Vena Cava Research Articles

Development and Validation of a Comprehensive Predictive Model for Surgical Planning in Patients with Renal Cell Carcinoma and Inferior Vena Cava Tumor Thrombus

ObjectiveTo investigate preoperative predictors for selecting different surgical approaches in patients with renal cell carcinoma with inferior vena cava (IVC) tumor thrombus (RCC-IVCTT), and to establish and validate corresponding predictive models. MethodsClinical data of 583 RCC-IVCTT patients were retrospectively analyzed. Of these, 465 cases were used to construct predictive models, and 118 cases were used for validation. Univariate and multivariate analyses identified independent predictors for surgical strategies. Two nomogram prediction models were established based on relevant independent factors to predict surgical approach. ResultsIn the development cohort, 342 patients underwent IVC thrombectomy (IVCT), 91 underwent IVC cavectomy (IVCC), and 32 underwent IVC reconstruction (IVCR). Multivariate logistic regression analysis identified the following predictors for inability to perform IVCT: higher Mayo classification of tumor thrombus (TT), IVC wall invasion, presence of bland thrombus, pan-immune-inflammation value (PIV) > 358×109, and maximum anteroposterior (AP) diameter of IVC at renal vein ostium (RVo) > 24mm. Platelet > 170×109/L and inadequate collateral circulation were predictors for IVCR. The developed model predicted capacity of the nomogram was evaluated in terms of its calibration, discrimination, and clinical utility. The validation set confirmed these findings. ConclusionThe comprehensive preoperative predictive model for RCC-IVCTT patients aids in preoperative determination of the required surgical approach and necessity for IVC angiography, facilitating perioperative preparation and reducing unnecessary invasive examinations.

Mice with Reduced PAR4 Reactivity show Decreased Venous Thrombosis and Platelet Procoagulant Activity.

Hypercoagulation and thrombin generation are major risk factors for venous thrombosis. Sustained thrombin signaling through PAR4 promotes platelet activation, phosphatidylserine exposure, and subsequent thrombin generation. A single-nucleotide polymorphism in PAR4 (rs2227376) changes proline to leucine extracellular loop 3 (P310L), which decreases PAR4 reactivity and is associated with a lower risk for venous thromboembolism (VTE) in a GWAS meta-analysis. The goal of this study is to determine the mechanism for the association of rs2227376 with reduced risk for VTE in using mice with a homologous mutation (PAR4-P322L). Venous thrombosis was examined using our recently generated PAR4-P322L mice in the inferior vena cava stasis and stenosis models. Coagulation and clot stability was measured using rotational thromboelastometry (ROTEM). Thrombin generating potential was measured in platelet-rich plasma. Phosphatidylserine surface expression and platelet-neutrophil aggregates were analyzed using flow cytometry. PAR4P/L and PAR4L/L had reduced size of venous clots at 48 hours. PAR4P/L and PAR4L/L platelets had progressively decreased phosphatidylserine in response to thrombin and convulxin, in addition to decreased thrombin generation and decreased PAR4-mediated platelet-neutrophil aggregation. The leucine allele in extracellular loop 3, PAR4-322L leads to fewer procoagulant platelets, decreased endogenous thrombin potential and reduced platelet-neutrophil aggregation. This decreased ability to generate thrombin and bind to neutrophils offers a mechanism for PAR4's role in VTE highlighting a key role for PAR4 signaling.

Double Outlet Right Ventricle: A Rare Finding in a 15-Month-Old Female With Failure to Thrive.

Double outlet right ventricle (DORV) is a rare congenital heart defect where both the aorta and pulmonary artery originate from the right ventricle, often accompanied by additional cardiac anomalies to mitigate circulatory imbalance, though such compensations usually fail. We report a 15-month-old infant with recurrent respiratory infections and poor weight gain, referred for computed tomography angiography. Physical examination showed a small, non-syndromic infant with pallor, tachypnea, irritability, and finger clubbing. Initial imaging revealed cardiomegaly and lung infiltrates; echocardiography and computed tomography angiography confirmed additional intracardiac defects of double superior vena cavae, a hypoplastic aortic arch, hypertrophic right ventricular wall, and a patent ductus arteriosus. Corrective surgery was delayed due to respiratory complications. This case emphasizes the critical need to consider cardiac pathology in pediatric patients with recurrent respiratory symptoms, as untreated DORV can lead to high mortality.

Pacemaker Implantation in a Patient With Isolated Persistent Left Superior Vena Cava: A Novel Approach.

Implanting pacemakers in patients with isolated persistent left superior vena cava (PLSVC) present unique challenges. Recognizing venous anomalies and adapting lead placement techniques are crucial for successful outcomes and stable pacemaker function.

Hemodialysis-Related Portal-Systemic Encephalopathy Possibly Associated with Right Femoral Vein Thrombosis: A Case Report.

In hemodialysis-related portal-systemic encephalopathy (HRPSE), transient negative pressure in the inferior vena cava (IVC) during dialysis increases the blood flow through a portal-systemic shunt, leading to encephalopathy. We report the case of a 74-year-old man with a gastrorenal shunt who developed HRPSE for the first time following venous occlusion due to thrombosis around a right femoral tunneled-cuffed hemodialysis catheter. Before the thrombosis dissolved, ammonia levels increased after dialysis. Conversely, after the thrombosis was dissolved, the ammonia levels decreased after dialysis. We hypothesized that venous stasis in the right lower limb due to thrombosis intensified the negative pressure in the IVC during dialysis, triggering HRPSE.

Computed Tomographic Assessment of the Main Abdominal Vessels in Dogs.

Computed tomographic (CT) characterisation of abdominal vessels is poorly studied. The objectives of this retrospective study were to assess during growth, by CT angiography, the evolution of the aorta (Ao), caudal vena cava (CVC), portal vein (PV), length of the second lumbar vertebra (L2) and different ratios between these structures; and to determine the influence of weight and age on the vessels' sizes and ratios. The first group included six beagles scanned every month from 4 to 12 months old, then every 3 months up to 24 months old. The second group included 26 dogs of different breeds and weights that were considered haemodynamically normal. These dogs were divided into three weight intervals: < 10, 10-30 and > 30 kg. The measurements were repeated three times by three operators. The diameter of the Ao, CVC and PV, the aortic length and the L2 length increased up to 7 months. Similarly, the different ratios, such as CVC/Ao, VP/Ao, Ao/L2 and CVC/L2, were variable up to 7 months old and became stable after 7 months. The diameter of the Ao, CVC and PV, the previously cited ratios and L2 length were variable between weight intervals but stable within one interval. The adult vascular standards and ratios published in the literature should not be used in medium-size dogs younger than 7 months old. As variability is observed between the weight intervals, measurements should be used with care in very small or very large dogs.

Ultrasound-Guided Axillary Vein Puncture Versus Landmark-Guided Approach for Cardiac Implantable Electronic Device Placement.

Ultrasound (US)-guided axillary vein puncture is a safe and effective approach for cardiac implantable electronic device (CIED) implantation, and it is highly recommended by the current consensus document. However, only reports on small populations are available in the current literature regarding the comparison of this technique with other traditional approaches (subclavian vein blind puncture and cephalic vein surgical cutdown). We aimed to assess the effectiveness and safety of US- guided axillary vein puncture using a microintroducer kit for CIED implantation as compared to the aforementioned traditional approaches. All consecutive patients with an indication to CIED implantation were prospectively enrolled in our observational study from March 2021 to July 2023. Patients were divided into three groups based on venous access route, according to the operator's preference: cephalic vein surgical cutdown (G1), US-guided axillary vein puncture (G2), and subclavian vein blind puncture (G3). Clinical and procedural characteristics, success and complication rates were considered for analysis. A total of 1000 patients (65.2% male, mean age 75.5 ± 10.8 years) were enrolled. Cephalic vein surgical cutdown was chosen in 172 (G1, 17.2%), US-guided axillary access in 433 patients (G2, 43.3%), and subclavian vein in 395 (G3, 39.5%). Success rate was 77.6% in G1, 96.3% in G2, and 97.2% in G3 (G2 vs. G3, p = 0.5; G1 vs. G2, p<0.0001; G1 vs. G2. vs. G3, p<0.0001). Compared to subclavian and cephalic groups, in the US-guided axillary group, a successful access was obtained with a reduced mean number of puncture attempts (G2 vs. G3: 1.3 ± 0.9 vs. 1.8 ±1, p<0.0001) and needed reduced times to get access (G2 vs. G3: 15s [10-30s] vs. 40 [20-65s]; p<0.0001, G1 vs. G2: 210s [180-247s] vs. 15s [10-30s]; p<0.0001) and to reach the superior vena cava, without differences in total procedural times (72.9 ±30.4 vs. 75.7 ±34.8min, p = 0.24). Bailout fluoroscopy times [1 (0-8) s vs. 20 (10-58) s, p<0.0001] and usage of vein angiography (11.9% vs. 51.3%, p<0.0001) were lower in G2 as compared to G3. Complication rate did not differ among the three study groups (early complications: 2.9% in G1, 2.5% in G2, and 2.5% in G3, p = 0.96; late complications: 2.9% in G1, 1.6% in G2, and 0.8% in G3, p = 0.15). US-guided axillary vein puncture for CIED implantation using a microintroducer kit is a safe technique with a very high success rate. Compared to other traditional approaches, it allows to get access with a lower number of puncture attempts and with reduced times, without prolonging the total procedural time. Moreover, x-ray use and need for contrast medium are very rare in US-guided axillary approach. Hence, it should be considered the strategy of choice for most patients undergoing CIED implantation.

Considerations in assessing blood glucose in mice: coping with interferences of intraperitoneal injection, noise, fasting, housing and blood sampling

Abstract Background Blood glucose levels can fluctuate for many reasons. This study is to discuss conditions in assessing blood glucose in C57BL/6J mice, providing references to help increase the success of blood glucose testing in mouse experiments. Methods Animals were fed common chow or high-fat diet, without fasting or with a fasting duration of 6 h in the daytime or overnight before the test. During the test, animals were awake or under good anesthesia induced by intraperitoneal (IP) injection of sodium pentobarbital, interfered by a record of construction noise or not, in grouped cages or individual cages. Blood glucose measurements by glucose meters and insulin tolerance tests (ITT) were performed. Results Both IP injection and noise independently raised blood glucose levels in conscious mice, while neither of these two interferences affected blood glucose levels in mice under good anesthesia. In an ITT, a fasting of 6 h in the daytime worked well, while an overnight fasting was at higher risk of hypoglycemia. During conscious ITT, animals housed in isolated cages were more likely to have smoothly decreased levels of blood glucose with a lower minimal value as compared to those in social cages. Blood glucose tested during different stages of blood sampling varied greatly, where values of blood collected by inferior vena cava puncture were significantly higher than those of tail-tip blood, and values of serum samples after immediate centrifugation of blood were the highest, followed by those of serum samples underwent a common clotting process of 2 h. Conclusions Interferences of IP injection and noise can be reduced by anesthesia. 6-h fasting in the daytime is suitable for mouse ITT. Single housing works better than group housing during serial measurements of blood glucose in conscious mice. Tail-tip blood rather than serum or blood from sampling processes with big surgery invasion is recommended for blood glucose testing.

Arterial hypertension and COVID-19 in Arctic rotating shift work: the impact of chronostructure disruptions on circadian blood pressure rhythm in relation to echocardiographic parameters

This study investigated the effects of chronostructure disruptions on circadian blood pressure (BP) rhythms and their association with echocardiographic parameters in men with arterial hypertension (AH) who contracted COVID-19 while engaged in rotating shift work in the Arctic. Methods – A random sample of 166 men with arterial hypertension (AH) was selected from the medical records database of patients treated at the hospital of the Medical Unit of Gazprom Dobycha Yamburg LLC in Yamburg (Nadymsky District, Russia, 68° 21’ 40” N) between June 2020 and March 2021. Randomization was achieved using a random number method. These patients underwent echocardiography (ECHO) and 24-hour ambulatory blood pressure monitoring (ABPM) before the COVID-19 pandemic (November 2019 to March 2020) and again in 2021. The group was then divided into those who had contracted COVID-19 (n=94) and those who had not (n=72). ABPM was performed using a BPLab v.3.2 device (BPlab, Russia). Chronobiological analysis was performed to identify the main hypertensive BP chronotypes (CT) based on the P. Cugini classification: “MESOR AH”, characterized by a 24-hour rhythm period (T); and “Aperiodic AH”, characterized by a predominance of oscillations with periods (T) of 4.0, 4.8, 6.0, and 8.0 hours within the circadian rhythm. Echocardiography (ECHO) was performed using a Philips CX 50 scanner (Netherlands). Results – Logistic regression analysis showed that the presence of the “Aperiodic AH” chronotype was associated with a threefold increase in the odds of contracting COVID-19, while a 1 g/m² increase in the left ventricular mass index (LVMI) increased these odds by a factor of 1.02. One year post-COVID-19, individuals with “Aperiodic AH”, in contrast to those with “MESOR AH”, exhibited increases in right atrial and inferior vena cava diameters, systolic pulmonary artery pressure, tricuspid regurgitation velocity, stroke volume, and cardiac output, as well as a more pronounced increase in left ventricular mass and LVMI. Associations were observed between structural alterations in the heart and parameters that reflect disruptions in the circadian BP rhythm. Conclusion — Within the context of Arctic rotating shift work, men with arterial hypertension (AH) exhibiting a disrupted chronostructure of the circadian BP rhythm, characterized by a predominance of irregular, short-term oscillations, and structural alterations in the heart, are more susceptible to COVID-19. This increased susceptibility is associated with more pronounced alterations in echocardiographic parameters following the infection.

Translumbar and Transhepatic Tunneled Dialysis Catheter Placements in the End Stage Renal Disease Population.

For end-stage renal disease (ESRD) patients requiring hemodialysis, reliable vascular access is crucial, especially when conventional supradiaphragmatic options are exhausted. This study reviews the technical aspects, clinical outcomes, and complications of translumbar and transhepatic tunneled dialysis catheter (TDC) placements. These alternative infradiaphragmatic approaches provide essential hemodialysis access for patients with central venous occlusions. Translumbar catheter placement is associated with high technical success rates and prolonged patency, while the transhepatic approach serves as a last resort for patients with both superior and inferior vena cava occlusions. Careful patient selection and operator expertise are critical for placement of these advanced infradiaphragmatic dialysis catheter approaches.

Assessment of results of using three types of vascular access for isolated hepatic chemoperfusion

INTRODUCTION: Uveal melanoma (UM) is an oncological disease, which develops metastases mainly to the liver. One of treatments for this pathology is isolated hepatic chemoperfusion (IHCP). The implementation of this method requires surgical isolation of the liver from the systemic circulation and the use of a heart-lung machine. Due to a small number of observations of this treatment method in the world, the optimal vascular access for its implementation has not been determined so far. AIM: To analyze the in-hospital results of IHCP in patients with UM metastases performed from three different vascular accesses. MATERIALS AND METHODS: Over three years, 38 IHCP procedures were performed of the Kostroma Clinical Oncological Dispensary. Depending on the vessels into which the cannula for perfusion with Melphalan was inserted, patients were divided into 3 groups: group 1 with cava-porto-arterial access (perfusion into the inferior vena cava, portal vein, and common hepatic artery), n = 14; group 2 with cava-arterial access (perfusion into the inferior vena cava and common hepatic artery), n = 21; group 3 with a forced access, n = 3. The study took into account major complications: death, bleeding; and minor complications: tumor lysis syndrome, abscess of the left lobe of the liver, peritonitis, a systole, deep vein thrombosis of the lower limbs, hydrothorax, acute liver failure, anasarca, polyserositis, ischemic cholangiopathy, thrombosis of the common hepatic artery, detachment of the common hepatic artery intima. A combined endpoint was the achievement of at least one of the listed complications. In case of several complications in one patient, they were not summed up and were considered as ‘1’. RESULTS: In the postoperative period, the highest number of bleedings including those requiring revision, was noted in groups 1 and 3. The combined endpoint in the total sample made 42.11% and was lowest in group 2. Fatal outcomes were recorded in 3 cases (2 in group 1 and 1 in group 2), and were caused by increasing liver failure. CONCLUSION: The lowest number of complications IHCP was identified with cava-arterial access. Further continuation of the study is necessary to investigate the immediate and remote outcomes of IHCP.

Echocardiography in the Ventilated Patient: What the Clinician Has to Know.

Heart and lung sharing the same anatomical space are influenced by each other. Spontaneous breathing induces dynamic changes in intrathoracic pressure, impacting cardiac function, particularly the right ventricle. In intensive care units (ICU), mechanical ventilation (MV) and therefore positive end-expiratory pressure (PEEP) are often applied, and this inevitably influences cardiac function. In ventilated patients, the use of positive pressures leads to an increase in intrathoracic pressure and, consequently, to a reduction in the right ventricular preload and thus cardiac output. The clinician working in the intensive care unit must be able to assess the effects MV has on the heart in order to set it up appropriately and to manage any complications. The echocardiographic evaluation of the ventilated patient has the main purpose of studying the right ventricle; in fact, they are the ones most affected by PEEP. It is therefore necessary to assess the size, thickness, and systolic function of the right ventricle. In the mechanically ventilated patient, it may be difficult to assess the volemic status and fluid responsiveness, in fact, the study of the inferior vena cava (IVC) is not always reliable in these patients. In patients with MV, it is preferable to assess fluid responsiveness with dynamic methods such as the end-expiration occlusion (EEO) test, passive leg raise (PLR), and fluid challenge (FC). The study of the diaphragm is also essential to identify possible complications, manage weaning, and provide important prognostic information. This review describes the basis for echocardiographic evaluation of the mechanically ventilated patient with the aim of supporting the clinician in managing the consequences of MV for heart-lung interaction.

Giant Pleural Solitary Fibrous Tumor Revealed by Superior Vena Cava Syndrome: A Case Report

Introduction: Solitary fibrous tumors are rare mesenchymal tumors, often benign, of pluripotent fibroblastic or myofibroblastic origin. They usually develop at the expense of the pleura, but they can be localized to any organ. Clinical observation: we report the case of a 50-year-old patient who was admitted to the department for a superior vena cava syndrome revealing a giant thoracic tumor. The biopsy of the mass was in favor of a pleural solitary fibrous tumor. Discussion: The etiopathogenesis of the disease is unclear, but it could be related to accumulated somatic mutations, including the NAB2-STAT6 fusion, TP53 mutations and TERT promoter mutations. Conclusion: The diagnosis of a pleural solitary fibrous tumor is confirmed by histology after biopsy or surgical excision. The prognosis depends on the size of the mass, the mitotic index, and the presence or absence of necrosis.

Caval vein obstruction resulting in right to left shunt and desaturation post endocardial pacing implantation in a 3 year old: a case report

Abstract Background Superior caval vein obstruction is a rare complication of endocardial pacing lead implantation that can result in a right to left shunt. Case summary A 3-year-old child with type 2 Brugada syndrome presented with mild cyanosis post endocardial pacing implantation due to evolutionary right superior caval vein obstruction. This obstruction resulted in a right to left shunt across a previously unrecognized patent levo-atrial cardinal vein associated with partial anomalous pulmonary venous drainage. The patient underwent endocardial pacing explantation, balloon dilation and stenting of the right superior caval vein, banding of the levo-atrial cardinal vein to left upper pulmonary vein venous channel and implantation of an epicardial pacing system. Discussion Levo-atrial cardinal vein and partial anomalous pulmonary venous drainage with dual drainage can go undetected on cardiac imaging and may not ever cause symptoms (high left-to-right shunt or cyanosis). The levo-atrial cardinal vein and associated partial anomalous venous drainage with dual drainage was missed on multiple occasions and with multiple imaging modalities in our patient. Blood flow may not be detected in a small calibre or collapsed levo-atrial cardinal vein with pulmonary venous connection when the pulmonary vein remains widely patent and connected to the left atrium. Detailed comprehensive echocardiography of any child referred for cardiac intervention should include pulsed wave Doppler and colour flow mapping interrogation of the innominate vein from the suprasternal approach.

A case of renal cell carcinoma with tumor thrombus extension into the right atrium

Introduction: Over the last half-century, mortality from renal cell carcinoma (RCC) has seen a dramatic reduction, while 5-year survival rates have reached an all-time high (34% to 75%). Case presentation: A 77-year-old female with Stage 4 RCC (cT3c, cN1, cM1) presented with acute onset chest and back pain. Imaging revealed interval enlargement of a left renal mass with propagation of tumor thrombus (TT) throughout the left renal vein, intrahepatic and suprahepatic inferior vena cava (IVC) with extension into the right atrium (RA). The patient successfully underwent a high-risk open left nephrectomy with caval thrombectomy, retroperitoneal lymph node dissection, and atrial thrombectomy. Discussion: Approximately 1% of RCC cases involve the right atrium, and radical nephrectomy with vena caval thrombectomy remains the most effective treatment for cavoatrial TT, with 5-year survival rates between 30% and 72%. While patients with renal vein involvement have better survival rates than those with IVC involvement, advanced TT cases (Types III and IV) often require extracorporeal circulation. Though the patient understood the prognosis of her RCC, discussing the risks of a complex procedure versus not intervening was challenging. Despite a typical median survival of 12 months for level IV tumor thrombus (TT), she remains stable 28 months post-surgery. Conclusion: Although the five-year survival rate for renal cell carcinoma (RCC) has increased from 34% to 75%, the disease still adversely affects patients’ quality of life. A multidisciplinary approach is essential when managing metastatic RCC, particularly involving the heart. Despite the associated risks, surgical intervention is more effective in prolonging life by preventing sudden cardiac death due to embolic events.

Hot Quadrate Sign Under Focus of F18-FDG PET-CT: An Incidental Finding

“Hot quadrate lobe sign” refers to visualization of caudate lobe of liver due to excess accumulation of radiotracersecondary to superior vena cava obstruction. Collateral channels are formed between thoracic and mediastinalvessels; internal mammary through the paraumbilical vessels which drain blood to the left portal vein and into thecaudate lobe of liver. It was first described on Tc99-m sulfur colloid scan. We present a case with superior vena cavaobstruction presenting as hot quadrate lobe sign on F18-FDG PET-CT.Keywords: F18-FDG PET-CT, caudate lobe, superior vena obstruction, collateral vessels.

Successful portosystemic shunt embolization resolves hepatic encephalopathy and enhances hepatic function and glycemic control in MASH-related cirrhosis: a case report.

We report the case of a 70-year-old woman with advanced hepatic encephalopathy (HE) secondary to metabolic dysfunction-associated steatohepatitis (MASH)-related cirrhosis who exhibited an excellent response to portosystemic shunt embolization. Four years earlier, she was diagnosed as having MASH-related cirrhosis accompanied by multiple mesenteric vein-inferior vena cava shunts. As her condition progressed, she suffered recurrent HE that was unresponsive to oral medication, prompting the decision to proceed with shunt embolization. The procedure was successful, with no ensuing HE recurrence. At the 1-year follow-up, she remained free from refractory ascites, and no new shunts were detected. Remarkably, her liver function and glucose metabolism also showed significant improvement after the embolization. This case demonstrates that shunt embolization may be an effective treatment option for refractory HE associated with cirrhosis not only in terms of encephalopathy, but also for ameliorating hepatic function and glycemic control.

Percutaneous Retrieval of a Dislodged and Migrated Port Catheter Using Ablation Catheter and Balloon Trapping Technique

Totally implantable venous access devices (TIVADs) are routinely used in oncology patients, especially those requiring long-term chemotherapy. However, they are associated with minimal complications including catheter fracture. The fundamental approach for dislodged TIVAD is via percutaneous method. Reported here is a case of a 62-year-old woman with underlying rectosigmoid carcinoma presenting with dislodged port catheter within the right atrial appendage and the distal end lodged deeply into the hepatic vein. After multiple unsuccessful attempts with pigtail catheter, conventional snaring device and home-made snare, a deflectable ablation catheter was used and successfully retracted the deeply seated port catheter into the inferior vena cava. However, difficulty was encountered retrieving the port catheter due to malalignment of the port catheter to the femoral sheath. This was overcome by balloon trapping technique which aligned the port catheter with the femoral sheath allowing it to be retrieved safely, and the patient made a full recovery without any complications from the procedure.

A Comprehensive Review of Catheter-Related Thrombosis.

Catheter-related thrombosis (CRT) is a frequent and potentially serious complication associated with the widespread use of intravascular devices such as central venous catheters, including peripherally inserted central catheters and implantable port systems, pacemakers or implantable cardioverter-defibrillators. Although CRT management has been informed by guidelines extrapolated from lower extremity deep vein thrombosis (DVT), unique challenges remain due to the distinct anatomical, pathophysiological, and clinical characteristics of upper extremity DVT. Risk factors for CRT are multifactorial, encompassing patient-related characteristics such as cancer, prior venous thromboembolism, and infection, as well as catheter-specific factors like device type, lumens, and insertion site. The diagnosis of CRT relies primarily on ultrasonography; however, computed tomography angiography and magnetic resonance imaging play a complementary role, particularly in anatomically challenging cases or when complications such as pulmonary embolism or superior vena cava syndrome are suspected. Treatment strategies for CRT include anticoagulation, catheter removal when feasible, and, in select cases, local thrombolysis or catheter-directed interventions. Anticoagulation remains the cornerstone of therapy, with direct oral anticoagulants increasingly favored due to their safety profile and efficacy. This article provides a detailed review of CRT, focusing on clinical features, diagnostic methods, and treatment strategies while addressing specific challenges in managing pacemaker and hemodialysis catheter-related thrombosis.

"Martin Mattress": Surgical Technique for Achieving Hemostasis in Redo Aortic Root Operations.

A 71-year-old gentleman with prior bioprosthetic aortic valve replacement was admitted with aortic valve dehiscence and an aortic root abscess. He underwent reoperative sternotomy, aortic root, mitral valve, and hemiarch replacement. To augment hemostasis, we implanted the "Martin Mattress"-a pericardial patch sutured to the fibrous ridge within the innominate vein, superior vena cava, right atrium, right ventricular outflow tract, and pulmonary artery-which is preferred to modified Cabrol fistula techniques in infectious root pathology.