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Goronzy IN, Yearwood A, Drews E, Brundage T, Ranade M, Moriarty JM. Endovascular thrombectomy provides durable, symptomatic relief in iliocaval tumor thrombosis. Clin Radiol 2024; 79:e1268-e1278. [PMID: 39084932 DOI: 10.1016/j.crad.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 07/04/2024] [Accepted: 07/06/2024] [Indexed: 08/02/2024]
Abstract
AIMS Iliocaval venous tumor thrombus is a morbid condition associated with chronic venous stasis, lower extremity edema/pain, extensive thrombus burden and high mortality secondary to critical flow obstruction, intracardiac thrombus extension and tumor embolization. Typically resistant to medical therapy, management is primarily surgical, presenting challenges for medically complex patients with widespread or end-stage disease. Mechanical or aspiration thrombectomy represents an appealing treatment strategy but data are lacking. MATERIALS AND METHODS We performed a single-center, 10-year, retrospective review of patients with pathology-confirmed, iliocaval tumor thrombus who underwent thrombectomy. 14 patients met inclusion criteria and were managed by 18 procedures over this period. RESULTS The most common malignancy was renal-cell carcinoma (n=7; 50%); other types included germ cell (n=2; 14%), other genitourinary (n=2; 14%), neuroendocrine (n=1; 7%), soft tissue (n=1; 7%), and skin cell malignancies (n=1; 7%). All patients had thrombus involving the distal inferior venous cava (IVC), 50% had bilateral iliac involvement and 29% atrial involvement. Common indications were venous obstruction symptoms (n=11; 65%) and evidence of embolism (n=6; 35%). All patients tolerated the procedures without acute complication. The technical success rate was 94%, with marked improvement of flow and reduction in thrombus burden, and 79% had subjective symptomatic improvement. All patients survived for >2 weeks and 50% had long-term survival of >1 year, with 86% of these patients having renal-cell carcinoma (RCC). Three patients underwent multiple thrombectomies within days to weeks, with ultimate symptomatic improvement. CONCLUSIONS Overall, our study results suggest mechanical or aspiration thrombectomy as a safe and efficacious treatment for patients with iliocaval tumor thrombus.
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Affiliation(s)
- I N Goronzy
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - A Yearwood
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; Department of Radiology, Los Angeles, CA 90095, USA
| | - E Drews
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; Department of Radiology, Los Angeles, CA 90095, USA
| | - T Brundage
- Rosalind Franklin University of Medicine and Science, North Chicago, IL 60064, USA
| | - M Ranade
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; Department of Radiology, Los Angeles, CA 90095, USA
| | - J M Moriarty
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; Department of Radiology, Los Angeles, CA 90095, USA.
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Bryk-Wiązania AH, Minasyan M, Świątkowska-Stodulska R, Undas A, Hubalewska-Dydejczyk A, Webb SM, Valassi E, Gilis-Januszewska A. The thrombotic risk in Cushing's syndrome-questions, answers, and the algorithm to consider in its assessment: part I-thrombotic risk not related to surgery. Front Endocrinol (Lausanne) 2024; 15:1350010. [PMID: 38529392 PMCID: PMC10961355 DOI: 10.3389/fendo.2024.1350010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/12/2024] [Indexed: 03/27/2024] Open
Abstract
Introduction Recently, it has been reported that there is a great diversity in strategies used for thromboprophylaxis in patients with Cushing's syndrome (CS). An aim of this review was to discuss these practices in light of the existing data on the thrombotic risk in patients with CS and guidelines for medically ill patients. Methods The four relevant topics and questions on thrombotic risk in CS were identified. The current guidelines on prevention and diagnosis of venous thromboembolism (VTE) were reviewed for the answers. An algorithm to consider in the assessment of the thrombotic risk in patients with CS was proposed. Results To address both generic and CS-specific risk factors for VTE, the algorithm includes the stepwise approach consisting of Padua Score, urine free cortisol, and CS-VTE score, with no indication for routine thrombophilia testing in the prediction of an index VTE episode. Having confirmed VTE, selected patients require thrombophilia testing to aid the duration of anticoagulant treatment. The separate part of the algorithm is devoted to patients with ectopic adrenocorticotropic hormone syndrome in whom exclusion of VTE precedes introducing routine thromboprophylaxis to prevent VTE. The cancer-related VTE also prompts thromboprophylaxis, with the possible vessel invasion. The algorithm presents a unifactorial and multifactorial approach to exclude high-bleeding risks and safely introduce thromboprophylaxis with low-molecular-weight heparin. Summary Our article is the first to present an algorithm to consider in the thrombotic risk assessment among patients with Cushing's syndrome as a starting point for a broader discussion in the environment. A plethora of factors affect the VTE risk in patients with CS, but no studies have conclusively evaluated the best thromboprophylaxis strategy so far. Future studies are needed to set standards of care.
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Affiliation(s)
- Agata Hanna Bryk-Wiązania
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Kraków, Poland
- Department of Endocrinology, Oncological Endocrinology and Nuclear Medicine, University Hospital, Kraków, Poland
| | - Mari Minasyan
- Department of Endocrinology, Oncological Endocrinology and Nuclear Medicine, University Hospital, Kraków, Poland
| | - Renata Świątkowska-Stodulska
- Department of Endocrinology and Internal Medicine, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - Anetta Undas
- The John Paul II Hospital, Kraków, Poland
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| | - Alicja Hubalewska-Dydejczyk
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Kraków, Poland
- Department of Endocrinology, Oncological Endocrinology and Nuclear Medicine, University Hospital, Kraków, Poland
| | - Susan M. Webb
- Department of Endocrinology, Hospital S Pau, Barcelona, Spain
- Sant Pau Biomedical Research Institute (IIB-Sant Pau), Research Center for Pituitary Diseases, Barcelona, Spain
- Centre for Biomedical Network Research on Rare Diseases (CIBERER) Unit 747, Instituto de Salud Carlos III, Madrid, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Elena Valassi
- Centre for Biomedical Network Research on Rare Diseases (CIBERER) Unit 747, Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Endocrinología, Hospital e Institut de Recerca Germans Trias i Pujol, Badalona, Barcelona, Spain
- Universitat Internacional de Catalunya (UIC), Barcelona, Spain
| | - Aleksandra Gilis-Januszewska
- Chair and Department of Endocrinology, Jagiellonian University Medical College, Kraków, Poland
- Department of Endocrinology, Oncological Endocrinology and Nuclear Medicine, University Hospital, Kraków, Poland
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Liu XR, Zhou W, Chen F. Severe compression of left iliac vein is a protective factor for the risk of inferior vena cava thrombosis. J Vasc Surg Venous Lymphat Disord 2022; 10:1107-1112. [PMID: 35716997 DOI: 10.1016/j.jvsv.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/12/2022] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The purpose of this study is to evaluate the association between left iliac vein (LIV) compression and inferior vena cava thrombosis (IVCT) in patients with LIV involvement of deep vein thrombosis (DVT). METHODS A total of 263 consecutive DVT patients were retrospectively reviewed and divided into group IVCT and non-IVCT. The influences of LIV smallest diameter and percentage compression on the risk of IVCT were investigated using logistic regression analysis. RESULTS The mean age of IVCT patients was significantly younger than that of non-IVCT patients (55.5±1.8 vs. 62.7±1.1, p=0.001). The percentage of provoked DVT in IVCT patients was higher than that in non-IVCT patients (67.1% vs 48.2%, p=0.01). The smallest diameter of LIV in ICVT patients was larger than that in non-IVCT patients (4.1±0.3 vs. 2.5±0.2, p<0.001). Mean percentage compression of LIV in IVCT patients was significantly lower than that in non-IVCT patients (63.5±2.2 vs. 74.3±1.3; P<0.001). Age was associated with decreased odds of ICVT (OR: 0.965, 95% CI: 0.965-0.985, P=0.001). Provoked DVT was associated with increased odds of ICVT (OR:2.011, 95% CI: 1.070-3.782, P=0.03). LIV compression was associated with decreased odds of ICVT for each 1mm decrease in smallest diameter of the LIV (OR, 0.717; 95% CI, 0.627-0.820; P <0.001), and for each 10% increase in percentage compression of the LIV (OR, 0.715; 95% CI, 0.612-0.835; P <0.001). CONCLUSION Among LIV involvement of DVT patients, non-IVCT patients had more severe LIV compression than IVCT patients. Severe LIV compression may be a protective factor for the risk of IVCT.
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Affiliation(s)
- Xin Ran Liu
- Department of Vascular and Interventional Radiology, the second affiliated Hospital, Nanchang University, Nanchang 330006, China;; Queen Mary School, Nanchang University, Nanchang 330006, China
| | - Wei Zhou
- Department of Vascular and Interventional Radiology, the second affiliated Hospital, Nanchang University, Nanchang 330006, China
| | - Feng Chen
- Department of Vascular and Interventional Radiology, the second affiliated Hospital, Nanchang University, Nanchang 330006, China;.
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Bosman NAM, Kuipers RS. Case report of a 'snake thrombus' in the right heart: a rare finding on echocardiography. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 4:1-6. [PMID: 33628990 PMCID: PMC7891233 DOI: 10.1093/ehjcr/ytaa424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/11/2020] [Accepted: 10/21/2020] [Indexed: 01/04/2023]
Abstract
Background A right heart thrombus originating from an inferior vena cava thrombosis (IVCT) is a rare entity. In accordance with venous thromboembolism (VTE), IVCT can be categorized as primary or secondary. Secondary ICVT can be the result of a predisposing hypercoagulable state and/or from external compression on the inferior vena cava (IVC) such as in case of malignancies. Renal cell carcinoma (RCC), amongst others, has been described in the context of secondary IVCT. Case summary An 80-year-old man was presented in our emergency department with complaints of dyspnoea and oedema. Echocardiography revealed a large snake-like thrombus in the IVC extending into the right atrium. Subsequent computed tomography resulted in a diagnosis of an RCC. The patient was considered to be in too poor clinical condition for surgical removal. In the next days, his condition deteriorated, after which palliative care was initiated and the patient deceased at day 12 of admission. Conclusion A right heart thrombus is a rare finding during echocardiography. This case demonstrates an incidental finding of a ‘snake thrombus’ in the IVC and right heart secondary to RCC. This case illustrates the importance and additional value of echocardiography in the setting of suspected right-sided heart failure.
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Affiliation(s)
- Nienke A M Bosman
- Department of Cardiology, OLVG Amsterdam, Oosterpark 9, 1091 AC Amsterdam, The Netherlands
| | - Remko S Kuipers
- Department of Cardiology, OLVG Amsterdam, Oosterpark 9, 1091 AC Amsterdam, The Netherlands
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Almohammad F, Bakour MM. Solitary fibrous renal tumor with thrombus extension into the inferior vena cava and right atrium. Asian Cardiovasc Thorac Ann 2021; 29:813-815. [PMID: 33611951 DOI: 10.1177/0218492321997391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A solitary fibrous tumor of the kidney with thrombus extended into the inferior vena cava and right atrium is very rare. The current surgical approach is to combine intra-abdominal and cardiac surgery with cardiopulmonary bypass. We describe a rare case of renal solitary fibrous tumor extended to the inferior vena cava and right atrium, treated with urgent cardiac surgery using deep hypothermic circulatory arrest one month after an inappropriate right nephrectomy because of the development of cavo-atrial obstruction symptoms.
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Sinclair TJ, Gillis A, Alobuia WM, Wild H, Kebebew E. Surgery for adrenocortical carcinoma: When and how? Best Pract Res Clin Endocrinol Metab 2020; 34:101408. [PMID: 32265101 DOI: 10.1016/j.beem.2020.101408] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Adrenocortical carcinoma (ACC) is a rare malignancy that is frequently asymptomatic at presentation, yet has a high rate of metastatic disease at the time of diagnosis. Prognosis is overall poor, particularly with cortisol-producing tumors. While the treatment of ACC is guided by stage of disease, complete surgical resection is the most important step in the management of patients with primary, recurrent, or metastatic ACC. Triphasic chest, abdomen, and pelvis computer tomography (CT) scans and 18F flourodeoxyglucose positron emission tomography CT scanning are essential for accurate staging; moreover, MRI may be helpful to identify liver metastasis and evaluate the involvement of adjacent organs for operative planning. Surgical resection with negative margins is the single most important prognostic factor for survival in patients with ACC. To achieve the highest rate of R0 resection, open adrenalectomy is the gold standard surgical approach for confirmed or highly suspected ACC. It is extremely important that the tumor capsule is not ruptured, regardless of the surgical approach used. The best post-operative outcomes (complications and oncologic) are achieved by high-volume surgeons practicing at high-volume centers.
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Affiliation(s)
- Tiffany J Sinclair
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrea Gillis
- Division of General Surgery, Department of Surgery, Albany Medical College, Albany, NY, USA
| | - Wilson M Alobuia
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Hannah Wild
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Electron Kebebew
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
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