Supply Costs in Complex and Routine Inferior Vena Cava Filter Retrieval: 10 Years' Data from a Single Center.

PURPOSE: To characterize the medical supply costs associated with inferior vena cava filter retrieval (IVCFR) using endobronchial forceps (EFs), a snare, or Recovery Cone (RC). MATERIALS AND METHODS: In total, 594 of 845 IVCFRs attempted at a tertiary referral hospital between October 1, 2012, and June 20, 2022 were categorized by intended retrieval strategy informed by, rotational cavography as follows: (a) EF (n = 312) for tilted or tip-embedded/strut-embedded filters and for long-dwelling closed-cell filters and (b) a snare (n = 255) or (c) RC (n = 27) for other well-positioned filters with or mostly without hooks, respectively. List prices of relevant supplies at time of retrieval were obtained or, rarely, estimated using a standard procedure. Contrast use, fluoroscopic time, filter type, dwell time, and patient age and sex were recorded. Mean between-group cost differences were estimated by linear regression, adjusting for date. Additional models evaluated filter type, dwell time, and patient-level effects. RESULTS: Of the 594 IVCFRs, 591 were successful, whereas 2 EF and 1 snare retrievals failed. Moreover, 4 EF retrievals were successful with a snare and 2 with smaller EF, 12 snare retrievals were successful with EF, 1 RC retrieval was successful with a snare and 2 with EF. Principal model indicated a significantly lower mean cost of EF ($564.70, SE ± 9.75) than that of snare ($811.29, SE ± 10.83; P < .0001) and RC ($1,465.48, SE ± 47.12; P < .0001) retrievals. Adjusted models yielded consistent results. Had all retrievals been attempted with EF, estimated undiscounted full-period supplies savings would be $87,201.51. CONCLUSIONS: EFs are affordable for complex IVCFR, and extending their use to routine IVCFR could lead to considerable cost savings.

Imaging predictors for assessment of inferior vena cava wall invasion in patients with renal cell carcinoma and inferior vena cava tumor thrombus: a retrospective study.

BACKGROUND: Renal cell carcinoma (RCC) has the propensity to lead to venous tumor thrombus (VTT). Nephrectomy with tumor thrombectomy is an effective treatment option but is a technically challenging surgical procedure that is accompanied by a high rate of complications. The aims of this study were to investigate pre-operative imaging parameters for the assessment of inferior vena cava (IVC) wall invasion due to a tumor thrombus in patients with RCC and to identify predictors from the intra-operative findings. METHODS: Clinical and imaging data were collected from 110 patients who underwent nephrectomy with IVC tumor thrombectomy (levels I-IV) for RCC and IVC tumor thrombus at the Peking University Third Hospital between May 2015 and March 2018. Univariable and multivariable logistic regression and receiver operating characteristic curves were used to assess the correlations between pre-operative imaging features and intra-operative macroscopic invasions of the IVC wall by tumor thrombus. RESULTS: Among the 110 patients, 41 underwent partial or segmental resection of IVC. There were univariate associations of pre-operative imaging parameters that could be used to predict the need for IVC resection, including those of the Mayo classification, maximum anterior-posterior (AP) diameter of the renal vein at the renal vein ostium (RVo), maximum AP diameter of the VTT at the RVo and IVC occlusion. For the multivariable analysis, the AP diameter of the VTT at the RVo and IVC occlusion were associated with a significantly increased risk of invasion of the IVC wall by tumor thrombus. The optimum imaging thresholds included an AP diameter of the VTT at the RVo larger than 17.0 mm and the presence of IVC occlusion, with which we predicted invasions of the IVC wall requiring IVC resection. The probabilities of intra-operative IVC resection for patients without both independent factors, with an AP diameter of the VTT at the RVo larger than 17.0 mm, with IVC occlusion, and with both concurrent factors were 5%, 23%, 56%, and 66%, respectively. CONCLUSION: An increase in the AP VTT diameter at the RVo and the presence of complete occlusion of the IVC are independent risk factors for a high probability of IVC wall invasion by tumor thrombus.

Direct venous pressure assessment pre-renal transplantation to optimise graft venous drainage.

BACKGROUND: Renal transplantation is the modality of choice in the treatment of end-stage kidney disease. Surgically challenging aspects of renal transplantation may include creation of vascular anastomoses where there is complex vascular anatomy. We present a paediatric case of living-related donor (LRD) renal transplantation in whom direct intravenous pressure measurement guided the management of the vascular anastomoses in the context of inferior vena cava (IVC) obstruction. CASE-DIAGNOSIS/TREATMENT: During venography for transplant assessment, 150 mL of 0.9% sodium chloride was infused for over 20 s into well-developed collateral paravertebral veins to simulate the anticipated high-volume venous return from an implanted kidney. Direct venous pressure measurements were 20 mmHg in the right paravertebral vein and 19 mmHg in the left paravertebral vein. We were reassured by this result that the collateralised venous system could sustain the high venous drainage and maintain the arteriovenous (AV) gradient required for adequate graft perfusion. Intra-operative measurement at the time of transplantation, following release of venous clamps, of 22 mmHg supported the validity of this approach. CONCLUSIONS: In children with complex venous anatomy pre-transplant, direct intravenous pressure measurement may provide a useful adjunct in deciding which vessel is most suitable for transplant anastomosis.

Saline Contrast Transesophageal Echocardiography in Fontan Patients: Assessment of the Presence, Type, and Size of Right to Left Shunts.

Right to left (R-L) shunts resulting in cyanosis or systemic embolization occur after the Fontan procedure. The primary modality of diagnosing these is angiography. Successful delineation of these shunts in Fontan patients using selective saline contrast transesophageal echocardiography (SCTEE) may allow for reduced radiation and contrast exposure. We hypothesized that SCTEE could accurately determine the presence, type, and semiquantitative shunt size of R-L shunts in Fontan patients. SCTEE was performed in Fontan patients undergoing angiography for clinical indications. Injections were performed in six sites: mid-Fontan, right and left pulmonary arteries, superior and inferior vena cavae, and innominate vein. R-L shunt size was subjectively graded as 0 = absent, 1 = small, and 2 = medium or large based on echo contrast density in the left atrium. SCTEE was compared to angiography. 33 patients with Fontan were studied with median age 15 years, median weight 50.1 kg, and median O2 saturation of 90% in the R-L shunt group and 95% in the no R-L shunt group. R-L shunt types included intracardiac shunts (ICS), veno-venous collaterals (VVCs), arteriovenous malformations (AVMs), and their combinations. SCTEE versus angiography results were the same for the presence, type, and size of R-L shunts in 79% (26/33). SCTEE identified shunts in 88% (29/33). Angiography identified shunts in 85% (28/33). Neither method missed any medium or large R-L shunts. SCTEE and angiography had similar accuracy. SCTEE accurately detected the presence, type, and size of R-L shunts in most Fontan patients in this study. This can be used to guide targeted angiography, reducing radiation exposure and contrast load.

Vena Cavoscopy in the Assessment of Intraluminal Vena Caval Tumor Involvement.

OBJECTIVE: To improve confirmation of complete tumor thrombus removal in advanced malignancy, we report on our experience using intraoperative vena cavoscopy using a flexible cystoscope to confirm complete thrombus resection. Patients with renal cell carcinoma or testicular cancer associated with inferior vena caval tumor involvement benefit from surgical resection of the primary tumor and the tumor thrombus. Intraoperative assessment of the vena cava represents a technical challenge, particularly when the thrombus is friable and involves the hepatic veins, or there is caudal extension of thrombus toward the bifurcation. MATERIAL AND METHODS: From 2006 to 2014, 36 patients underwent tumor thrombectomy and vena cavoscopy. When residual caval thrombus was suspected, a flexible cystoscope was inserted into the vena cava for direct visual inspection of the caval lumen. Perioperative outcomes including residual tumor, changes in management, and postoperative complications were analyzed. RESULTS: All patients underwent endoscopy of the caval lumen without complications. Eight of 36 (22%) patients were found to have residual tumor thrombus visualized during cavoscopy. Five of these patients had evidence of residual mass and caval invasion within the caval lumen that ultimately resulted in cavectomy. Two patients had residual tumor thrombus that was bluntly removed. One patient was found to have significant involvement of the hepatic veins. CONCLUSION: Vena cavoscopy using a flexible cystoscope is a practical technique that may be utilized intraoperatively to ensure clearance of residual thrombus burden within the inferior vena cava and to assess for caval invasion.

Money well spent? A cost and utilization analysis of prophylactic inferior vena cava filter placement in high-risk trauma patients.

BACKGROUND: Inferior vena cava filters (IVCF) for venous thromboembolic prophylaxis in high-risk trauma patients is a controversial practice. Utilization of IVCF prophylaxis was evaluated at a level 1 trauma center. Daily cost of IVCF prophylaxis, time to IVCF, duration between IVCF and chemoprophylaxis, and number of patients needed to treat (NNT) to prevent pulmonary embolism (PE) was calculated. METHODS: A retrospective review of prophylactic IVCF over a 5-year period (2010-2014). Demographic, physiologic, injury, procedural, and outcome data were abstracted from the administrative trauma database. Medicare fees and days without chemoprophylaxis were used to determine daily IVCF cost. NNT was calculated using PE events in a cohort without IVCF. RESULTS: Over the 5-year period, 146 patients with mean age 56.3 y (SD ± 24.2), 67.8% male, underwent prophylactic IVCF. Predominant mechanisms of injuries were falls (45.9%) and motor vehicle accidents (20.5%) with median Injury Severity Score of 25 (intraquartile range [IQR] 16-29) and head Abbreviated Injury Score of 3 (IQR 3-5). Most common operative interventions required in 24.7% were orthopedic (25.3%) and neurosurgical (21.9%). Median time to IVCF was 78 h (IQR 48-144). Most common IVCF indications were closed head injury (48.6%) and spinal injuries (30.8%). Median time to administration of chemoprophylaxis was 96 h after IVCF (IQR 24-192) in 57.5%. Median IVCF cost was $759/d (IQR $361-$1897) compared with $4.32 for chemoprophylaxis. PE occurred in 0.26% without IVCF. PE did not occur with prophylactic IVCF. Estimated NNT was 379 (95% CI 265, 661). CONCLUSIONS: Prophylactic IVCF placement is a costly practice with relatively low benefit. Anticipated time without chemoprophylaxis and patient criteria should be considered before routine IVCF placement.

Retrievable Inferior Vena Cava Filters in Trauma Patients: Prevalence and Management of Thrombus Within the Filter.

OBJECTIVE: The incidence of thrombus was investigated within retrievable filters placed in trauma patients with confirmed DVT at the time of retrieval and the optimal treatment for this clinical scenario was assessed. A technique called "filter retrieval with manual negative pressure aspiration thrombectomy" for management of filter thrombus was introduced and assessed. METHODS: The retrievable filters referred for retrieval between January 2008 and December 2015 were retrospectively reviewed to determine the incidence of filter thrombus on a pre-retrieval cavogram. The clinical outcomes of different managements for thrombus within filters were recorded and analyzed. RESULTS: During the study 764 patients having Aegisy Filters implanted were referred for filter removal, from which 236 cases (134 male patients, mean age 50.2 years) of thrombus within the filter were observed on initial pre-retrieval IVC venogram 12-39 days after insertion (average 16.9 days). The incidence of infra-filter thrombus was 30.9%, and complete occlusion of the filter bearing IVC was seen in 2.4% (18) of cases. Retrieval was attempted in all 121 cases with small clots using a regular snare and sheath technique, and was successful in 120. A total of 116 cases with massive thrombus and IVC occlusion by thrombus were treated by CDT and/or the new retrieval technique. Overall, 213 cases (90.3%) of thrombus in the filter were removed successfully without PE. CONCLUSIONS: A small thrombus within the filter can be safely removed without additional management. CDT for reduction of the clot burden in filters was effective and safe. Filter retrieval with manual negative pressure aspiration thrombectomy seemed reasonable and valuable for management of massive thrombus within filters in some patients. Full assessment of the value and safety of this technique requires additional studies.

Different surgical strategies of patients with intravenous leiomyomatosis.

Intravenous leiomyomatosis (IVL) is a rare benign tumor. The study aimed to assess outcomes of patients treated surgically for IVL.Between November 2002 and January 2015, 76 patients were treated for IVL. The stage of IVL was evaluated preoperatively by echocardiography and enhanced computerized tomography (CT) scan, and graded into 4 stages according to intravascular tumor progression. We recorded age, lower limb edema before surgery, surgical parameters, and hospitalization expenses. Patients were followed up every 6 months and tumor recurrence was assessed by CT and ultrasound. Patients were followed up for a mean of 4.5 ±â€Š2.5 years (range 1-13 years) and there was no operative, hospital, or long-term mortality or were lost to follow-up.The rate of lower extremity edema, amount of blood loss, postoperative transfusion, length of intensive care unit (ICU) stay, postoperative hospitalization, and hospitalization expenses differed significantly between patients at different presurgery stages. Tumors recurred in 4 of 7 patients with stage I IVL that opted for surgery that preserved the ovaries and uterus. No recurrence was observed in patients graded stage II or more, in all of which the uterus and ovaries were removed. Recurrence was observed in only 4 of 76 cases of IVL, all of whom opted for surgery that spared the ovaries and uterus.Different surgical strategies should be decided based on the staging to completely remove the tumor and ensure the safety of patients. Removal of both ovaries is necessary for inhibiting tumor growth and avoiding recurrence.

Computerized tomography angiography in preoperative assessment of intravenous leiomyomatosis extending to inferior vena cava and heart.

BACKGROUND: Intravenous leiomyomatosis (IVL) extending to inferior vena cava and heart is one of the most challenging conditions for surgical treatment. We explored the use of computerized tomography angiography (CTA) in preoperative assessment for this disease. METHODS: A cohort of 31 patients with IVL extending to inferior vena cava and heart were reviewed from the year 2002 to 2014, focusing on the preoperative CTA imaging characteristics and the surgical procedures in clinical treatment. RESULTS: All patients were diagnosed correctly combining the clinical medical history and CTA imaging. Thirteen patients had tumors confined within the inferior vena cava, and 18 patients had tumors intruding into the right heart. Furthermore, 15 tumors were located in the right atrium alone, and 3 tumors involved both the right atrium and the right ventricle. All patients had simple or multiple soft tissue masses from the pelvis, with 22 tumors extending into inferior vena cava through the iliac veins and 9 tumors through the ovarian veins. Three patients had tumors invading into lung and underwent tumor thrombus resection in the pulmonary artery. Patients received either one-stage surgery or two-stage surgery dependent on patient general condition and tumor status. All operations were successfully performed by multidisciplinary cooperation, including gynecology, cardiac surgery, and vascular surgery, without severe surgical-related complications or deaths. CONCLUSIONS: CTA imaging can present location, size, and full-scale extension pathway of IVL lesions, and can be used as first-line imaging technique in preoperative assessment, having great significance in making surgical plan and obtaining successful outcome.

Incidence, risk factors, and management options for portal vein thrombosis after hepatectomy: a 14-year, single-center experience.

BACKGROUND: Portal vein thrombosis (PVT) after hepatectomy is rare; however, it increases mortality and morbidity. Few studies have been conducted that focused on PVT following major hepatectomy. METHODS: Patients who underwent hepatectomy at a single institution were retrospectively reviewed, and risk factors and management options were evaluated. RESULTS: Of the 1,193 patients undergoing hepatectomy, 25 patients developed PVT. Right-sided hepatectomy, caudate lobectomy, splenectomy, and postoperative bile leakage were independent risk factors for PVT following hepatectomy. PVT occurred more frequently after major hepatectomy compared with minor hepatectomy. Increased instability and reduced portal venous flow caused by kinking was the reason for increasing the risk of PVT after right-sided hepatectomy with caudate lobectomy. The new operative procedure, suturing the posterior wall of the portal vein with the anterior wall of the inferior vena cava, was effective for reducing the risk of PVT following right-sided hepatectomy. Operative thrombectomy showed significant benefits for PVT detected within 5 days after hepatectomy. CONCLUSIONS: PVT frequently occurs following major hepatectomy. Urgent operative thrombectomy is strongly recommended for PVT with early detection.

Comparison between transthoracic echocardiography and cardiac magnetic resonance imaging in patients status post atrial switch procedure.

OBJECTIVES: This study compares image quality, cost, right ventricular ejection fraction analysis, and baffle visualization between transthoracic echocardiography and cardiac magnetic resonance imaging in those status post atrial switch for transposition of the great arteries. BACKGROUND: This population requires imaging for serial evaluations. Transthoracic echocardiography is often first line but has drawbacks, many of which are addressed by cardiac magnetic resonance imaging. METHODS: Twelve patients (mean age 25 years) with relatively concurrent (mean 157 days) studies were included. Three separate echocardiography and magnetic resonance imaging physicians independently analyzed baffles, image quality, and right ventricular ejection fractions. Institutional and Medicaid charges were compared. RESULTS: For right ventricular ejection fraction, echocardiography (36.1%) underestimated cardiac magnetic resonance imaging (47.8%, P = .002). Image quality for transthoracic echocardiography was significantly rated lower than cardiac magnetic resonance imaging (P = .002). Baffles were better seen in cardiac magnetic resonance imaging (transthoracic echocardiography vs. cardiac magnetic resonance imaging: superior vena cava 86% vs. 100% [P = .063]; inferior vena cava 33% vs. 97% [P = .002]; pulmonary vein 92% vs. 100% [P = .250]). Comparing hospital charges and Medicaid reimbursement, transthoracic echocardiography respectively costs 18% and 38% less than cardiac magnetic resonance imaging. CONCLUSIONS: In conclusion, transthoracic echocardiography underestimated right ventricular ejection fraction compared to cardiac magnetic resonance imaging. Cardiac magnetic resonance imaging had consistently higher image quality and better visualization of the baffles. Cost differences are minimal. We propose that cardiac magnetic resonance imaging be considered first line for imaging in certain patients' status post atrial switch procedure.

Comparison of survival and quality of life of hepatectomy and thrombectomy using total hepatic vascular exclusion and chemotherapy alone in patients with hepatocellular carcinoma and tumor thrombi in the inferior vena cava and hepatic vein.

BACKGROUND: The prognosis for hepatocellular carcinoma (HCC) along with portal vein tumor thrombi (PVTT) is poor, and surgery has not been considered an option. AIMS: To compare the outcomes and the quality of life (QoL) of patients with HCC and PVTT who underwent hepatic resection and thrombectomy for tumor thrombi in the inferior vena cava and hepatic vein with total hepatic vascular exclusion to the patients who received only chemotherapy. METHODS: We retrospectively reviewed the medical records of patients who received hepatectomy and thrombectomy (n=65), and those who received only chemotherapy (n=50). The surgical outcomes, survival, and QoL that was determined using the Functional Assessment of Cancer Therapy-Hepatobiliary instrument were analyzed and compared. RESULTS: Patients who underwent surgery had a median overall survival of 17 months, compared with patients who underwent chemotherapy for 8 months (P<0.0001). Patients who underwent surgery had a median recurrence-free survival of 14 months, as compared with patients who underwent chemotherapy for 7 months (P<0.0001). The probabilities of 1-year recurrence in the surgery and chemotherapy groups were 27.7 and 70%, respectively (P<0.0001). The QoL total score of the surgery group was significantly higher than that of the control group (P<0.0001). Surgery was slightly, though significantly more cost-effective than chemotherapy based on the quality-adjusted life years. CONCLUSION: Hepatectomy and thrombectomy using the total hepatic vascular exclusion, is a viable surgical management for patients with HCC and PVTT, and is associated with longer overall survival and recurrence-free survival and better QoL than chemotherapy alone.

Cardiovascular magnetic resonance imaging in assessment of intracaval and intracardiac extension of renal cell carcinoma.

OBJECTIVES: About 1 in 5 patients with renal cell carcinoma have intravascular tumoral extension at presentation. Level of tumoral extension within inferior vena cava determines surgical approach, with higher extension requiring cardiopulmonary bypass. Tumoral invasion of inferior vena caval wall is associated with poor prognosis. We evaluated accuracy of magnetic resonance imaging (MRI) in assessing level of intravascular extension of renal cell carcinoma and predicting vessel wall invasion. METHODS: MRIs and surgical database were reviewed from January 1999 to December 2008. Sixty-four patients with suspected intravascular extension of renal cell carcinoma underwent MRI. Forty-one underwent curative or palliative surgery at our institution and were included in final analysis. MRI scans were reviewed to determine intravascular extension and tumoral adherence to the vessel wall, as assessed by circumferential flow around the intravascular tumor and its mobility during different phases of cardiac cycle. MRI findings were correlated with surgical findings to assess accuracy. RESULTS: There was 87.8% agreement (P < .001; κ = 0.82) between MRI and surgical findings regarding level of intravascular extension of tumor. MRI was highly sensitive and specific (93%) in assessing supradiaphragmatic extension (negative predictive value, 96%). Depending on sign used, sensitivities and negative predictive values in assessing tumoral adherence to vessel wall ranged from 86% to 95% and 81% to 91%, respectively. CONCLUSIONS: MRI is highly accurate in staging intravascular and intracardiac extension, aiding in accurate preoperative surgical planning. MRI may help determine prognosis of renal cell carcinoma by accurately assessing tumoral adherence to the vessel wall.

[Comparative topographic anatomical assessment of the operative approaches to the bodies of lumbar vertebrae].

This investigation was aimed at the topographic anatomical comparison of operative approaches to the bodies of lumbar vertebrae according to A.Yu. Sozon-Yaroshevich quantitative criteria and the qualitative characteristic of traumaticity. Modeling of operative approaches according to P.G. Kornev, W.O. Southwick and R.A. Robinson, and V.D. Chaklin was performed on 50 human corpses of both sexes. Five variants of the position of abdominal aorta and inferior cava vein relative to the bodies of vertebrae are described, together with the variants of the interrelation between the lumbar vertebral segment, abdominal aorta and inferior cava vein, 3 variants of aortal bifurcation level and 3 variants of the level of the inferior cava vein formation. No quantitative differences were detected between the right- and left-sided variants of each approach and no significant interrelations between the values of A.Yu. Sozon-Yaroshevich's quantitative criteria and the constitution form (P>0.05). It is shown that from the point of view of topographic anatomical features, P.G. Kornev approach is least favorable. Concerning the approach to LIII, the best topographic anatomical characteristics belong to W.O. Southwick and R.A. Robinson approach, while V.D. Chaklin approach is preferable for the access to LIV.

[Ligation and resection of the inferior vena cava during surgical removal of the retroperitoneal tumors involving the inferior vena cava: feasibility and safety assessment].

OBJECTIVE: To assess the feasibility and safety of excising or patching the inferior vena cava (IVC) without replacement in patients with primary retroperitoneal tumors (PRPT) involving the IVC. METHODS: A retrospective analysis was conducted in 116 consecutive patients with PRPT presented to our Hospital between December 2007 and December 2008. IVC involvement was found in 11.2% of the cases, and in 93 cases receiving surgical tumor removal, the complete resection rate was 93.55%. According to the location of IVC involvement by the PRPT, the cases were classified into 3 groups with IVC involvement in the segment from the second hepatic portal vein to the renal vein (segment A), the segment on the bilateral renal vein plane (segment B), and the segment from the caval bifurcation to the renal vein (segment C). RESULTS: The most common vascular involvement occurred in segment C (61.54%, 8/13), and 2 cases presented with segment A involvement and 2 had segment B involvement. All the 3 segments of IVC were involved in 1 case. Five cases with IVC involvement received IVC patching only, and 4 had resection or ligation of the segment C of the IVC, and resection of the segment A and B of the IVC was performed in 2 and 1 case, respectively. One patient received complete resection of whole IVC involved. All patients recovered smoothly and were discharged. CONCLUSION: The infrarenal IVC can be ligated or resected safely without reconstruction. Combined resection of the bilateral renal vein and segment B of the IVC may result in renal insufficiency. IVC involvement and occlusion between the second hepatic portal and renal veins can be ligated safely without affecting the renal function.

Hemodynamic assessment during auxiliary heterotopic liver transplantation with portal vein arterialization in a Swine model: preliminary report of 10 transplants.

UNLABELLED: Portal vein arterialization (PVA) is a technical variation of auxiliary heterotopic liver transplantation (AHLT) that is rarely studied but that simplifies the AHLT surgical technique because it does not act on the portal area. The objective of this study was to analyze the hemodynamic consequences of this auxiliary transplant in an experimental model. MATERIALS AND METHODS: Ten AHLT-PVA were analyzed in a pig model. A PiCCO (Pulsion) monitor was used for the hemodynamic study of the recipient. The following were measured: cardiac index, (CI), systemic vascular resistance index, (SVRI), mean arterial pressure (MAP), global end-diastolic volume, central venous pressure, and intrathoracic blood volume. The measurements were taken at four times during transplant: at baseline, after inferior vena cava clamping, after graft reperfusion, and at closure. RESULTS: After graft reperfusion there was a reduction in SVRI (968 +/- 168.03 vs 1686.25 +/- 290.66; P < .05) and in MAP, and there was an increase in CI. At the end of the transplant MAP and SVRI recovered (1254.2 +/- 225.79 vs 968 +/- 168.03; P < .05) but CI remained slightly high. The end-diastolic volume showed greater variation than central venous pressure, although this was only statistically significant at the inferior vena cava clamping phase (244.75 +/- 52.05 vs 333.37 +/- 170.13; P < .05). DISCUSSION: Heterotopic liver transplantation with portal arterialization is well-tolerated hemodynamically. Graft reperfusion decreases SVRI and increases CI to compensate for this. This behavior, which in healthy recipients like ours is not a problem, could imply a contraindication in patients with a prior hyperdynamic state.

Should the inferior vena cava be reconstructed after resection for malignant tumors?

BACKGROUND: Caval replacement after circumferential resection of the inferior vena cava remains controversial. The aim of the current study is to determine whether or not inferior vena cava replacement should be performed. METHODS: We reviewed 36 cases undergoing resection of the inferior vena cava concomitant with resection of malignant neoplasms. Our criteria for circumferential resection of the inferior vena cava were half or more of the circumference of the vessel wall invaded by tumor, a primary tumor of the caval wall, or massive intraluminal tumor thrombus suspected of adhering to the caval wall. We detailed 10 patients undergoing circumferential resection of the inferior vena cava. RESULTS: Most of patients who did not undergo replacement of the inferior vena cava showed no sign of swelling of the lower limbs, but one showed persistent leg edema with oliguria. This patient had poor development of collateral circulation and mild obstruction of the inferior vena cava before surgery. Two patients who underwent replacement of inferior vena cava had no venous sequelae, although they had poor development of collateral circulation before surgery. CONCLUSION: Caval replacement after circumferential resection of the inferior vena cava may be necessary in patients who have preoperative poor development of collateral circulation or who have oliguria or unstable hemodynamics intraoperatively.

Assessment of the regularity of hepatic arterio-portal anastomosis exploiting in vivo microscopy.

PURPOSE: To determine the regularity of hepatic arterio-portal anastomosis (i.e., does every branch of the portal system receive a tributary from the hepatic arterial system and, if so, does it occur at a constant level?). MATERIALS AND METHODS: Ten male Wistar mice weighing 50 g each were divided into two groups. The first group underwent portal vein ligation, and the second group underwent ligation of the portal vein, aorta, and inferior vena cava simultaneously. Fluorescence and heparin were injected prior to ligation, via the jugular vein. The liver surface circulation was monitored, using in vivo microscopy before and after ligation. RESULTS: Prior to ligation, two kinds of blood flow were noticed, fast and slow, regardless of the position of the examined site on the liver surface, in the distributing venules, terminal portal venules, and sinusoids. Following ligation, results were similar in both groups with four types of blood flow: (1) complete cessation of blood flow; (2) respiration-related blood movement; (3) slow blood flow, starting either in the distributing venules, terminal portal venules, or sinusoids; (4) fast blood flow, starting either in the distributing venules, or terminal portal venules or sinusoids. CONCLUSION: The presence of two types of blood flow, before ligation, and the presence of four types of blood flow after ligation, starting at different levels, lead to the conclusion that arterio-portal anastomosis does not follow a regular pattern in the peripheral zone. That is to say, a 1-to-1 ratio does not exist, and, where it exists, it does not occur at a constant level of the vascular tree.

Haemodynamic assessment following inferior vena cava resection without replacement.

BACKGROUND: Treatment of bulky retroperitoneal malignancy may require en bloc resection of the infrarenal inferior vena cava. A number of reconstructive options are available to the surgeon but objective haemodynamic assessment of the peripheral venous system following resection without replacement is lacking. The aim of the present paper was thus to determine the symptomatic and haemodynamic effects of not reconstructing the resected infrarenal inferior vena cava. METHODS: A retrospective descriptive study was carried out at Princess Alexandra Hospital in Queensland. Five patients underwent resection of the thrombosed infrarenal inferior vena cava as part of retroperitoneal lymph node dissection for testicular cancer (n = 3), radical nephrectomy for renal cell carcinoma (n = 1) and thrombosed inferior vena cava aneurysm (n = 1). Clinical effects were determined via the modified venous clinical severity score and venous disability score. Haemodynamic data were obtained postoperatively using venous duplex ultrasound and air plethysmography. RESULTS: None of the present patients scored >2 (out of 30) on the modified venous clinical severity score or >1 (out of 3) on the venous disability score. Haemodynamic studies showed only minor abnormalities. CONCLUSIONS: Not reconstructing the resected thrombosed infrarenal inferior vena cava results in minor signs and symptoms of peripheral venous hypertension and only minor abnormalities on haemodynamic assessment.

Surgical anatomy of retrohepatic inferior vena cava and hepatic veins: a quantitative assessment.

BACKGROUND: Accurate knowledge of the surgical anatomy of the retrohepatic inferior vena cava (IVC) and hepatic veins is necessary for hepatic surgery. METHODS: Lengths of different segments of retrohepatic IVC and their diameters, and prevalence of various types of ramification and lengths of different hepatic veins, were noted in 100 disease-free human livers during autopsy. RESULTS: The mean lengths of the IVC from entry into atrium to diaphragmatic hiatus, from the hiatus to the upper margin of right hepatic vein, between the upper margins of the right hepatic vein and the right suprarenal vein, from right suprarenal vein to the lowermost dorsal hepatic vein, and from the lower-most dorsal hepatic vein to the right renal vein were 29.1 mm, 8.6 mm, 40.6 mm, 28.6 mm and 33.7 mm, respectively. The mean diameter of IVC at the diaphragmatic level was 30.1 mm. The commonest ramification pattern of the hepatic veins was type I (82%) for the right hepatic vein, type II (63%) for the middle and left hepatic veins, and type II (55%) for the caudate veins. In 96% of cases the middle and left hepatic veins formed a common trunk. In a majority of cases, the diameters of the right and left hepatic veins were between 7 mm and 12 mm. No gender differences were found. CONCLUSION: This study provides an anatomical perspective for various hepatic surgical techniques.