An Exploratory Investigation into Optimal Indicators and Thresholds for Anemia Diagnosis Through Abdominal CT Plain Scans.

Objective: This study aimed to assess the diagnostic utility and optimal thresholds of abdominal CT plain scans in identifying various degrees of anemia. Methods: We included 40 participants in each of the mild, moderate, and severe anemia groups, totaling 120 participants, along with 40 healthy controls. We measured CT values of several abdominal structures, including the abdominal aorta (AA), inferior vena cava (IVC), liver, bilateral kidneys, spleen, and lumbar spinal cord (LSC), in both the normal and anemia groups. Additionally, we calculated the difference and ratio of CT values between AA and LSC and IVC and LSC. We analyzed the correlation between these parameters and hemoglobin (Hb) concentration. The most effective indicators and thresholds for diagnosing varying degrees of anemia using abdominal CT plain scans were identified. Results: Significant differences were observed in hemoglobin concentration, CT values of AA, CT values of IVC, liver CT values, kidney CT values, and the ratios of CT values between AA and LSC, as well as IVC and LSC, among the four groups (P < .05). However, no significant differences were found in spleen CT values and CT values of LSC between the groups (P > .05). The CT values of AA, IVC, the ratios of AA to LSC, and IVC to LSC displayed significant positive linear correlations with hemoglobin concentration. Optimal thresholds for diagnosing mild, moderate, and severe anemia in AA were found to be 35.43, 33.2, and 30.2 HU, respectively, while for IVC, they were 34.18, 31.27, and 28.1 HU, respectively. Conclusions: Among the various parameters obtained from abdominal CT plain scans, the CT value of the abdominal aorta demonstrated the highest diagnostic efficacy in distinguishing between different degrees of anemia.

Managing Budd-Chiari Syndrome with Ayurvedic Treatment: A Case Report.

Ayurvedic therapy has been shown to be effective in treating various liver disorders. Budd-Chiari syndrome (BCS) is a rare but serious disorder characterized by obstruction of the hepatic venous outflow. The prognosis of patients is usually poor. We hereby present the case of a 42-year-old, obese female patient with BCS who was treated exclusively with herbo-mineral Ayurvedic medicines. This patient had inferior vena cava, portal vein, and hepatic vein thromboses with moderate liver fibrosis. The main line of treatment was the use of herbo-mineral compounds to remove the blood clots present in the above-mentioned veins. Ayurvedic treatment resulted in the restoration of health with normalization of liver function and regression of thromboses. This case study provides primary evidence of the probable potential of Ayurveda in improving therapeutic outcomes inpatients with BCS.

Which cava anastomotic techniques are optimal regarding immediate and short-term outcomes after liver transplantation: A systematic review of the literature and expert panel recommendations.

BACKGROUND: It has long been debated whether cava anastomosis should be performed with the piggyback technique or cava replacement, with or without veno-venous bypass (VVB), with or without temporary portocaval shunt (PCS) in the setting of liver transplantation. OBJECTIVES: To identify whether different cava anastomotic techniques and other maneuvers benefit the recipient regarding short-term outcomes and to provide international expert panel recommendations. DATA SOURCES: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. METHODS: A systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel (CRD42021240979). RESULTS: Of 3205 records screened, 307 publications underwent full-text assessment for eligibility and 47 were included in qualitative synthesis. Four studies were randomized control trials. Eighteen studies were comparative. The remaining 25 were single-center retrospective noncomparative studies. CONCLUSION: Based on existing data and expert opinion, the panel cannot recommend one cava reconstruction technique over another, rather the surgical approach should be based on surgeon preference and center dependent, with special consideration toward patient circumstances (Quality of evidence: Low | Grade of Recommendation: Strong). The panel recommends against routine use of vevo-venous bypass (Quality of evidence: Very Low | Grade of Recommendation: Strong) and against the routine use of temporary porto-caval shunt (Quality of evidence: Very Low | Grade of Recommendation: Strong).

Suprahepatic Cava Thrombus Due to Wilms Tumor: Technique Without Cardiopulmonary Bypass.

Wilms tumor is a frequent malignant neoplasia in pediatric population. Extension to the inferior vena cava is a complication that occurs in approximately 4%-15% of cases. Surgical techniques derived from the field of adult transplant surgery allow the resection of the tumor with its thrombus extension. In the case of a 6-year-old male patient with a stage III Wilms tumor that originated from the left renal vein, thrombectomy and left radical nephroureterectomy were accomplished without extracorporeal circulation. Surgical technique applied in adult transplant surgery for removal of advanced renal tumors, could be a safe and feasible technique in pediatric population.

Systematic review of electrophysiology procedures in patients with obstruction of the inferior vena cava.

AIMS: The objective of the study was to conduct a systematic review to describe and compare the different approaches for performing cardiac electrophysiology (EP) procedures in patients with interrupted inferior vena cava (IVC) or equivalent entities causing IVC obstruction. METHODS: We conducted a structured search to identify manuscripts reporting EP procedures with interrupted IVC or IVC obstruction of any aetiology published up until August 2020. No restrictions were applied in the search strategy. We also included seven local cases that met inclusion criteria. RESULTS: The analysis included 142 patients (mean age 48.9 years; 48% female) undergoing 143 procedures. Obstruction of the IVC was not known before the index procedure in 54% of patients. Congenital interruption of IVC was the most frequent cause (80%); and, associated congenital heart disease (CHD) was observed in 43% of patients in this setting. The superior approach for ablation was the most frequently used strategy (52%), followed by inferior approach via the azygos or hemiazygos vein (24%), transhepatic approach (14%), and retroaortic approach (10%). Electroanatomical mapping (58%), use of long sheaths (41%), intracardiac echocardiography (19%), transesophageal echocardiography (15%) and remote controlled magnetic navigation (13%) were used as adjuncts to aid performance. Ablation was successful in 135 of 140 procedures in which outcomes were reported. Major complications were only reported in patients undergoing AF ablation, including two patients with pericardial effusion, one of whom required surgical repair, and another patient who died after inadvertent entry into an undiagnosed atrioesophageal fistula from a previous procedure. CONCLUSION: The superior approach is most frequent approach for performing EP procedures in the setting of obstructed IVC. Transhepatic approach is a feasible alternative, and may provide a "familiar approach" for transseptal access when it is required. Adjunctive use of long sheaths, intravascular echocardiography, electro-anatomical mapping and remote magnetic navigation may be helpful, especially if there is associated complex CHD. With careful planning, EP procedures can usually be successfully performed with a low risk of complications.

En bloc excision of giant polycystic liver with hepatic cava and its auto-transplant caval reconstruction as a safe surgical procedure for liver transplantation.

Safely excising a giant liver while leaving the hepatic inferior vena cava intact is difficult. Hata et al. present images and videos describing their novel technique consisting of total hepatectomy including the hepatic cava; extracorporeal retrieval; and auto-transplant inferior vena cava reconstruction, for an extremely enlarged polycystic liver weighing 24 kg.

Aqueous extract of Paeoniae Radix Rubra prevents deep vein thrombosis by ameliorating inflammation through inhibiting GSK3ß activity.

BACKGROUND: Deep vein thrombosis (DVT) is a kind of blood stasis syndrome. Paeoniae Radix Rubra (PRR) has long been widely used for eliminating blood stasis in China, but its effect on DVT has not yet been reported. PURPOSE: The present study aimed to assess the potential inhibitory effect of the aqueous extract of PRR (i.e.,PRR dispensing granule, PRRDG) on DVT and explore the underlying mechanism. STUDY DESIGN/METHODS: The chemical profile of PRRDG was analyzed by high-performance liquid chromatography. Sprague-Dawley rats were intragastrically treated with PRRDG (0.625, 1.25 and 1.875 g crude drug/kg/d) once daily for 7 consecutive days. On the sixth day, a model of inferior vena cava (IVC) stenosis-induced DVT was established. All rats were sacrificed on the seventh day. Serum was collected for enzyme-linked immunosorbent assay. Thrombus-containing IVC was weighed and further processed for histopathologic examination, immunohistochemical analysis and western blotting. LiCl and LY294002 were adopted to block and increase the activity of glycogen synthase kinase 3ß (GSK3ß), respectively. RESULTS: The chemical profile analysis showed that paeoniflorin, benzoylpaeoniflorin, albiflorin, gallic acid and catechin were the main constituents of PRRDG. LiCl decreased thrombus weight, reduced the number of inflammatory cells in thrombus and vein wall, down-regulated phosphorylated NF-κB p65 (p-p65) protein expression. Similarly, PRRDG decreased thrombus weight and tissue factor (TF) protein expression. PRRDG reduced the protein expression levels of P-selectin, monocyte chemoattractant protein-1 (MCP-1), intercellular cell adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) in venous endothelium, serum levels of tumor necrosis factor-α (TNF-α) and interleukin-1ß (IL-1ß), and the number of inflammatory cells in thrombus and vein wall. Moreover, PRRDG down-regulated p-p65 protein expression and up-regulated phosphorylated GSK3ß (p-GSK3ß) protein expression. LY294002 abrogated the inhibitory effects of PRRDG on thrombus weight, TF protein expression, TNF-α and IL-1ß serum levels, inflammatory cells influxes, and p-p65 protein expression. CONCLUSION: PRRDG prevents DVT by ameliorating inflammation through inhibiting GSK3ß activity.

Treatment of vena cava inferior leiomyosarcoma with cavotomy and right renal vein neoimplantation / Vena cava inferior leiomyosarcoma kezelése cavotomiával és a jobb vena renalis neoimplantatiójával

Leiomyosacroma of the inferior vena cava is an extremely rare malignancy originating from the tunica media of the venous wall. Its symptoms and radiomorphological signs do not always lead to an accurate diagnosis. Histological sampling can be dangerous due to its location. Therefore the diagnosis is often a challenge for clinicians. Its treatment is primarily surgical, supplemented by radiotherapy and chemotherapy applied together or in monotherapy. In our case, an asymptomatic 74-year-old female patient was diagnosed with a tumor of the inferior caval vein located just above the right renal vein and involving the right adrenal gland. As serum cortisol, epinephrine, norepinephrine, adrenocorticotropic hormone (ACTH), total and free testosterone, dehydroepiandrosterone sulfate (DHEA-S), sex hormone binding globulin (SHBG) was at normal level, the tumor showed no hormone secretion. Primary surgical resection was planned. Preoperative biopsy was not performed due to its high risk of complications. During operation, tumor resection was performed by resection of the venous wall, removal of the right adrenal gland and neoimplantation of the right renal vein. For better exposure, cholecystectomy was also performed at the beginning of surgery. There were no postoperative complications. The patient received adjuvant radiation therapy. Thanks to the early diagnosis of the tumor and the complete resection, we significantly increased the patient's chances of total recovery. With the radiotherapy performed, we reduced the likelihood of tumor recurrence.

Duplicate inferior vena cava complicating the evaluation of primary aldosteronism.

A 64-year-old man with a known duplicate inferior vena cava (D-IVC) and resistant hypertension presented to our emergency department in a hypertensive crisis. He had a longstanding history of hypertension and unexplained hypokalemia treated with oral potassium supplementation. The patient was diagnosed with primary aldosteronism and MRI of the abdomen revealed a left-sided adrenal adenoma. Adrenal venous sampling (AVS) lateralised aldosterone hypersecretion to the left adrenal gland. The patient subsequently underwent an uncomplicated laparoscopic left adrenalectomy. The patient's postoperative course was uneventful, and he was discharged on a single antihypertensive medication on postoperative day 1. D-IVC is one of several rare IVC anatomical variants that have been well described in the literature. Knowledge of this patient's unique abdominal venous anatomy enabled successful AVS and appropriate surgical management. It is necessary to identify potential anatomical variants of abdominal venous anatomy that may complicate these invasive procedures.

Outcomes in Renal Cell Carcinoma With IVC Thrombectomy: A Multiteam Analysis Between an NCI-Designated Cancer Center and a Quaternary Care Teaching Hospital.

INTRODUCTION: Interteam performance and Clavien-Dindo (C-D) complications in renal cell carcinoma with inferior vena cava thrombectomy (RCC-IVCT) have not been reported. We aimed to describe complications by the degree of complexity and surgical teams in a collaborative effort between a National Cancer Institute-designated Comprehensive Cancer Center and a Quaternary Care Teaching Hospital. METHODS: Between January 2011 and May 2019, 73 consecutive RCC-IVCT were included. C-D grades III or higher were captured. Teams involved were urologic-oncology, vascular, hepatobiliary/transplant, and cardiothoracic. The Mayo Clinic tumor thrombus classification was used. RESULTS: Overall complication rate was 42% (n = 31). Nineteen percent had grade III, 18% had grade IV, and 6% had grade V complications. Patients with level IV thrombus had the highest in-hospital mortality rate (75%). Thrombus level did not show a correlation to complication rates (14% level I, 45% level II, 32% level III, 42% level IV). A positive correlation found between the number of teams involved and complication rates (35% with 2-team, 59% with 3-team, P = .059). Thromboembolic events (6% vs 24%, P = .02) and disposition other than home (22% vs 48%, P = .01) were statistically lower for the 2-team groups. Two-team in-hospital mortality was 1/51 (2%) versus 3-team (3/22,14%, (P = .07). No statistical differences were found in infections, thromboembolic events, and grades of complications between surgical teams. CONCLUSIONS: Despite similar interteam performance, the consistency of surgeons in high complexity cases could improve outcomes further. Complexity was higher for hepatobiliary/transplant and cardiothoracic teams. A combination of intraoperative events and patient selection (comorbidities and age) contributed to death. Overall, in-hospital mortality was lower than in most reported series.

Refractory Lymphatic Ascites After Radical Prostatectomy.

Lymphatic ascites after pelvic lymphadenectomy is a rare complication and is rarely reported after urologic surgery. We report a case of delayed and refractory lymphatic ascites following robotic-assisted laparoscopic radical prostatectomy.

Analysis of imaging-guided thermal ablation puncture routes for tumors of the hepatic caudate lobe.

AIMS: The goal of this study was to analyze the puncture routes of imaging-guided thermal ablation for tumors of the hepatic caudate lobe. MATERIALS AND METHODS: The imaging-guided thermal ablation puncture routes of 12 cases of hepatic caudate lobe tumors were collected in our hospital from January 2013 to February 2019. The puncture routes were retrospectively analyzed, and the experience of thermal ablation therapy for hepatic caudate lobe tumors was summarized. RESULTS: Among the 12 cases of hepatic caudate lobe tumors, puncture routes were divided into the anterior (through the left lobe of the liver) approach (six cases), the right hepatic approach (five cases), and the transthoracic approach (one case). Different ablation electrodes were selected according to the puncture route and method of guiding. No serious postoperative complications were noted. CONCLUSION: The hepatic caudate lobe is surrounded by the inferior vena cava, hepatic vein, and hepatic hilum, leading to great difficulties and risks in performing minimally invasive treatment of hepatic caudate lobe malignancies. Therefore, selecting an appropriate puncture route is an important factor in the success of the treatment.

Three Possible Variations in Ex Vivo Hepatectomy: Achieving R0 Resection by Auto-transplantation.

The collaboration of hepatopancreaticobiliary with transplant surgery expands technical options and opportunity for potentially curative resection in traditionally inoperable cases.  We identified and describe three different types of ex vivo hepatic resections that include (1) explantation with formal hepatectomy, (2) explantation with re-implantation of the whole liver after vascular reconstruction, and (3) explantation with formal hepatectomy after future liver remnant volume augmentation.

Pharmacological treatment of hepatocellular carcinoma with cavoatrial tumor thrombus - case series and literature review.

Hepatocellular carcinomas (HCC) that extend into the vena cava and the right atrium have a poor prognosis. Surgical approaches including partial hepatectomy and thrombectomy are the most frequently reported treatment options. However, most patients with advanced HCC are not eligible for complex surgical interventions due to reduced liver function, comorbidities, and metastases. At the same time, systemic treatment options of HCC have expanded in recent years. Here, we report 3 cases of patients with advanced HCC who developed a cavoatrial tumor thrombus (CATT) after initial surgical or interventional therapy. The patients were consequently treated with sorafenib or nivolumab. In all cases, the tumor responded to systemic treatment with disease stabilization or partial regression. Overall survival after diagnosis of CATT was 3 and 17 months for sorafenib and 7 + months for nivolumab. Compared to survival rates of alternative treatment options, systemic therapies demonstrated comparable outcomes. In summary, pharmacotherapy is an efficient and well worth option to treat patients with HCC and CATT and should be an integral part of a multimodal therapy concept.

Stimulation of Caveolin-1 Signaling Improves Arteriovenous Fistula Patency.

Objective- Arteriovenous fistulae (AVF) are the most common access created for hemodialysis; however, many AVF fail to mature and require repeated intervention, suggesting a need to improve AVF maturation. Eph-B4 (ephrin type-B receptor 4) is the embryonic venous determinant that is functional in adult veins and can regulate AVF maturation. Cav-1 (caveolin-1) is the major scaffolding protein of caveolae-a distinct microdomain that serves as a mechanosensor at the endothelial cell membrane. We hypothesized that Cav-1 function is critical for Eph-B4-mediated AVF maturation. Approach and Results- In a mouse aortocaval fistula model, both Cav-1 mRNA and protein were increased in the AVF compared with control veins. Cav-1 KO (knockout) mice showed increased fistula wall thickening ( P=0.0005) and outward remodeling ( P<0.0001), with increased eNOS (endothelial NO synthase) activity compared with WT (wild type) mice. Ephrin-B2/Fc inhibited AVF outward remodeling in WT mice but not in Cav-1 KO mice and was maintained in Cav-1 RC (Cav-1 endothelial reconstituted) mice (WT, P=0.0001; Cav-1 KO, P=0.7552; Cav-1 RC, P=0.0002). Cavtratin-a Cav-1 scaffolding domain peptide-decreased AVF wall thickness in WT mice and in Eph-B4 het mice compared with vehicle alone (WT, P=0.0235; Eph-B4 het, P=0.0431); cavtratin also increased AVF patency (day 42) in WT mice ( P=0.0275). Conclusions- Endothelial Cav-1 mediates Eph-B4-mediated AVF maturation. The Eph-B4-Cav-1 axis regulates adaptive remodeling during venous adaptation to the fistula environment. Manipulation of Cav-1 function may be a translational strategy to enhance AVF patency.