Impact of Left Renal Vein Ligation on Renal Function Following En Bloc Resection of Segmental Inferior Vena Cava and Right Kidney.

BACKGROUND: Renal function after left renal vein (LRV) ligation following en bloc resection of segmental inferior vena cava (IVC) and right kidney is understudied. We assessed the impact of LRV ligation on postoperative renal function following en bloc resection of segmental IVC and right kidney. METHODS: We retrospectively reviewed 28 patients who underwent LRV ligation during en bloc resection of segmental IVC and right kidney. Patient demographics, tumor characteristics, intraoperative factors, complications, length of hospital and intensive care unit (ICU) stay, and patient survival were collected. Pre- and postoperative renal function was retrospectively analyzed. RESULTS: Twenty patients underwent robot-assisted surgery and eight patients underwent open surgery. The median operative time was 162 min and estimated blood loss was 350 mL. Ten patients had normal renal function and 12 patients had an initial increase in creatinine but improved gradually. Six patients developed acute renal failure; five patients gradually recovered in 5-32 days after temporary hemodialysis. Renal replacement therapy significantly correlated with maximal anterior-posterior diameter of the LRV (p = 0.001). Complications were observed in 11 cases, four of which were Clavien-Dindo grades I-II. Thirteen patients were alive with no recurrence, nine patients were alive with metastasis, and six cases died during the follow-up period. CONCLUSIONS: LRV ligation following en bloc resection of segmental IVC and right kidney is feasible, with no significant long-term impact on renal function. The maximum anterior-posterior diameter of the LRV is a reliable method for predicting renal replacement therapy in the absence of collateral circulation.

Use of Real-Time Cine MRI to Assess the Respirophasic Variation of the Inferior Vena Cava-Proof-of-Concept and Validation Against Transthoracic Echocardiography.

BACKGROUND: In clinical practice, the right heart filling status is assessed using the respirophasic variation of the inferior vena cava (IVC) assessed by transthoracic echocardiography (TTE) showing moderate correlations with the catheter-based reference standard. PURPOSE: To develop and validate a similar approach using MRI. STUDY TYPE: Prospective. POPULATION: 37 male elite cyclists (mean age 26 ± 4 years). FIELD STRENGTH/SEQUENCE: Real-time balanced steady-state free-precession cine sequence at 1.5 Tesla. ASSESSMENT: Respirophasic variation included assessment of expiratory size of the upper hepatic part of the IVC and degree of inspiratory collapse expressed as collapsibility index (CI). The IVC was studied either in long-axis direction (TTE) or using two transverse slices, separated by 30 mm (MRI) during operator-guided deep breathing. For MRI, in addition to the TTE-like diameter, IVC area and major and minor axis diameters were also assessed, together with the corresponding CIs. STATISTICAL TESTS: Repeated measures ANOVA test with Bonferroni correction. Intraclass correlation coefficient (ICC) and Bland-Altman analysis for intrareader and inter-reader agreement. A P value <0.05 was considered statistically significant. RESULTS: No significant differences in expiratory IVC diameter were found between TTE and MRI, i.e., 25 ± 4 mm vs. 25 ± 3 mm (P = 0.242), but MRI showed a higher CI, i.e., 76% ± 14% vs. 66% ± 14% (P < 0.05). As the IVC presented a noncircular shape, i.e., major and minor expiratory diameter of 28 ± 4 mm and 21 ± 4 mm, respectively, the CI varied according to the orientation, i.e., 63% ± 27% vs. 75% ± 16%, respectively. Alternatively, expiratory IVC area was 4.3 ± 1.1 cm2 and showed a significantly higher CI, i.e., 86% ± 14% than diameter-based CI (P < 0.05). All participants showed a CI >50% with MRI versus 35/37 (94%) with TTE. ICC values ranged 0.546-0.841 for MRI and 0.545-0.704 for TTE. CONCLUSION: Assessment of the respirophasic IVC variation is feasible with MRI. Adding this biomarker may be of particular use in evaluating heart failure patients. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY STAGE: 2.

The role of point-of-care ultrasound to monitor response of fluid replacement therapy in pregnancy.

Fluid management in obstetrical care is crucial because of the complex physiological conditions of pregnancy, which complicate clinical manifestations and fluid balance management. This expert review examined the use of point-of-care ultrasound to evaluate and monitor the response to fluid therapy in pregnant patients. Pregnancy induces substantial physiological changes, including increased cardiac output and glomerular filtration rate, decreased systemic vascular resistance, and decreased plasma oncotic pressure. Conditions, such as preeclampsia, further complicate fluid management because of decreased intravascular volume and increased capillary permeability. Traditional methods for assessing fluid volume status, such as physical examination and invasive monitoring, are often unreliable or inappropriate. Point-of-care ultrasound provides a noninvasive, rapid, and reliable means to assess fluid responsiveness, which is essential for managing fluid therapy in pregnant patients. This review details the various point-of-care ultrasound modalities used to measure dynamic changes in fluid status, focusing on the evaluation of the inferior vena cava, lung ultrasound, and left ventricular outflow tract. Inferior vena cava ultrasound in spontaneously breathing patients determines diameter variability, predicts fluid responsiveness, and is feasible even late in pregnancy. Lung ultrasound is crucial for detecting early signs of pulmonary edema before clinical symptoms arise and is more accurate than traditional radiography. The left ventricular outflow tract velocity time integral assesses stroke volume response to fluid challenges, providing a quantifiable measure of cardiac function, which is particularly beneficial in critical care settings where rapid and accurate fluid management is essential. This expert review synthesizes current evidence and practice guidelines, suggesting the integration of point-of-care ultrasound as a fundamental aspect of fluid management in obstetrics. It calls for ongoing research to enhance techniques and validate their use in broader clinical settings, aiming to improve outcomes for pregnant patients and their babies by preventing complications associated with both under- and overresuscitation.

A novel two-stage approach to the treatment of renal cell carcinoma with intra-cardiac tumour extension and Budd-Chiari syndrome.

OBJECTIVE: To present the early results of a new technique for the treatment of renal cell carcinoma with intra-cardiac tumour extension and Budd-Chiari syndrome. PATIENTS AND METHODS: The first stage involves transdiaphragmatic debulking of the right heart, inferior vena cava (IVC) and hepatic veins via median sternotomy, followed by a purse-string suture placed in the IVC below the hepatic veins. The second stage is performed separately and involves en bloc resection of the affected kidney, and IVC and vascular reconstruction via an abdominal incision. RESULTS: Three of five patients presented with clinical Budd-Chiari syndrome; two had radiological features only. The median time between surgical procedures was 12 days (IQR 13 days). Four of the five patients had a R0 resection. While all five patients successfully completed both operative stages, one patient died 22 days after the second stage. Of the remaining four, all survive with no disease recurrence. CONCLUSION: While we continue to compile longer-term data for a larger follow-up series, these preliminary findings show the feasibility of this technique and support the development of this programme of surgery.

Vena cava leiomyosarcoma surgery results in a retrospective cohort of 41 patients from two centers.

BACKGROUND: Leiomyosarcoma of the vena cava (LMS-VC) is a rare entity with poor oncological outcomes and a lack of histological staging prognostic factors. METHODS: Outcomes of consecutive patients operated on LMS-VC between March 2003 and May 2022, in two specialized sarcoma centers were reported. RESULT: Forty-one patients were identified. Median size of LMS-VC was 9 cm with 68% of complete obstruction. After surgery, severe complication rate was 30%. No postoperative mortality was reported. Microscopic complete excision was obtained for 71% of patients, R1 for 27% and one patient presented an R2 resection. Grade 3 was found in 24%. After a median follow-up of 70 months, 3 years disease-free survival (DFS) and 5 years DFS were 34% and 17%, and 3 years overall survival (OS) and 5 years OS were 74% and 50%. Distant metastasis concerned 54% of recurrences, local 7% and local and distant 5%. Multivariate analysis showed that FNCLCC grade (p < 0.001) and perioperative chemotherapy (p = 0.026) were significant factors for DFS. In multivariate analysis, FNCLCC grade was a significant factor for OS (p = 0.004). DISCUSSION: Perioperative chemotherapy may have a role to play in lowering the risk of recurrence for LMS-VC, particularly in high-grade tumor.

Deep venous thrombosis in patients with atresia of the inferior vena cava and right kidney hypoplasia (KILT syndrome): Systematic review of the literature.

Inferior vena cava (IVC) anomalies are uncommon congenital causes of deep vein thrombosis (DVT). KILT syndrome (kidney and IVC abnormalities with leg thrombosis) has only been described as case reports in the literature. Therefore, the characteristics, evaluation, and management of patients with KILT syndrome have not yet been standardized. This study aimed to systematically review and analyze the clinical and radiographic data and treatment of previously reported cases of KILT syndrome. In this systematic review, we performed a literature search of the PubMed, Scopus, and Web of Science databases in December 2023, with no restrictions on the publication date. After duplicate extractions, 4195 articles were screened. Case reports and case series reporting on KILT syndrome were included. In addition to previously published cases, we included a new case of a previously healthy 25-year-old man with KILT syndrome in the analysis. A total of 34 cases were therefore included in this study. The majority (76.5%) were male patients with a median age of 24 years. In most patients, unprovoked bilateral iliofemoral thrombosis was diagnosed, and 64.7% had left kidney abnormalities. Our study suggests that anomalies of the IVC should be suspected in all young patients, especially male patients, with proximal, recurrent, or idiopathic DVT. If an IVC anomaly is confirmed, the kidneys should be examined to monitor and preserve healthy kidneys in cases of KILT syndrome. The data collected from all patients emphasize the requirement of long-term anticoagulation and risk factor control. Surgical measures may be effective for treating symptomatic refractory cases.

Independent association between IVC filter placement and VTE risk in patients with upper gastrointestinal bleeding and isolated distal DVT: A retrospective cohort study.

BACKGROUND: The placement of inferior vena cava (IVC) filters often emerges as an alternative preventative measure against pulmonary embolism in patients with upper gastrointestinal (GI) bleeding and isolated distal deep vein thrombosis (DVT). We aimed to investigate the association of IVC filter placement and the incidence of venous thromboembolism (VTE) recurrence in this patient population. METHODS: We performed a retrospective cohort study including 450 patients with upper GI bleeding and isolated distal DVT. Propensity score matching using logistic regression was conducted to mitigate potential selection bias. Logistic regression models and additional sensitivity analyses were conducted to estimate the association between IVC filter implantation and VTE recurrence. Interaction and stratified analyses were also performed according to the background covariates. RESULTS: Patients who underwent IVC filter placement were significantly younger than patients in the surveillance group (55.8 ± 9.0 vs 58.4 ± 11.2 years, p = 0.034). Patients in the IVC filter group demonstrated a higher distal thrombus burden. The VTE recurrence composite was significantly higher in patients who underwent IVC filter placement (44.1% [45/102] vs 25% [87/348], p < 0.001). Unmatched crude logistic regression analysis identified a significant association between IVC filter placement and VTE recurrence composite (OR = 2.37; 95% CI, 1.50-3.75). Sensitivity analyses yielded congruent outcomes. CONCLUSION: This study revealed an increased risk of VTE recurrence among patients receiving IVC filter placement, suggesting that IVC filter placement may not be suitable as a primary treatment for patients with upper GI bleeding and isolated distal DVT.

Acute caval thrombosis leading to obstructive shock in the early post insertion period of an inferior vena cava filter: a case report and literature review.

BACKGROUND: Obstructive shock is extremely rare in clinical practice and is caused by acute blood flow obstruction in the central vessels of either the systemic or pulmonary circulation. Utilizing inferior vena cava filters (IVCFs) to prevent pulmonary embolism (PE) is associated with some potential complications, such as inferior vena cava thrombosis (IVCT). Shock as a direct result of IVCT is rare. We present a case of obstructive shock secondary to extensive IVCT caused by inadequate anticoagulant therapy after the placement of an IVCF. CASE PRESENTATION: A 63-year-old male patient with a traffic accident injury presented orthopaedic trauma and lower limb deep vein thrombosis (DVT). He experienced sudden and severe abdominal pain with hypotension, tachycardia, tachypnea, oliguria and peripheral oedema 5 days after IVCF placement and 3 days after cessation of anticoagulant therapy. Considering that empirical anti-shock treatment lasted for a while and the curative effect was poor, we finally recognized the affected vessels and focused on the reason for obstructive shock through imaging findings-inferior vena cava thrombosis and occlusion. The shock state immediately resolved after thrombus aspiration. The same type of shock occurred again 6 days later during transfer from the ICU to general wards and the same treatment was administered. The patient recovered smoothly in the later stage, and the postoperative follow-up at 1, 3, and 12 months showed good results. CONCLUSION: This case alerts clinicians that it is crucial to ensure adequate anticoagulation therapy after IVCF placement, and when a patient presents with symptoms such as hypotension, tachycardia, and lower limb and scrotal oedema postoperatively, immediate consideration should be given to the possibility of obstructive shock, and prompt intervention should be based on the underlying cause.

Inferior vena cava collapsibility index and stroke volume as predictors of blood transfusion in upper gastrointestinal bleeding in the emergency department.

BACKGROUND AND AIM: This study investigates the effectiveness of bedside ultrasonography in predicting blood transfusion requirements in patients with upper gastrointestinal bleeding (UGIB). It focuses on evaluating the inferior vena cava (IVC) diameter, IVC collapsibility index (CI), and stroke volume (SV) as ultrasonographic measures. METHODS: A hundred adult patients enrolled in this prospective clinical study. The patients were divided into two groups (group 1: only saline administered group, group 2: saline and blood administered group). IVC diameter, IVC CI, and SV were measured at the time of admission and after treatment. RESULTS: At the initial admission, group 1 exhibited an IVC CI of 20.4% and an SV of 65.0 mL, whereas group 2 displayed an IVC CI of 26.6% and an SV of 58.0 mL. Upon analyzing the relationship between the Glasgow-Blatchford score (GBS) and SV, we identified a significant negative correlation (r = -0.7350; P < 0.001). Similarly, a weak negative correlation was observed between the Rockall score (RS) and SV (r = -0.4718; P < 0.001). It is worth noting that patients with UGIB require blood transfusion if their SV falls below 62.5 mL, with an area under the curve (AUC) of 89.1% and a 95% confidence interval (CI) ranging from 82.8% to 95.4%. CONCLUSION: IVC CI and SV can be used as parameters to predict the need for blood transfusion in the ED in patients with UGIB.

Effect of inferior caval valve implantation on circulating immune cells and inflammatory mediators in severe tricuspid regurgitation.

BACKGROUND: Interventional valve implantation into the inferior vena cava (CAVI) lowers venous congestion in patients with tricuspid regurgitation (TR). We evaluated the impact of a reduction of abdominal venous congestion following CAVI on circulating immune cells and inflammatory mediators. METHODS: Patients with severe TR were randomized to optimal medical therapy (OMT) + CAVI (n = 8) or OMT (n = 10). In the OMT + CAVI group, an Edwards Sapien XT valve was implanted into the inferior vena cava. Immune cells and inflammatory mediators were measured in the peripheral blood at baseline and three-month follow-up. RESULTS: Leukocytes, monocytes, basophils, eosinophils, neutrophils, lymphocytes, B, T and natural killer cells and inflammatory markers (C-reactive protein, interferon-gamma, interleukin-2, -4, -5, -10, and tumor necrosis factor-alpha) did not change substantially between baseline and three-month follow-up within the OMT + CAVI and OMT group. CONCLUSION: The present data suggest that reduction of venous congestion following OMT + CAVI may not lead to substantial changes in systemic inflammation within a short-term follow-up. CLINICAL TRIAL REGISTRATION: NCT02387697.

Assessment of volume status of pediatric hemodialysis patients.

BACKGROUND: Accurate volume status assessment and dry weight achievement are the most challenging goals for a nephrologist. We aimed to evaluate the role of ultrasonographic parameters including lung ultrasound and inferior vena cava (IVC) measurements as practical methods of volume status assessment in children on hemodialysis by comparing them with established techniques, such as clinical evaluation and bioimpedance spectroscopy. METHODS: A prospective cross-sectional study compared pre- and post-dialysis volume status using bioimpedance spectroscopy (BIS) parameters and clinical data with ultrasonographic lung B-lines and IVC parameters in children on regular hemodialysis. RESULTS: A total 60 children (mean age 9.4 ± 2.8 years) were enrolled. Twenty patients (33.3%) were clinically overloaded to varying degrees (17 patients had mild to moderate signs of fluid overload and 3 patients had moderate to severe signs of fluid overload). All other patients (66.7%) were clinically euvolemic. Sonographic parameters were significantly lower post-dialysis than pre-dialysis, including lung B-line count and IVC diameter. IVC collapsibility index mean was significantly higher post-dialysis than pre-dialysis. There was a significant correlation between the lung B-line count, IVC parameters, and BIS-measured overhydration both before and after hemodialysis. Nine patients had ≥ 8 B-lines post-dialysis, only three of them were hypertensive. CONCLUSIONS: Clinical criteria alone are not specific for determining accurate fluid status in pediatric hemodialysis patients. Lung B-line score, IVC parameters, and BIS may be complementary to each other and to clinical data. Lung B-lines outperform IVC measurements and BIS in subclinical volume overload detection in pediatric hemodialysis patients.

Inferior vena cava reconstruction with non-fascial autologous peritoneum: Retrospective study and literature review.

BACKGROUND: Inferior vena cava (IVC) resection is essential for complete (R0) excision of some malignancies. However, the optimal material for IVC reconstruction remains unclear. Our objective is to demonstrate the efficacy, safety, and advantages of using Non-Fascial Autologous Peritoneum (NFAP) for IVC reconstruction. To conduct a literature review of surgical strategies for tumors involving the IVC. METHODS: We reviewed all IVC reconstructions performed at our institution between 2015 and 2023. Preoperative, operative, postoperative, and follow-up data were collected and analyzed. RESULTS: A total of 33 consecutive IVC reconstructions were identified: seven direct sutures, eight venous homografts (VH), and 18 NFAP. With regard to NFAP, eight tubular (mean length, 12.5 cm) and 10 patch (mean length, 7.9 cm) IVC reconstructions were performed. Resection was R0 in 89% of the cases. Two patients had Clavien-Dindo grade I complications, 2 grade II, 2 grade III and 2 grade V complications. The only graft-related complication was a case of early partial thrombosis, which was conservatively treated. At a mean follow-up of 25.9 months, graft patency was 100%. There were seven recurrences and six deaths. Mean overall survival (OS) was 23.4 months and mean disease-free survival (DFS) was 14.4 months. According to our results, no statistically significant differences were found between NFAP and VH. CONCLUSIONS: NFAP is a safe and effective alternative for partial or complete IVC reconstruction and has many advantages over other techniques, including its lack of cost, wide and ready availability, extreme handiness, and versatility. Further comparative studies are required to determine the optimal technique for IVC reconstruction.

ET1 acts as a potential plasma biomarker and therapeutic target in deep venous thrombosis rat model.

Deep venous thrombosis (DVT) is the third leading cause of death in cardiovascular disease, following heart attacks and strokes. Early diagnosis and intervention are crucial for effective DVT therapy. We aim to investigate whether endothelin-1 (ET-1) could serve as an early diagnostic marker or a potential therapeutic target in a DVT rat model. CCK8 assay, invasion assay, and flow cytometry were used to detect the proliferation, migration and apoptosis of HUVECs, respectively. Elisa assay was used to detect ET-1 and coagulation factor VII in cell supernatant and rat?s plasma. Western blot was used to detect antioxidant signaling protein. Inferior vena cava stenosis was used to construct the DVT rat model. Lentivirus mediated overexpression of ET-1 in HUVECs impaired the cell proliferation and migration, increased cell apoptosis, inhibited the antioxidant signaling pathway proteins expression (e.g., NQO1, GCLC, Nrf-2), and upregulated coagulation factor VII. Furthermore, overexpression of ET-1 further impaired antioxidant signaling pathway protein in response to H2O2 treatment. However, lentivirus mediated ET-1 knockdown and BQ123 (an ET-1 inhibitor), showed the opposite results with ET-1 overexpression. We then established a DVT rat model by inferior vena cava stenosis. The stenosis induced early expression of ET-1 and coagulation factor VII in plasma at day 1 and restore their level at day 10. BQ123 could downregulate the coagulation factor VII to ameliorate the stenosis effects. Our findings suggest that ET-1 might serve as an early diagnostic marker for DVT rat model and a potential therapeutic target for treating DVT.

Does Pelvic Floor Muscle Exercise Change the Hemodynamic Responses of the Inferior Vena Cava in Pregnant Women? A Prospective-Controlled Study.

INTRODUCTION AND HYPOTHESIS: This study was aimed at exploring the immediate impacts of pelvic floor muscle exercises (PFMEs) on various maternal physiological parameters in pregnant women. METHODS: The study included a total of 52 women, 26 pregnant (Pregnant group: 28.04±6.01 years; 26.83±3.81 kg/m2) and 26 nonpregnant (Control group: 29.42±5.73 years; 25.41±3.03 kg/m2) individuals. All women received PFME as follows: PFME was performed for 5 min (6-s holding contraction, 10 s of relaxation, 3 rapid PFM contractions). Evaluations were conducted before, immediately after, and 5 min post-exercise, with measurements including inferior vena cava (IVC) diameters and pulsatility index, blood pressure, oxygen saturation, and heart rates. Two-way analysis of variance was performed for group and time comparisons in repeated measurements. RESULTS: In both groups, the IVC collapsibility index values were lower 5 min after exercise, although this decrease, although clinically significant, did not reach statistical significance (p = 0.057). Post-exercise systolic blood pressure significantly decreased in both groups, whereas diastolic blood pressure decreased significantly in the pregnant group (p = 0.001, p = 0.023). CONCLUSIONS: The study found no statistically significant changes in the collapsibility index of the IVC after PFME but observed a clinically suggestive decrease. The clinical decrease in the collapsibility index can be interpreted as PFME in the supine position increasing venous return. Additionally, PFME was found not to alter maternal and fetal heart rates but contributed to the decrease in maternal systolic and diastolic blood pressure. Our study supports the view that the acute effects of PFME neither induce fetal stress nor pose maternal risks.

A change in strategy for filter choice leads to improved filter retrieval rates.

OBJECTIVE: To assess whether a new strategy for the choice of inferior vena cava filter placed would improve filter retrieval rates at our institution. METHODS: Consecutive patients who underwent retrievable filter placement for temporary embolic protection between January 2021 and January 2023 were considered for study inclusion. Risk factors for nonretrieval of short-term filters were identified in patients receiving filters between January 2021 and January 2022 (prestrategy group). For patients treated between February 2022 and January 2023 (poststrategy group), a long-term filter was recommended for those with these risk factors, and a short-term filter was recommended for those without these risk factors. RESULTS: The study population included 303 patients (prestrategy group, n = 154; poststrategy group, n = 149). Long-term immobilization (odds ratio [OR] = 38.000; 95% confidence interval [CI]: 6.858-210.564), active cancer (OR = 17.643; 95% CI: 5.462-56.993), and venous thromboembolism detected in the intensive care unit (OR = 28.500; 95% CI: 7.419-109.477) were identified as independent risk factors for nonretrieval of short-term filters. The total retrieval rate was significantly higher in the poststrategy group (87.2%) than in the prestrategy group (72.7%; P = 0.002); the short-term filter retrieval rate was also significantly higher in the poststrategy group (84.5%) than in the prestrategy group (68.5%; P < 0.001). CONCLUSION: The proposed strategy for filter choice based on risk factors for short-term filter nonretrieval can accurately identify patients who need long-term filter placement while also increasing the retrieval rates for both short-term filters retrieval rates and overall retrieval rates.

The inferior vena cava filter placement parameters may predict filter retrieval outcomes.

OBJECTIVE: We aimed to investigate the potential correlation between the placement factors of various retrievable inferior vena cava filters and retrieval outcomes. Additionally, we aimed to identify the factors affecting the placement tilt of the filter. MATERIALS AND METHODS: This retrospective study was conducted at a tertiary care center to investigate patients who had previously undergone retrievable filter placement at our center and who subsequently had their filters removed between January 2020 and December 2021. Patient characteristics and filter-related factors were recorded. Complex filter retrieval was defined as cases that required a minimum of 8 minutes of fluoroscopy or that involved advanced techniques. Regression models were used to explore patient- and placement procedure-related factors that could influence retrieval outcomes and the placement tilt angle. RESULTS: The study included 163 patients, and all filters were successfully retrieved. Thirty-seven (22.7%) retrievals were classified as complex retrievals. The mean diameter of the inferior vena cava in the preplacement position for the entire cohort was 16 ± 1.8 mm. The median filter tilt angles at placement and retrieval were 5.0° (IQR, 1.8°- 9°) and 4.6° (IQR, 2.1°-8.0°), respectively. The placement tilt angle was not significantly associated with complex retrieval (p=0.59). The filter hook abutment to the vena cava wall (OR, 10.76, p = 0.003), dwell time (OR, 1.02, p =0.029), and diameter of the vena cava (OR, 10.21, p < 0.001) were associated with complex retrieval. The diameter (p=0.049), age (p=0.049), and filter brand (p=0.001) were found to be significantly associated with placement tilt. CONCLUSIONS: The inferior vena cava diameter at the time of placement predicts difficulty in filter retrieval. In addition, the filter hook abutting the IVC wall and long indwelling time may complicate retrieval. The vena cava diameter is also closely related to the degree of filter tilt.

The Degree of Inferior Vena Cava Filter Tilt Associated with Challenging Retrieval.

OBJECTIVE: Inferior vena cava (IVC) filter tilt is associated with technical difficulties at the time of retrieval. However, the degree of tilt that predisposes patients to undergo complex or failed retrieval has not been defined. METHODS: The electronic charts of patients undergoing IVC filter removal between 2010 and 2019 at a single tertiary center were reviewed. Patient and procedural characteristics were recorded. Venograms of placement and retrieval procedures were reviewed, and IVC filter tilt was determined based on its deviation from the IVC axis. IVC diameter and the distance from the lowest renal vein were measured using corresponding filter's length for calibration. All measurements were performed by 3 reviewers and confirmed by 2 reviewers. Patients were divided into 2 groups: those who underwent successful removal procedures requiring standard retrieval methods ("simple retrieval group") and those who required advanced endovascular techniques or had failed completely IVC filter retrievals ("challenging retrieval group"). A regression analysis was performed to determine factors associated with challenging retrieval. RESULTS: There were 365 patients who underwent IVC filter retrieval (n=294 (80.6%) and n=71 (19.4%) in the simple and challenging groups, respectively) with no difference in age, sex, comorbidities or indication between the 2 groups. Failed retrieval occurred in 21 patients (5.8%) and was more common among patients requiring advanced endovascular techniques compared to standard techniques (18.0% vs. 3.2%, p < 0.001). In the overall cohort, the mean filter tilt at the time of retrieval was 4.9° ± 4.4° [0 - 27°], and 145 patients (39.7%) had a filter tilt ≥ 5.0°. Compared to the simple retrieval group, patients in the challenging group had significantly longer dwell time, greater tilt of IVC filter during placement and retrieval, as well as higher tilt change between the 2 venograms. There was no correlation between the access site during placement and challenging retrieval. However, patients undergoing filter placement via right jugular vein had lower filter tilt as compared to femoral access. Patients with filter tilt ≥ 5.0° were more likely to have a challenging filter retrieval compared to patients with ˂ 5.0° tilt (29.7% vs 12.7%, p<0.001). Regression analysis showed that tilt ≥ 5.0° (OR=1.18 [1.11-1.25]), dwell time (OR=1.04 [1.01-1.07]), and age (OR=0.97 [0.95-0.99]) were independently associated with challenging retrieval. CONCLUSION: IVC filter tilt ≥ 5.0°, dwell time and age are associated with challenging retrieval. Right jugular vein access, multiple imaging projections, and careful filter manipulation during deployment should be considered to maintain tilt at ˂ 5.0° and decrease the likelihood of challenging retrieval.

Circumferential Inferior Vena Cavectomy Without Caval Replacement in the Management of Renal Cell Carcinoma with Tumor Thrombus.

PURPOSE OF REVIEW: Renal cell carcinoma presents a unique proclivity for vascular involvement giving rise to a peculiar form of locally advanced disease so-called tumor thrombus. To date, the only curative strategy for these cases remains surgery, which should aim to remove every vestige of macroscopic disease. Most of the preexisting literature advocates opening the vena cava to allow tumor thrombus removal and subsequent venous suture closure. However, inferior vena cava circumferential resection (cavectomy) without caval replacement is possible in the majority of cases since progressive occlusion facilitates the development of a collateral venous network aimed at maintaining cardiac preload. RECENT FINDINGS: Radical nephrectomy with tumor thrombectomy remains a surgical challenge not exempt of operative complications even in experienced hands. In opposition to what traditional cavotomy and thrombus withdrawal can offer, circumferential cavectomy without caval replacement would provide comparable or even better oncologic control, decrease the likelihood of operative bleeding, and prevent the development of perioperative pulmonary embolism. This review focuses on the rationale of circumferential IVC resection without caval replacement and the important technical aspects of this approach in cases of renal cell carcinoma with vascular involvement. We also include an initial report on the surgical outcomes of a contemporary series of patients managed under this approach at our center.

An inferior vena cava-priority approach in laparoscopic isolated hepatic caudate lobectomy.

PURPOSE: Laparoscopic isolated caudate lobectomy is still a challenging operation for surgeons. The access route of the operation plays a vital role during laparoscopic caudate lobectomy. There are few references regarding this technique. Here, we introduce a preferred inferior vena cava (IVC) approach in laparoscopic caudate lobectomy. METHODS: Twenty-one consecutive patients with caudate hepatic tumours between June 2016 and December 2021 were included in this study. All of them received laparoscopic caudate lobectomy involving an IVC priority approach. The IVC priority approach refers to prioritizing the dissection of the IVC from the liver parenchyma before proceeding with the conventional left or right approach. It emphasizes the importance of the IVC dissection during process. Clinical data, intraoperative parameters and postoperative results were evaluated. Sixteen patients were performed pure IVC priority approach, while 5 patients underwent a combined approach. We subsequently compared the intraoperative and postoperative between the two groups. RESULTS: All 21 patients were treated with laparoscopic technology. The operative time was 190.95 ± 92.65 min. The average estimated blood loss was 251.43 ± 247.45 ml, and four patients needed blood transfusions during the perioperative period. The average duration of hospital stay was 8.43 ± 2.64 (range from 6.0 to 16.0) days. Patients who underwent the pure inferior vena cava (IVC) approach required a shorter hepatic pedicle clamping time (26 vs. 55 min, respectively; P < 0.001) and operation time (150 vs. 380 min, respectively; P = 0.002) than those who underwent the combined approach. Hospitalization (7.0 vs. 9.0 days, respectively; P = 0.006) was shorter in the pure IVC group than in the combined group. CONCLUSIONS: Laparoscopic caudate lobectomy with an IVC priority approach is safe and feasible for patients with caudate hepatic tumours.

Perioperative outcomes of utilizing infrahepatic inferior vena cava clamping and Pringle maneuver during hepatectomy: a meta-analysis.

PURPOSE: Intraoperative bleeding during hepatectomy is primarily controlled through anaesthesiological interventions or surgical techniques such as Pringle maneuver (PM). Infrahepatic IVC clamping (IIVCC) is an alternative surgical technique to reduce central venous pressure and prevent retrograde hepatic venous bleeding. The aim of the meta-analysis was to compare IIVCC+PM with PM alone in terms of intraoperative outcomes and perioperative complications. METHODS: Medline, Cochrane Library, Scopus, Web of Science, and EMBASE were searched for comparative studies till 16.04.2024, resulting in 679 articles, of which eight studies met inclusion criteria. Data on patient demographics, surgical technique, and perioperative outcomes was assessed. Cochrane Risk of Bias 2.0 (RoB 2.0) Tool and Newcastle-Ottawa Scale (NOS) were used for risk of bias assessment. RESULTS: Two randomized controlled trials, one prospective, and five retrospective cohort studies with 358 patients in IIVCC+PM and 397 patients in PM alone group were included. IIVCC+PM resulted in significantly greater CVP reduction, less intraoperative blood loss (MD (95% CI) = - 233.03 (- 360.48 to - 105.58), P < 0.001), and less intraoperative blood transfusion (OR (95% CI) = 0.38 (0.25 to 0.57), P < 0.001) compared to PM alone. The two groups had comparable total operative time, transection time and total intraoperative fluid infusion. Patients undergoing IIVCC+PM had significantly shorter length of stay (MD (95% CI) = - 0.63 days (- 1.21 to - 0.05 days), P = 0.03) and overall complication rates (OR (95% CI) = 0.63 (0.43-0.92), P = 0.02) compared to PM alone group. CONCLUSION: The utilization of IIVCC along with PM during liver resection may be beneficial in reducing intraoperative bleeding and blood transfusion without adversely influencing operative times or perioperative outcomes compared to PM alone.