Heterozygosity for the Budapest 3 mutation in SERPINC1 in a family with thrombophilia and structural anomalies of the inferior vena cava.

BACKGROUND: Atresia of the infrarenal inferior vena cava (IVC) is associated with thrombophilia and antithrombin (AT) deficiency (ATD) due to homozygosity for the so-called Budapest 3 variant, c.391C > T, in the gene, SERPINC1. CASE PRESENTATION: We report on a father and his two sons that had severe thrombosis at a young age. One son had absence of, and the other had very gracile infrarenal IVC. The father had gracile vena iliaca. All had significant collateral building. AT activity was determined with four different methods and varied between moderately reduced and borderline normal values, depending on the method. While all were heterozygous for c.391C > T, the father was also heterozygous for a variant of uncertain significance in SERPINC1. CONCLUSIONS: The findings support the association between c.391C > T in SERPINC1, thrombophilia, and atresia of the IVC system and indicate that even heterozygosity for c.391C > T may contribute to such anomalies. ATD detection was hampered by the varying sensitivity of methods used for AT activity measurement.

The Importance of Lumbar Lordosis During Laparoscopic Trocar Entry.

STUDY OBJECTIVE: Investigating the effect of lumbar lordosis on the relationship between abdominal trocar entry points and major vascular structures. DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: Distances between the skin and the aorta and inferior vena cava at the trocar entry points, both at the umbilicus and 3 cm and 5 cm superior to the umbilicus, were measured at entry angles of 90 and 45 degrees in 101 abdominal computer tomography images. INTERVENTIONS: The relationship of these values with lumbar lordosis was investigated concerning menopausal status, body mass index (BMI), and parity differences. To assess the isolated effect of lumbar lordosis, a simulated 30-degree increase in the lordosis angle was applied to the patients' computed tomography images. The impact of this increased lumbar lordosis angle on the distances between the skin and major vessels was then evaluated at both the umbilical and supraumbilical trocar entry sites. MEASUREMENTS AND MAIN RESULTS: In the tomographic images of all patients, the distances from the skin to vascular structures were measured at a 90-degree entry angle, resulting in measurements of 8.97 cm ± 2.81 at the umbilicus, 10.89 cm ± 3.02 at 3 cm above the umbilicus, and 11.36 cm ± 2.88 at 5 cm above the umbilicus. These distances exhibited significant differences between patients with BMI <30 and BMI ≥30, as well as between premenopausal and postmenopausal patients. However, at a 45-degree entry angle, vascular structures were observed in only a few patients during trocar projection, and no measurable values were determined. In the simulation, it was found that a 1-degree increase in lumbar lordosis angle resulted in a decrease of 0.272 mm ± 0.018 in the distance between the skin and vascular structures at the umbilicus, 0.425 mm ± 0.024 at 3 cm above the umbilicus, and 0.428 mm ± 0.024 at 5 cm above the umbilicus. CONCLUSION: An increase in the degree of lumbar lordosis reduces the distance between trocar entry points and major vascular structures. Along with other factors during Veress and trocar entry, lumbar lordosis should be carefully considered.

A Case of Complete Resolution of Cauda Equina Syndrome Caused by Extensive Iliocaval Thrombosis: The Role of Thrombolysis and Venous Stents.

PURPOSE: The cauda equina syndrome (CES) is a rare condition affecting less than 1 in 100,000 patients annually. Diagnosing CES is challenging because of its rare incidence, potentially subtle presentation, and various underlying etiologies. Vascular causes, such as inferior vena cava (IVC) thrombosis, are uncommon but should be considered, since timely recognition and treatment of deep vein thrombosis (DVT) as a cause of CES can avoid irreversible neurological damage. CASE REPORT: A 30-year-old male presented with partial CES caused by nerve root compression due to venous congestion from an extensive iliocaval DVT. He completely recovered after thrombolysis and stenting of the IVC. His iliocaval tract remained patent until the last date of follow-up at 1 year without signs of post-thrombotic syndrome. Broad molecular, infectious, and hematological laboratory tests did not reveal any underlying disease for the thrombotic event, particularly no hereditary or acquired thrombophilia. CONCLUSION: Timely recognition of venous thrombosis as a cause of CES is essential. This is the first case report of CES caused by an extensive iliocaval DVT successfully treated with thrombolysis and venous stenting with good resolution of DVT and CES. CLINICAL IMPACT: This case-report describes a patient with cauda equina syndrome resulting from an extensive iliocaval deep vein thrombosis due to an underlying stenosis of the inferior vena cava. Thrombolysis and venous stenting succesfully restored venous patency and thereby relieved symptoms and signs of cauda equina syndrome, in addition to (long-term) therapeutic dose anticoagulation. It is important to timely recognize deep vein thrombosis as a cause of cauda equina syndrome and to consider endovenous treatment in a specialized center.

Evaluation of Inferior and Superior Vena Cava and the Vena Cava Ratio in Growth Restricted Fetuses.

OBJECTIVE: To evaluate the changes in the diameters of superior vena cava (SVC) and inferior vena cava (IVC) and to measure the ratio between SVC and IVC in growth-restricted fetuses and compare these results with normally grown fetuses. METHODS: Twenty-three consecutive patients with fetal growth restriction (FGR) (Group I) and 23 pregnant gestational age-matched controls (Group II) between 24 and 37 weeks of gestation were enrolled in the study between January 2018 and October 2018. The diameter of the SVC and IVC from inner wall to inner wall was measured in all patients by sonographic examination. The ratio between the diameter of the SVC and IVC was also measured in each patient to eliminate the gestational age factor. We have named this ratio the "vena cava ratio" (VCR). All parameters were compared between the two groups. RESULTS: The diameter of the SVC was significantly greater in the fetuses with FGR (2.6-7.7 [5.4]) than in controls (3.2-5.6 [4.1]; P = .002; P < .01). The diameter of the IVC was significantly less in the fetuses with FGR (1.6-4.5 [3.2]) than in controls (2.7-5 [3.7]; P = .035; P < .05). The VCR was between 1.1 and 2.3 and the median value was 1.8 in Group I. The VCR was between 0.8 and 1.7 and the median value was 1.2. VCR was significantly higher in fetuses with FGR (P = .001 P < .01). CONCLUSION: This study shows that VCR is higher in fetuses with growth restriction. Further studies are needed to clarify the association between VCR and antenatal prognosis and postnatal results.

Surgical resection of retrohepatic inferior vena cava leiomyosarcoma without vascular reconstruction: case report.

Inferior vena cava leiomyosarcoma (IVCL) is a rare malignant mesenchymal tumor. Surgical treatment is a challenge because it must combine free surgical margins with vascular reconstruction, using prosthetic or autologous grafts, primary suture, or simple ligation without vein reconstruction. The ligation option is possible thanks to the slow growth of the tumor, allowing collateral venous circulation to develop. We present a case of an IVCL treated with radical resection without vascular reconstruction. The patient was a 48-year-old female with abdominal pain in the right upper quadrant, asthenia, and postprandial dyspeptic symptoms. Abdominal tomography revealed a mass with an expansive formation located in the infrahepatic segment of the inferior vena cava and reduced vessel lumen. During surgery, vein clamping did not provoke hemodynamic repercussions, suggesting sufficient collateral circulation formation. It was decided to perform a radical resection of the entire portion of the retrohepatic vena cava and ligate the vena cava without vascular reconstruction. The patient recovered without complications.

A Decade of Robotic-Assisted Radical Nephrectomy with Inferior Vena Cava Thrombectomy: A Systematic Review and Meta-Analysis of Perioperative Outcomes.

PURPOSE: Open radical nephrectomy with inferior vena cava thrombectomy (O-CT) is standard management for renal cell carcinoma with inferior vena cava thrombus. First reported a decade ago, robotic-assisted radical nephrectomy with inferior vena cava thrombectomy (R-CT) is a minimally invasive option for this disease. We aimed to perform a systematic review to assess the safety and feasibility of R-CT in terms of perioperative outcomes and compare the outcomes between R-CT and O-CT. MATERIALS AND METHODS: The PubMed®, Scopus®, Cochrane Central Register of Controlled Trials and Web of ScienceTM databases were searched using the free-text and MeSH terms "renal cell carcinoma," "inferior vena cava," "thrombosis" or "thrombus," "robot" and "thrombectomy." Studies reporting perioperative outcomes of R-CT and studies comparing R-CT with O-CT were included. The review was done in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS: The search retrieved 28 articles describing R-CT, including 7 comparative studies. This systematic review included 1,375 patients, out of which 329 patients were in single-arm studies and 1,046 patients were in comparative studies. Of the 329 patients who underwent R-CT, 14.7% were level I, 60.9% level II, 20.4% level III and 2.5% level IV thrombus. Operative time ranged from 150 to 530 minutes; blood transfusion was administered in 38.2% (126). The overall complication rate was 30.3% (99). R-CT, in comparison to O-CT, was associated with a lower blood transfusion rate (18.4% vs 64.3%, p=0.002) and a lower complication rate (14.5% vs 36.7%, p=0.005). Major complication and 30-day mortality rates were similar in both groups. CONCLUSIONS: R-CT has acceptable perioperative outcomes in carefully selected patients. Compared with O-CT, R-CT is associated with a lower blood transfusion rate and fewer overall complications. In experienced hands with carefully selected patients, R-CT is feasible and safe, with acceptable outcomes; however, selection bias limits definitive inference of these results, and optimal patient selection criteria remain to be described.

Leiomyosarcoma of the inferior vena cava as etiology of chronic abdominal pains - a case report.

Inferior vena cava leiomyosarcomas are rare tumors that account for less than 0.7% of all retroperitoneal leiomyosarcomas. They are more common in women and cause nonspecific chronic abdominal pain. In this report, we present the case of a 53-year-old female patient complaining of chronic nonspecific periumbilical abdominal pain with initial onset 8 months previously who was diagnosed with inferior vena cava leiomyosarcoma by computed tomography angiography. The patient was treated with complete resection of the tumor and reconstruction of the inferior vena cava with interposition of a Dacron prosthetic graft. The treatment considered the gold standard consists of complete surgical excision, because these tumors are resistant to chemotherapy and radiotherapy. The prognosis of these patients is closely related to early diagnosis. Therefore, it is very important that vascular and general surgeons know that this disease is a possible differential diagnosis of chronic abdominal pains.

The outcomes of interventional treatment for Budd-Chiari Syndrome complicated by inferior vena cava thrombosis: Systematic review and meta-analysis.

PURPOSE: The aim of this study was to perform a systematic review and meta-analysis to assess the safety and efficacy of interventional treatment for Budd-Chiari syndrome (BCS) complicated by Inferior Vena Cava thrombosis (IVCT) patients. METHODS: We evaluated the published studies on interventional treatment for BCS complicated by IVCT. Meta-analysis was used to calculate the combined effect size and their 95% confidence intervals (CI) based on random effect. The publication bias was assessed by Begg's test. RESULTS: Sixteen studies on interventional treatment for BCS complicated by IVCT patient were selected for meta-analysis, a total of 767 BCS complicated by IVCT patients were included. The combined effect size (95% CI) were 99% (98-100%) for the total successful rate of IVC recanalization, 15% (11-21%) for the rate of IVC restenosis after initial operation, 92.0% (86-97%) for the rate of clinical improvement, 76% (68-84%) for the rate of thrombus clearance and 0.00% (0-1%) for the incidence of pulmonary embolism (PE). Through subgroup meta-analysis about the rate of thrombus clearance, we got the pooled results (95% CI) of individualized treatment strategy (ITS) group and non-individualized treatment strategy (non-ITS) group, were 81% (71-92%) and 73% (63-83%), respectively. CONCLUSIONS: The interventional treatment for BCS complicated by IVCT patients is safe and effective with low incidence of PE, high thrombus clearance rate, high technically successful rate, good patency, and high clinical improvement rate. Moreover, subgroup analysis indicated that management based on the type and extent of the thrombus is proposed.

Intra-individual consistency of spectral detector CT-enabled iodine quantification of the vascular and renal blood pool.

OBJECTIVES: The objective of this study was to evaluate the intra-individual, longitudinal consistency of iodine measurements regarding the vascular and renal blood pool in patients that underwent repetitive spectral detector computed tomography (SDCT) examinations to evaluate their utility for oncologic imaging. METHODS: Seventy-nine patients with two (n = 53) or three (n = 26) clinically indicated biphasic SDCT scans of the abdomen were retrospectively included. ROI-based measurements of Hounsfield unit (HU) attenuation in conventional images and iodine concentration were performed by an experienced radiologist in the following regions (two ROIs each): abdominal aorta, vena cava inferior, portal vein, and renal cortices. Modified variation coefficients (MVCs) were computed to assess intra-individual longitudinal between the different time points. RESULTS: Variation of HU attenuation and iodine concentration measurements was significantly lower in the venous than in the arterial phase images (attenuation/iodine concentration: arterial - 4.2/- 3.9, venous 0.4/1.0; p ≤ 0.05). Regarding attenuation in conventional images of the arterial phase, the median MVC was - 1.8 (- 20.5-21.3) % within the aorta and - 6.5 (- 44.0-25.0) % within the renal cortex while in the portal venous phase, it was 0.62 (- 11.1-11.7) % and - 1.6 (- 16.2-10.6) %, respectively. Regarding iodine concentration, MVC for arterial phase was - 2.5 (- 22.9-28.4) % within the aorta and - 5.8 (- 55.9-29.6) % within the renal cortex. The referring MVCs of the portal venous phase were - 0.7 (- 17.9-16.9) % and - 2.6 (- 17.6-12.5) %. CONCLUSIONS: Intra-individual iodine quantification of the vascular and cortical renal blood pool at different time points works most accurately in venous phase images whereas measurements conducted in arterial phase images underlay greater variability. KEY POINTS: • There is an intra-individual, physiological variation in iodine map measurements from dual-energy computed tomography. • This variation is smaller in venous phase examinations compared with arterial phase and therefore venous phase images should be preferred to minimize this intra-individual variation. • Care has to be taken, when considering iodine measurements for clinical decision-making, particularly in the context of oncologic initial or follow-up imaging.

Cavographic vs. cross-sectional measurement of the inferior vena cava diameter before filter placement: are we routinely oversizing?

OBJECTIVE: A megacava (vena cava with a diameter of 28 mm or greater) requires a particular filter to avoid migration. However, caval morphologies are variable. As the inferior vena cava (IVC) usually adopts a circular geometry after a filter is inserted, this study aims (a) to classify caval geometry and orientation; (b) to compare discrepancy between anterioposterior projective diameter (PD) and circumference-based calculated diameter (CD) measurements on cross-sectional computed tomography (CT) images; (c) if a discrepancy exists, determine how often it can affect IVC filter selection. METHODS: A total of 1503 patients were retrospectively reviewed. Caval morphology was classified. PD and CD were measured at infrarenal IVC. Differences between the PD and CD were assessed by the Wilcoxon signed-rank test or paired t test (if appropriate). The scatterplot of PD vs. CD was used to show whether one is consistently larger than the other. RESULTS: The PD was significantly larger than the CD (22.3 ± 3.5 vs. 20.4 ± 2.8, p < 0.001). The caval morphologies were divided into five types. Type 1 was oval IVC oriented left-anterior-oblique to the horizontal line with an angle (n = 999, 66.5%), type 2 was round IVC (n = 49, 3.3%), type 3 was oval IVC with a vertical long axis (n = 8, 0.5%), type 4 was oval IVC with a horizontal long axis (n = 75, 5.0%), and type 5 was irregularly shaped IVC (n = 372, 24.7%). CONCLUSION: Patients with round IVC are rare. Measurement of CD may be better to assess maximum IVC diameter compared with PD for the purpose of IVC filter placement. KEY POINTS: • Five types of IVC orientation are described in this paper: type 1 (n = 999, 66.5%), type 2 (n = 49, 3.3%), type 3 (n = 8, 0.5%), type 4 (n = 75, 5.0%), and type 5 (n = 372, 24.7%). • The incidence of megacava (vena cava with a diameter of 28 mm or greater) measured on anterioposterior projective imaging may be overestimated. • As an IVC will adopt a circular geometry following filter placement, circumference-based calculated diameter may be an appropriate approach for caval size determination.

Pre-procedural CT angiography inferior vena cava measurements: a predictor of mortality in patients undergoing transcatheter aortic valve implantation.

OBJECTIVES: To assess the value of pre-procedural computed tomography angiography (CTA) measurements of the suprahepatic inferior vena cava (IVC) to detect elevated central venous pressure (CVP) assessed by right heart catheterisation (RHC), and to predict post-procedural 1-year mortality in a cohort of patients undergoing transcatheter aortic valve implantation (TAVI). METHODS: We retrospectively evaluated 408 consecutive patients undergoing CTA before TAVI between January 2011 and December 2014. Two hundred and five patients were included in the RHC cohort, who underwent RHC and CTA within ≤1 day prior to TAVI. Two hundred and three patients not fulfilling this requirement were included in the validation cohort. Measurements of the IVC were performed between diaphragm and right atrium on axial slices. Receiver operating characteristic (ROC) analyses, Kaplan-Meier analyses and Cox regression analyses were performed. RESULTS: In the RHC cohort, ROC curve analyses for IVC area measurements indicated an AUC of 0.77 (p < 0.001) to detect CVP ≥10mmHg and an area under the ROC curve (AUC) of 0.72 (p < 0.001) to predict 1-year mortality. An IVC area cut-off of ≥665 mm2 predicted 1-year mortality with a specificity of 84% and a sensitivity of 63%. Kaplan-Meier analysis showed that patients with an IVC area ≥665 mm2 had a significantly higher post-procedural 1-year mortality (38% versus 7%, log-rank p < 0.001) with a hazard ratio of 5.5 (95% CI, 2.2-13.6; p < 0.001). Applying this cut-off value to the validation cohort confirmed a significantly higher 1-year mortality after TAVI (34% versus 11%; log-rank p = 0.004) for patients with an IVC area ≥665 mm2. CONCLUSIONS: Pre-procedural enlargement of the suprahepatic IVC is a predictor of post-procedural 1-year mortality in patients evaluated for TAVI. KEY POINTS: • IVC measurements are moderate predictors of an elevated CVP in TAVI patients. • Pre-procedural IVC enlargement is a predictor of 1-year mortality after TAVI. • IVC enlargement is associated with right heart dysfunction in TAVI patients.

[Stent placement for filter-related chronic occlusion of the inferior vena cava].

Objective: To assess the technical success rate, stent patency, clinical efficacy and complications of stent placement for filter-related chronic occlusion of the inferior vena cava. Methods: A retrospective analysis was carried out for 12 patients with filter-related chronic occlusion of the inferior vena cava associated with severe post-thrombotic syndrome, who underwent stent placement after ineffective conservative therapy at Nanjing First Hospital from March 2016 to December 2018,9 males and 3 females, aged from 48 to 77 years, mean age 60 years, six had bilateral lower extremity symptoms and six had unilateral lower extremity symptoms.Technical success rate, stent patency, clinical efficacy and complications of stent placement were recorded. Clinical success was defined as relief of symptoms and a decrease in clinical, etiology, anatomy, and pathophysiology (CEAP) score for at least grade 1. Results: Stent placement in the unilateral or bilateral iliocaval occlusion was successful in 11 patients. The cause of technical failure in the single patient with failed stent placement was an inability to cross the occluded left iliacvein and the patient was treated with stent placement in the right iliocaval vein.There were 7 patients with inferior vena cava and unilateral iliocaval stent placement; 5 patients with inferior vena cava and bilateral iliocaval stent placement. Acute stent thrombosis occlusion occurred in 1 case after the operation, the blood flow recanalized after catheter-directed thrombolysis and re-stenting. All patients were followed up for 6 to 24 months, with an average of (13±6) months. During the follow-up period, CTV or venography of lower limbs showed that the blood flow in the stent was unobstructed. At the last follow-up, 12 patients were evaluated as clinically effective. Three patients had transient treatment of lateral lumbar pain during operation, which alleviated by themselves.No significant abdominal pain, severe hemorrhage, symptomatic pulmonary embolism and other complications related to treatment occurred in all patients during perioperative period and follow-up. Conclusion: Stent placement is safe and feasible in the treatment of filter-related chronic occlusion of the inferior vena cava, which can alleviate the clinical symptoms of severe post-thrombotic syndrome.

Comparison of retrievable stents and permanent stents for Budd-Chiari syndrome due to obstructive inferior vena cava.

BACKGROUND AND AIM: The aim of this study is to compare long-term outcomes of retrievable stents (RSs) and permanent stents (PSs) for Budd-Chiari syndrome (BCS) due to long-segment obstructive inferior vena cava (IVC). METHODS: Between July 2000 and August 2016, 42 patients with BCS due to long-segment obstructive IVC were treated with RSs, and 41 patients were treated with PSs. The RSs were removed eventually after thrombus disappeared. Patients were subsequently followed up by color Doppler sonography or computed tomography scanning. RESULTS: All RS placements were successful, and 37 RSs were retrieved 8 to 29 days later. Forty-two stents were implanted in PS group. One failure retrieval of RSs occurred, and two failures of cannulations were found in PS group. Two deaths may be procedure related and died from acute pulmonary thromboembolism perioperatively. One patient developed acute cerebral infarction and recovered after treatment. In PS group, minor complications were found in three patients. The length of IVC lesion segment and length and thickness of IVC thrombus decreased significantly, and diameter of retrocaval IVC and diaphragm IVC increased significantly in both groups. During follow-up, three patients died from liver failure in RS group, and two patients died in PS group. RS group showed a significantly higher primary patency rate than PS group. Cumulative 1-, 3-, and 5-year secondary patency rates were 95.2%, 89.6%, and 89.6% in RS group and 100%, 96.6%, and 96.6% in PS group (P = 0.7109). CONCLUSIONS: Retrievable stents are effective for BCS because of long-segment obstructive IVC, with a higher primary patency rate.

Adult Wilms tumor with inferior vena cava thrombus and distal deep vein thrombosis - a case report and literature review.

BACKGROUND: Adult Wilms tumor (WT, nephroblastoma) is a rare, but well-described renal neoplasm. Although inferior vena cava tumor thrombosis is present in up to 10% of Wilms tumors in childhood, only few cases of this clinical manifestation in adults have been reported. To the best of our knowledge, this is the first case of adult WT infiltrating into inferior vena cava (IVC) with concomitant distal deep vein thrombosis. CASE PRESENTATION: A 28-year-old male patient with gross hematuria and right flank pain was diagnosed with right kidney tumor penetrating to IVC. Preoperatively, acute distal thrombosis in inferior vena cava and lower extremities veins occurred. Right radical nephrectomy with tumor thrombectomy via cavotomy was performed. In order to prevent pulmonary embolism, IVC was ligated below left renal vein level. Histopathological examination revealed a triphasic nephroblastoma without anaplastic features. Postoperatively, patient was diagnosed with metastatic liver disease, which was treated with two lines of chemotherapy followed by radiotherapy with achievement of complete response. CONCLUSIONS: Adult WT occurs usually in young patients, under 40 years of age. Neoadjuvant chemotherapy proved to be effective in children, resulting with tumor shrinkage and venous tumor thrombus regression. Therefore, percutaneous biopsy should be always considered in young patients presenting with renal tumor invading venous system. IVC ligation is a safe treatment option in the event of complete inferior vena cava occlusion due to distal thrombosis concomitant to tumor thrombus, provided collateral venous pathways are well-developed.

[Characteristics and prognosis of interrupted inferior vena cava with azygous continuation].

Objective: To explore the clinical characteristics of interrupted of the inferior vena cava with azygous continuation and the prognosis. Methods: Retrospective analysis of 21 fetuses diagnosed with interrupted inferior vena cava with azygous continuation among 28 567 pregnant women who underwent routine ultrasound scan. The clinical data, ultrasonographic features, genetic information and prognosis were collected. Results: Interrupted of the inferior vena cava with azygous continuation occurred in 21(0.07%, 21/28 567) of 28 567 patients. Three fetuses (14%, 3/21) complicated with heart and extracardiac malformations, including endocardiac cushion defect, single atrium and single ventricle, double superior vena cava, dextrocardia, asplenia syndrome, visceral heterotaxy, duodenal atresia; six fetuses (29%, 6/21) were associated with cardiac anomalies, such as hypoplastic left heart syndrome, double outlet right ventricle, pulmonary stenosis, ventricular septal defect, persistent left superior vena cava, endocardiac cushion defect and transposition of the great arteries; six cases (29%, 6/21) were only combined with extracardiac malformations, includingasplenia syndrome, visceral heterotaxy, duodenal atresia. Three fetuses (14%, 3/21) were nonorganic abnormalities included thickening of the right ventricle wall, fetal bradycardia, pericardial effusion, hydrops abdominis, increased peak systolic velocity/end diastolic velocity and single umbilical artery. Three fetuses (14%, 3/21) were isolated interrupted inferior vena cava with azygous continuation, but without other anomalies and 2 of them had normal fetal karyotype. Five cases (24%, 5/21) were successfully vaginal delivery, 1 case (5%, 1/21) had cesarean section. After 12-40 months follow-up, we didn't obeserve obviously abnormality, nor any chromosomal abnormality. Ten patients (48%, 10/21) opted for termination of the pregnancy and the autopsies were not done. Five cases (24%, 5/21) were lost to follow up. Conclusions: Interrupted inferior vena cava with azygous continuation are associated with cardiovascular and extracardiac anomalies, cardiac malformation and visceral heterotaxy are the most common anomalies. Visceral heterotaxy should be considered and fetal karyotype should be suggested. In the cases of isolated interrupted inferior vena cava with azygous continuation and normal karyotype, the outcome is favorable.

[Left-sided renal cell cacrinoma with vena cava inferior thrombus: totally laparoscopic removal].

A surgical treatment of patients with tumor thrombus in the inferior vena cava (IVC) of levels II-III, originating from the left renal vein involves performing thrombectomy, radical nephrectomy and lymph nodes dissection. In most cases it requires major open surgery which leads to complications in 38% of patients and perioperative mortality of 4-10%. In recent years, the laparoscopic radical nephrectomy with thrombectomy have been gradually introduced. However, there are anecdotal reports about performing of such interventions in case of left-sided renal tumor with thrombus in the IVC. A description of technique and own experience of performing laparoscopic radical nephrectomy with thrombectomy from the IVC in 3 patients with tumor thrombus of levels II-III, originating from left kidney are presented. In one case distant metastases were detected preoperatively and in another patient an involvement of tail of the pancreas by the tumor was diagnosed. There was no conversion to open surgery. The maximum tumor size ranged from 5 to 16 cm. The length of tumor thrombus in the IVC was 2.4-7 cm and estimated blood loss was 300-2500 ml. In one case a blood transfusion was required postoperatively. The follow-up period was 4-26 months. One patient died from progression of the disease after 5 months, two other patients are alive without any signs of relapse. The initial experience of laparoscopic radical nephrectomy with thrombectomy from IVC in patients with left-sided renal cell cancer suggests that this technique is reproducible and relatively safe with respecting of basic principles of oncology and vascular surgery. The surgery is not associated with major perioperative complications, significant blood loss and is accompanied by a rather favorable postoperative period. An accumulation of a larger number of cases is needed to assess the oncological results of this technique.

[The analysis of anesthetic management for renal cell carcinoma with associated inferior vena cava tumor thrombus].

Objective: To explore the key points of anesthetic management for renal cell carcinoma combined with inferior vena cava (IVC) tumor thrombus. Methods: Twenty-seven cases of renal cell carcinoma with inferior vena cava (IVC) tumor thrombus underwent radical nephrectomy and inferior caval venous thrombectomy were reviewed retrospectively during January 2014 to January 2017 in our hospital.Analyzed data includs demographics, classification of tumor, perioperative anesthetic management and monitoring approaches, IVC clamping time , vital signs during cardiopulmonary bypass(CPB), estimated blood loss (EBL), usage of blood products, hospitalization time and ICU time , as well as postoperative outcomes. Results: Clinical staging revealed 5 patients(18.5%) with classⅠtumor thrombus, 11 patients(40.7%) with levelⅡtumor thrombus, 6 patients (22.2%) with level Ⅲ tumor thrombus and 5 patients (18.5%) with level Ⅳ tumor thrombus. All patients had underwent a balanced general anesthesia technique with volatile agents, opioids and muscle relaxants. In addition to standard ASA monitors, all patients had direct arterial pressure and central venous pressure monitoring, and blood warming and infusing system. TEE was utilized in 9(33.3%)patients and in which contains all 5 patients(100%)with level Ⅳ tumor thrombus. Intraoperative TEE guidance resulted in a significant surgical plan modification in 1 patient(11.1%). Compared to patients with class Ⅰ(313 (136, 346) min), classⅡ(302(245, 393)min)and classⅢthrombus tumor(391(272, 505)min), patients with Class Ⅳ had longer operating time (525(481, 647)min, P<0.05). Compared to patients with Class Ⅰ(600(500, 850)ml), Class Ⅱ(1 700(750, 3 000)ml), and Class Ⅲ(1 775(1 500, 3 000)ml), patients with Class Ⅳ had more blood loss(4 000(2 000, 7 000)ml, P<0.05). The clamping time of Class Ⅰ, Class Ⅱ and Class Ⅲ was 8(8, 9)min, 20(13, 26)min and 10(6, 25)min, respectively, and there is no significant difference (P>0.05) within theses group. The probability of pumping norepinephrine of Class Ⅰ(8(8, 9)min), Class Ⅱ(20(13, 26)min), and Class Ⅲ(10(6, 25)min)had no significant difference (χ(2)=5.147, P>0.05). Perioperative mortality was 7.4%. Conclusions: The anesthetic management of Inferior vena cava (IVC) tumor thrombus is rather challenging.The preoperative evaluation with accurate classification of the tumor and the intraoperative intense monitoring of vital signs with appropriate reaction are the key points of anesthetic management for this kind of surgery.

Caval Penetration by Inferior Vena Cava Filters: A Systematic Literature Review of Clinical Significance and Management.

BACKGROUND: Limited penetration into the caval wall is an important securing mechanism for inferior vena cava (IVC) filters; however, caval penetration can also cause unintentional complications. The aim of this study was to assess the incidence, severity, clinical consequences, and management of filter penetration across a range of commercially available IVC filters. METHODS AND RESULTS: The MEDLINE database was searched for all studies (1970-2014) related to IVC filters. A total of 88 clinical studies and 112 case reports qualified for analysis; these studies included 9002 patients and 15 types of IVC filters. Overall, penetration was reported in 19% of patients (1699 of 9002), and 19% of those penetrations (322 of 1699) showed evidence of organ/structure involvement. Among patients with penetration, 8% were symptomatic, 45% were asymptomatic, and 47% had unknown symptomatology. The most frequently reported symptom was pain (77%, 108 of 140). Major complications were reported in 83 patients (5%). These complications required interventions including surgical removal of the IVC filter (n=63), endovascular stent placement or embolization (n=11), endovascular retrieval of the permanent filter (n=4), and percutaneous nephrostomy or ureteral stent placement (n=3). Complications led to death in 2 patients. A total of 87% of patients (127 of 146) underwent premature filter retrieval or interventions for underlying symptoms or penetration-related complications. CONCLUSIONS: Caval penetration is a frequent but clinically underrecognized complication of IVC filter placement. Symptomatic patients accounted for nearly 1/10th of all penetrations; most of these cases had organ/structure involvement. Interventions with endovascular retrieval and surgery were required in most of these symptomatic patients.

Pure Yolk sac presenting with inferior vena cava thrombus extending from bilateral external iliac veins to hepatic vein.

INTRODUCTION: Vena cava thrombus is an extremely rare complication of testicular tumors. We report on an unusual case of testicular tumor presenting with inferior vena cava thrombus extending from the left spermatic and bilateral external iliac veins to the hepatic vein. CASE REPORT: A-35-year old man presented with a 6-month history of left scrotal mass and a 1-day history of bilateral lower extremity edema. Computed tomography (CT) revealed the presence of thrombus extending from the left spermatic vein and bilateral external iliac veins to the hepatic vein, and multiple lymph node and lung metastases. 3 cycles of chemotherapy were given after the left high inguinal orchiectomy. Pathological examination demonstrated a pure yolk sac carcinoma with lymphovascular invasion and direct tumor extension into the left spermatic cord. CT and positron emission tompgraphy-CT obtained no findings of metastasis or recurrence at 3 months after the chemotherapy. CONCLUSION: We review this seldom case and discuss the literature with regard to its diagnosis and treatment.