new treatment method - reconstruction of the SRS into a DSRS, which has reduced the risk of all these complications. This operation has already shown promising results in a follow-up study of 25 children, as demonstrated in this article.

Features of the anatomy of the inferior pyramidal space tendon in the fetal and newborn heart: a pilot study

Background. Anatomy of the inferior pyramidal space tendon (Todaro tendon, TT) in fetal and newborns’ hearts is of a great importance for perinatal cardiac surgery, but it has not been studied. Aim. To evaluate the possibility of dissection and studying TT mesoscopically, and to obtain preliminary data on the presence, shape, size, branching and local topography of TT in fetal and newborn hearts. Methods. The study is pilot, observational, cross-sectional, sampling, masked. We studied 15 normal human hearts of 16–40 gestational weeks. In 10 hearts, we dissected TT with Olympus SZX2-ZB10 microscope (Japan) at magnification from 6.3 to 30x, and measured the length and width of the TT using a Levenhuk M1000 camera (10 MP) and Levenhuk lite software. We calculated mean, standard deviation, median, extreme values, coefficient of variation, and Spearman correlation coefficient (Rs). In 5 hearts, histological slices were made and stained with Masson trichrome. Results. TT was dissected in all 10 hearts. Along entire length, the TT ran intramyocardially and/or through the loose connective tissue. In all cases, the TT arose from the right fibrous triangle anterosuperiorly to the atrioventricular bundle and node. Posteriorly, the TT followed between the lower edge of the foramen ovale and the coronary sinus orifice and entered the valve of the inferior vena cava. In 6/10, the TT was monolithic, in 4/10 it embraced the ostium of the coronary sinus by two branches. One specimen showed fibers reached the right coronary artery. The median width of the TT at the inferior vena cava (0.35 mm) correlated with TT length (4.63 mm; Rs=0.821; p=0.023) and with its width at the origin (0.24 mm; Rs=0.929; p =0.0003). Conclusion. The tendon of the inferior pyramidal space of the heart (Todaro tendon) in the human late antenatal and perinatal periods showed common topography and structural variability. The variability included branching differences, a wide range of the lengths and widths. The common topography consisted in the invariability of the beginning, running and insertion of the tendon. Methodically, TT can be clarified by mesoscopic dissection.

Physicians’ clinical experience and perspectives following a pilot, blended learning, point of care ultrasound course in Ghana- a mixed methods analysis

BackgroundPoint of Care ultrasound (POCUS) is rapidly gaining popularity in resource constrained settings. Optimising training is important to ensure safe and effective implementation. To expand POCUS expertise in Ghana, we co-developed and piloted a context specific, multi-disciplinary, blended learning programme, targeted at physicians of any grade or speciality providing acute care in the public health sector. In this retrospective mixed method study, we capture the “real world” experience of participants, using POCUS in their daily practice, as well as the barriers and enablers they perceived to implementation.ResultsEight emergency and internal medicine specialists and residents participated, working across three teaching hospitals, treating both general and specialist patients. They implemented each POCUS application taught, with cardiac indications, inferior vena cava (IVC) assessment, deep venous thrombosis (DVT) diagnosis, lung/pleural assessment and peripheral vascular access being most frequent at 3–6 times/week. An estimated 40% of patients could not have afforded any other diagnostic tests. They considered the pilot curriculum adequate for general practice and the majority of applications of low difficulty (71%). For cases sent for second opinion, they are self-reported that their findings were confirmed in 60–78% of cases. Perceptions about the relative advantage of POCUS over the usual approaches to diagnosing patients enabled implementation. Generally, they believed that POCUS improved their clinical decision making and that more certified training courses need to be run at lower cost to make them more accessible. All participants valued ongoing connections after training to ask for help and consolidate their skills. Continued evaluation and reflection on their POCUS practice to improve quality was unanimously reported as important, yet none had a formal system for this. The strongest barrier was access to equipment and maintenance. A lack of training opportunities and local mentors, and negative beliefs from other departments and hospital administration were further barriers.ConclusionOur new blended learning curriculum met the needs of physicians caring for patients with general and specialist presentations, with strong reported positive experience of improved bedside diagnostic capabilities, especially for the large proportion of patients unable to afford or access alternative diagnostic tests. Their experience drives the need for further training and for solutions to current barriers of equipment availability, training costs and lack of quality assurance mechanisms.

Morphological data of the superior vena cava predicted by multiple linear regression equations

This study explores the main surface markers in the hemodialysis puncture catheterization pathway and the relative spatial position of venous vessels in the puncture results, providing data support for venous puncture. Seventy cadavers were studied; angles of vertical axis with superior vena cava, left and right brachiocephalic vein at the confluence and circumference of superior vena cava were the primary parameters. Bivariate correlation analysis was used to determine in relation to other body parameters, and a regression equation was also obtained. The angle of the vertical axis with the superior vena cava at the confluence was linearly correlated with the distances between the coracoid processes and the jugular notch to coracoid processes. The angle of the vertical axis with left brachiocephalic vein was linearly correlated with the thickness of thorax and the length from the upper pericardial margin to the confluence. The angle of the vertical axis with right brachiocephalic vein was correlated with clavicular midline length, acromial distance, intersection point of clavicle to clavicular midline, confluence to clavicular midline, superior edge of the blood vessels to superior edge of clavicle at the right intersection, and superior edge of pericardium to confluence. There is a linear relationship between the superior vena cava circumference and the distance from the superior vena cava to the aorta. A number of parameters influence angles of the vertical axis with superior vena cava, left and right brachiocephalic veins and the superior vena cava circumference which can provide guidance for intubation.

IVC filter use in patients with a history of venous thromboembolism undergoing bariatric surgery: a MBSAQIP study.

Research on the use of prophylactic inferior vena cave filter (IVCF) placement prior to metabolic and bariatric surgery (MBS) in high risk patients has yielded conflicting results. We evaluated thrombotic events and mortality in patients with a history of venous thromboembolism (VTE) who underwent IVCF placement in anticipation of MBS. We queried the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for all patients undergoing primary sleeve gastrectomy or Roux-en-Y gastric bypass from 2015 to 2019 with a history of VTE. We tabulated yearly IVCF use and compared 30-day rates of deep venous thrombosis (DVT), pulmonary embolism (PE), readmission, mortality, and serious adverse events in patients with and without prophylactic IVCF placement. Multivariate logistic regression was used to assess the relationship between preoperative placement of an IVCF and postoperative outcomes. Of 754,397 patients undergoing MBS, 16,683 (2.2%) had a prior VTE. Placement of IVCF in anticipation of MBS decreased from 285/2245 (10.4%) in 2015 to 85/3750 (2.2%) in 2019 (p < 0.01). The incidence of PE did not differ significantly between patients with prophylactic IVCF vs. those without (0.1% vs 0.5%, p = 0.13). Postoperative DVT was more common in patients who underwent IVCF placement (1.7% vs. 0.8%, p < 0.01). No significant differences were observed in mortality. Preoperative placement of an IVCF was an independent risk factor for development of a postoperative DVT (OR 2.45; 95% CI 1.39-4.32). These data do not support a history of VTE as an indication for prophylactic IVCF placement in anticipation of MBS.

Fully biologic endothelialized-tissue-engineered vascular conduits provide antithrombotic function and graft patency.

Tissue-engineered vascular conduits (TEVCs), often made by seeding autologous bone marrow cells onto biodegradable polymeric scaffolds, hold promise toward treating single-ventricle congenital heart defects (SVCHDs). However, the clinical adoption of TEVCs has been hindered by a high incidence of graft stenosis in prior TEVC clinical trials. Herein, we developed endothelialized TEVCs by coating the luminal surface of decellularized human umbilical arteries with human induced pluripotent stem cell (hiPSC)-derived endothelial cells (ECs), followed by shear stress training, in flow bioreactors. These TEVCs provided immediate antithrombotic function and expedited host EC recruitment after implantation as interposition inferior vena cava grafts in nude rats. Graft patency was maintained with no thrombus formation, followed by complete replacement of host ECs. Our study lays the foundation for future production of fully biologic TEVCs composed of hiPSC-derived ECs as an innovative therapy for SVCHDs.

Port-access Totally Thoracoscopic Atrial Fibrillation Procedure: Epicardial Isolations and Left Atrial Appendage Stapler-closure

Minimally invasive heart surgery is developing to treat non-valvular atrial fibrillation, which can achieve rhythm-control and prevention of cardiogenic thromboembolisms. Our procedure is a port-access totally thoracoscopic technique: radio-frequency bipolar endoscopic clamp-isolators and pen-coagulator perform endocardial isolations of the left atrium and superior vena cava and an endoscopic stapler removes the left atrial appendage. This communication briefly explains the procedural indications, clinical settings, surgical technique (and its tips and pitfalls) and medication protocols associated with the operative course. The clinical outcomes, which were published before, are shared and the procedural characteristics, such as extensive clamp-isolations which can exclude important ganglionated plexi on the left atrium, is discussed. Our port-access totally thoracoscopic procedure for treatment of non-valvular atrial fibrillation is a promising minimally invasive choice, which can satisfactorily maintain sinus rhythm and prevent cardiogenic stroke.Central Message: Our port-access thoracoscopic technique for surgical treatment of non-valvular atrial fibrillation consisting of epicardial isolations and left atrial appendage resection is explained.

"Navigating Danger: Emergency Thoracotomy For Superior Vena Cava Injury During Dialysis Access In An Elderly Patient"

Superior vena cava (SVC) injury is a rare but life-threatening complication during the insertion of central venous catheters, especially in elderly patients with multiple comorbidities. We report a case of an 81-year-old woman with a complex medical history, including diabetes mellitus, hypertension, dyslipidemia, and end-stage renal disease (ESRD), who suffered an SVC injury during the placement of a PermCath for hemodialysis. The patient was initially admitted with fever and altered sensorium, requiring urgent dialysis. A femoral catheter was initially used, but a more permanent solution was sought. During the placement of the PermCath, the patient developed hypotension and shock, necessitating immediate transfer to the intensive care unit (ICU). Imaging revealed a severe right hemothorax and active bleeding from a perforation of the SVC. Emergency right exploratory thoracotomy was performed, revealing a 2 cm laceration at the insertion of the azygous vein into the SVC and a linear laceration of the right lower lung lobe. Both injuries were repaired, and the patient was stabilized. She recovered well postoperatively and was discharged on the fifth postoperative day. This case underscores the importance of early recognition and prompt surgical intervention in managing SVC injuries during central venous catheterization

Small cell lung cancer presenting with pleural effusion and superior vena cava obstruction.

Small cell lung cancer with concurrent pleural effusion and superior vena cava obstruction is a rare presentation with high risk of respiratory and circulatory compromise warranting prompt and multidisciplinary treatment.

Morphological Characteristics of Interatrial Septum and Its Clinical Relevance

ABSTRACTBackgroundThe development of new trans‐septal transcatheter interventions for patients with structural heart disease necessitates a precise and comprehensive understanding of the anatomy of the interatrial septum (IAS). The scarcity of gross anatomical studies has triggered our interest in exploring the morphometry and morphology of IAS.AimsTo study the morphology, morphometry and variations of the interatrial septum in autopsied human hearts.MethodsThe study was conducted on 97 autopsied fresh human hearts, in which we observed the position and shape of fossa ovalis (FOv), along with prominence of the limbus and its location. The diameter of FOv, thickness of its floor, redundancy and any variation in the IAS were noted.ResultsIn most cases (72.9%), the FOv was situated toward the inferior vena cava and was oval shaped (69.8%), with mean horizontal and vertical diameters of 17.21 ± 4.11 mm and 12.74 ± 3.78 mm, respectively. The limbus was prominent in 72.2% specimens, most commonly prominent all around (36.6%), followed by antero‐superior (28.2%), antero‐inferior (16.9%) and anterior (8.5%) prominence. The mean thickness of the floor of FOv was 0.71 ± 0.98 mm, and redundancy was observed in 47% of samples. Probe patency was seen only in 10.3% specimens. The right surface of the IAS showed more variations (71.1%) compared to the left (44.3%), in form of recesses, atrial septal pouches, fibrous strands, retinacular‐type fibrous networks and combination of more than one type.ConclusionVariations in the location of FOv, the prominence of limbus and the common occurrence of anatomical variants of the IAS mandate the preprocedural imaging of the region to reduce the failure rate and complications.

High-definition flow showing the drainage of type III persistent left superior vena cava into the left atrium.

High-definition flow showing the drainage of type III persistent left superior vena cava into the left atrium.

High-definition flow combined with STIC demonstrating the drainage of type III persistent left superior vena cava into the left atrium.

High-definition flow combined with STIC demonstrating the drainage of type III persistent left superior vena cava into the left atrium.