Management of Acute Saddle Pulmonary Embolism in Pregnancy Following Fetal Surgery

A 33-year-old gravidity three parity three (G3P3) woman at 34 weeks of pregnancy underwent fetal surgery to repair an open lumbosacral myelomeningocele at 22 weeks gestation and experienced preterm premature rupture of membranes as a result. She developed a saddle pulmonary embolus with signs of right heart strain while on prolonged bed rest. She was treated emergently with aspiration thrombectomy and suprarenal inferior vena cava (IVC) filter placement, followed by an uncomplicated cesarean delivery thereafter.

Tumor Thrombus of Hepatocellular Carcinoma: A Direct Extension From the Liver to the Right Atrium

Hepatocellular carcinoma (HCC) is a very aggressive type of cancer and can either invade or spread distantly through the portal vein to the inferior vena cava (IVC) and the right atrium (RA). The presentation varies based on the stage of the cancer at the time of diagnosis. Liver transplantation or surgical resection is the ideal management of small lesions without metastases, while systemic therapy can help in extensive cases to decrease the tumor burden to allow surgical resection of the tumor. We present a rare case of HCC with a tumor thrombus (TT) extending to the RA. Unfortunately, the patient did not survive the cancer. We hope that this case report can contribute to saving the lives of future patients with HCC.

Inferior Vena Cava Thrombus Associated With Renal Cell Carcinoma With an Atypical Radiological Presentation: A Case Report

Renal cell carcinoma (RCC) is characterized by the development of kidney masses, which can lead to various long-term complications. Among the extrarenal manifestations associated with RCC, the formation of a thrombus within the inferior vena cava (IVC) is particularly prevalent due to the substantial tumor burden imposed by the kidneys. In this report, we present an exceptional case involving an 80-year-old male patient who presented with an intravascular thrombus within the inferior vena cava (IVC), which originated from RCC. The diagnosis of RCC was conclusively established through core needle biopsy and subsequent tumor marker staining. Remarkably, despite the confirmation of RCC within the IVC thrombus through biopsy and tumor marker analysis, radiological assessments failed to reveal any discernible renal cell masses within the kidneys. The patient subsequently received treatment for RCC with a combination regimen of cabozantinib and nivolumab, which resulted in a noteworthy improvement in his clinical condition. The presentation of RCC in this report is notably atypical, given that the biopsy of the thrombus yielded definitive evidence of RCC while radiological investigations did not yield any indications of renal masses or a tumor burden within the kidneys that would typically be associated with RCC.

Cephalic inferior vena cava non-clamping technique versus standard procedure for robot-assisted laparoscopic level II-III thrombectomy: a prospective cohort study

BACKGROUND

Renal tumour can invade the venous system and ~4-10% patients with renal tumour had venous thrombus. Although the feasibility of robot-assisted laparoscopic inferior vena cava thrombectomy (RAL-IVCT) in patients with inferior vena cava (IVC) thrombus has been validated, the wide application is still a challenge due to the complexity of IVC control. The objective was to describe our novel cephalic IVC non-clamping technique and to compare the outcomes versus standard RAL-IVCT.

MATERIALS AND METHODS

A prospective single-centre cohort containing 30 patients with level II-III IVC thrombus was established since August 2020. Fifteen patients underwent cephalic IVC non-clamping approach and 15 patients received standard RAL-IVCT. The authors decided the surgical technique according to the echocardiographic assessment of the right heart and IVC.

RESULTS

The non-clamping group had less operative time (median 148 versus 185 min, P =0.04), and lower Clavien-grade II complication rate (26.7% versus 80.0%, P =0.003). The median intraoperative blood loss were 400 ml [interquartile range (IQR) 275-615 mL] and 800 ml (IQR 350-1300 ml), respectively ( P =0.05). The most common complication in standard RAL-IVCT group was liver dysfunction. No gas embolism, hypercapnia or tumour thrombus dislodgment occurred in non-clamping group. After a median follow-up of 17.0 months (IQR 13.5-18.5 months) and 15.5 months (IQR 13.0-17.0 months), two patients (16.7%) in the non-clamping group and 3 patients (20.0%) in the standard RAL-IVCT group died (hazard ratio 0.59, 95% CI 0.10-3.54, P =0.55).

CONCLUSIONS

The cephalic IVC non-clamping technique can be performed safely with acceptable surgical outcomes and short-term oncologic outcomes in patients with level II-III IVC thrombus. Compared with standard procedure, it had less operative time and lower complication rate.

Renal Angiomyolipoma Causing Inferior Vena Cava Thrombus in a Young Girl With Tuberous Sclerosis

Angiomyolipomas (AML), also known as hamartomas, are benign mesenchymal tumors of the kidneys which consist of vascular tissue, smooth muscles, and adipose tissue, with a higher prevalence in females than males. AML may be associated with tuberous sclerosis, and the growth of the mass may present as hematuria or flank pain. We present a case of a 14-year-old female patient who had a known case of tuberous sclerosis since early childhood. She has a history of numerous bilateral renal masses radiographically consistent with AML. A special and unique entity of our case is the age of presentation which is 14 years and the presence of TSC. In contrast to our case, which was invading the right renal vein and IVC at a young age, AML is well known for its benign nature. According to a recent literature review, the youngest patient reported was 16 years old. Typically, non-complicated AMLs less than 4 cm in size are managed by annual radiological imaging which is preferably a CT scan, while larger AMLs of more than 4 cm that present with perinephric hemorrhages or intralesional aneurysms are treated by partial nephrectomy or selective angioembolization. A radical nephrectomy and IVC thrombectomy are typically necessary due to the risks that the IVC thrombus carries as well as the AML itself and its unpredictable behavior. In cases like ours with the extension into the renal vein and IVC, the surgical approach is similar to the venous invasion of renal cell carcinomas.

Multidisciplinary Approach for a Rare Metastatic Low-Grade Endometrial Stromal Sarcoma to the Inferior Vena Cava and the Right Atrium

Endometrial stromal sarcoma (ESS) is a rare, malignant tumor of the endometrium. Low-grade endometrial stromal sarcoma (LG-ESS) is a less aggressive subtype of ESS that rarely metastasizes to the heart and large blood vessels. In the present study, we report a case of recurrent LG-ESS after treating the initial mass in the uterus six years ago in a 49-year-old female who presented with a four-month history of dyspnea and easy fatigability. Investigations revealed a right pulmonary embolism, suspicious right psoas muscle mass, and a large inferior vena cava (IVC) thrombus. One month later, she presented with multiple gastrointestinal symptoms and weight loss. Investigations then showed the development of a new right atrial mass, infra-diaphragmatic metastatic lymphadenopathy, progression of the presacral soft tissue component, invasion of the ileal bowel loop, and a tumoral thrombus in the IVC besides new metastatic lymphadenopathy and pulmonary metastasis. Therefore, a multidisciplinary team, which had a crucial role in this complicated case, decided to commence chemotherapy treatment. Such an unusual aggressive metastatic course of LG-ESS is limited in the literature; herein, we recognize a rarely documented disease.

Perioperative Challenges in a Septic Shock Patient With Extensive Splanchnic and Extra-Splanchnic Vein Thrombosis Up to the Right Atrium

Venous thromboembolism (VTE) has a significant disease burden worldwide and comprises deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT most commonly occurs in the lower extremities, very rarely it can present in the splanchnic venous circulation or inferior vena cava or both. We report an unusual presentation of a 68-year-old woman with septic shock secondary to ischemic bowel, complicated by non-tumor related, extensive right hepatic vein thrombosis extending up to the inferior vena cava (IVC) and right atrium. She underwent bowel resection surgery emergently and was started on systemic anticoagulation in the perioperative period after an extensive evaluation and resuscitation. She was managed by a multidisciplinary team during her admission and was discharged after four weeks. This case poses an interesting therapeutic challenge to the team as there is little literature to guide treatment in a critically ill patient with ischemic bowel, septic shock with extensive splanchnic and IVC thrombosis who also had likely pseudo-heparin resistance with artifactual activated partial thromboplastin time (aPTT) values. This case report seeks to share our experience of a multidisciplinary and patient-centric approach in this rare presentation of a disease spectrum.