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Implantación de Prótesis , Filtros de Vena Cava , Humanos , Resultado del Tratamiento , Implantación de Prótesis/instrumentación , Implantación de Prótesis/efectos adversos , Diseño de Prótesis , Factores de Riesgo , Embolia Pulmonar/prevención & control , Vena Cava Inferior/diagnóstico por imagen , Trombosis de la Vena/terapia , Trombosis de la Vena/diagnóstico por imagen , Selección de Paciente , Toma de Decisiones ClínicasRESUMEN
Background: Fluid resuscitation is an essential component for sepsis treatment. Although several studies demonstrated that dynamic variables were more accurate than static variables for prediction of fluid responsiveness, fluid resuscitation guidance by dynamic variables is not standard for treatment. The objectives were to determine the effects of dynamic inferior vena cava (IVC)-guided versus (vs.) static central venous pressure (CVP)-guided fluid resuscitation in septic patients on mortality; and others, i.e., resuscitation targets, shock duration, fluid and vasopressor amount, invasive respiratory support, length of stay and adverse events. Methods: A single-blind randomized controlled trial was conducted at Thammasat University Hospital between August 2016 and April 2020. Septic patients were stratified by acute physiologic and chronic health evaluation II (APACHE II) <25 or ≥25 and randomized by blocks of 2 and 4 to fluid resuscitation guidance by dynamic IVC or static CVP. Results: Of 124 patients enrolled, 62 were randomized to each group, and one of each was excluded from mortality analysis. Baseline characteristics were comparable. The 30-day mortality rates between dynamic IVC vs. static CVP groups were not different (34.4% vs. 45.9%, p=0.196). Relative risk for 30-day mortality of dynamic IVC group was 0.8 (95%CI=0.5-1.2, p=0.201). Different outcomes were median (interquartile range) of shock duration (0.8 (0.4-1.6) vs. 1.5 (1.1-3.1) days, p=0.001) and norepinephrine (NE) dose (6.8 (3.9-17.8) vs. 16.1 (7.6-53.6) milligrams, p=0.008 and 0.1 (0.1-0.3) vs. 0.3 (0.1-0.8) milligramâ kilogram -1, p=0.017). Others were not different. Conclusions: Dynamic IVC-guided fluid resuscitation does not affect mortality of septic patients. However, this may reduce shock duration and NE dose, compared with static CVP guidance.
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Fluidoterapia , Resucitación , Sepsis , Humanos , Fluidoterapia/métodos , Masculino , Femenino , Sepsis/terapia , Sepsis/mortalidad , Persona de Mediana Edad , Resucitación/métodos , Anciano , Presión Venosa Central , Método Simple Ciego , Vena Cava InferiorRESUMEN
BACKGROUND: Kyphoplasty-associated cement extravasation into surrounding tissue and vasculature can lead to life-threatening complications. We present a rare case of significant inferior vena cava cement burden that resulted in pulmonary embolism. CASE PRESENTATION: A 74-year-old Caucasian woman with a history of severe osteoporosis, recurrent falls, and spinal compression fracture status post-kyphoplasty of the L4-L5 vertebrae, presents to the emergency department 2 days post-vertebral kyphoplasty due to chest pain, back pain, and dyspnea. Computed tomography of the chest and abdomen showed a metallic density within the inferior vena cava extending superiorly approximately 10 cm from the vertebral L5 level. She was also found to have right lower lobe pneumonia. The patient finished a 10-day course of antibiotics and was discharged home with a 1-month long course of anticoagulation with apixaban per recommendations of a multidisciplinary team consisting of Hematology/Oncology, Interventional Radiology, Vascular Surgery, and Orthopedic Surgery. Unfortunately, the patient was readmitted a month later with shortness of breath. Work up was notable for an influenza type A infection and computed tomography findings of pulmonary cement embolism. The respiratory distress was resolved with supportive care. Despite pulmonary cement burden, the multidisciplinary care team recommended no further anticoagulation. Patient was discharged home with close clinical follow-up and 6 months has since passed at the time of this report without reported complications. CONCLUSIONS: A large cement burden in the inferior vena cava leading to pulmonary cement embolism is a rare event. A high burden of cement predisposes development of pulmonary embolism. A short course of anticoagulation may only be needed for asymptomatic patients.
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Cementos para Huesos , Fracturas por Compresión , Cifoplastia , Embolia Pulmonar , Humanos , Cifoplastia/efectos adversos , Anciano , Femenino , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/etiología , Cementos para Huesos/efectos adversos , Fracturas por Compresión/cirugía , Fracturas por Compresión/diagnóstico por imagen , Vena Cava Inferior/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Fracturas de la Columna Vertebral/cirugía , Vértebras LumbaresRESUMEN
Background: Canine pheochromocytomas (PCCs) are rare tumors of the adrenal medulla. Clinical signs are often vague, resulting in intermittent catecholamine over secretion or neoplastic invasion of adjacent structures. Case Description: A 12-year-old Epagneul Breton dog with a 1-year history of chronic kidney disease, was examined for acute onset of severe neurological signs. Based on clinical and instrumental data, hypertensive encephalopathy was suspected. Cardiac and abdominal ultrasound were performed. Severe hypertensive cardiopathy and a right adrenal gland mass with invasion of the caudal vena cava were diagnosed. Computed tomography imaging confirmed the suspect of invasive malignant neoplasia. Emergency pharmacological therapy was started to reduce systemic pressure, improve clinical signs, and stabilize the dog in view of surgical resolution. After initial improvement, patient conditions abruptly worsened, and euthanasia was elected. Histology examination confirmed a right adrenal PCC, with caval invasion. Conclusion: To the authors' conclusions, acute hypertensive encephalopathy is a peculiar manifestation of PCCs. Ultrasound is a useful, and rapid test to suspect PCC as it can detect adrenal alterations, caval invasion, metastasis, and cardiac sequelae consistent with the condition. PCC can mimic multiple affections, and be misinterpreted, especially when a concurrent disease has already been diagnosed. Veterinarians need to be aware that comorbidities could mask clinical signs and delay diagnosis. Furthermore, this clinical case reminds us to include PCC also in the differential diagnosis of dogs with an acute onset of severe neurological signs.
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Neoplasias de las Glándulas Suprarrenales , Enfermedades de los Perros , Encefalopatía Hipertensiva , Feocromocitoma , Animales , Perros , Neoplasias de las Glándulas Suprarrenales/veterinaria , Neoplasias de las Glándulas Suprarrenales/complicaciones , Neoplasias de las Glándulas Suprarrenales/patología , Neoplasias de las Glándulas Suprarrenales/diagnóstico , Enfermedades de los Perros/patología , Enfermedades de los Perros/diagnóstico , Enfermedades de los Perros/etiología , Encefalopatía Hipertensiva/veterinaria , Encefalopatía Hipertensiva/diagnóstico , Encefalopatía Hipertensiva/etiología , Encefalopatía Hipertensiva/patología , Invasividad Neoplásica , Feocromocitoma/veterinaria , Feocromocitoma/complicaciones , Feocromocitoma/patología , Feocromocitoma/diagnóstico , Vena Cava Inferior/patologíaRESUMEN
Inferior vena cava filter (IVCF) implantation is a common method of thrombus capture. By implanting a filter in the inferior vena cava (IVC), microemboli can be effectively blocked from entering the pulmonary circulation, thereby avoiding acute pulmonary embolism (PE). Inspired by the helical flow effect in the human arterial system, we propose a helical retrievable IVCF, which, due to the presence of a helical structure inducing a helical flow pattern of blood in the region near the IVCF, can effectively avoid the deposition of microemboli in the vicinity of the IVCF while promoting the cleavage of the captured thrombus clot. It also reduces the risk of IVCF dislodging and slipping in the vessel because its shape expands in the radial direction, allowing its distal end to fit closely to the IVC wall, and because its contact structure with the inner IVC wall is curved, increasing the contact area and reducing the risk of the vessel wall being punctured by the IVCF support structure. We used ANSYS 2023 software to conduct unidirectional fluid-structure coupling simulation of four different forms of IVCF, combined with microthrombus capture experiments in vitro, to explore the impact of these four forms of IVCF on blood flow patterns and to evaluate the risk of IVCF perforation and IVCF dislocation. It can be seen from the numerical simulation results that the helical structure does have the function of inducing blood flow to undergo helical flow dynamics, and the increase in wall shear stress (WSS) brought about by this function can improve the situation of thrombosis accumulation to a certain extent. Meanwhile, the placement of IVCF will change the flow state of blood flow and lead to the deformation of blood vessels. In in vitro experiments, we found that the density of the helical support rod is a key factor affecting the thrombus trapping efficiency, and in addition, the contact area between the IVCF and the vessel wall has a major influence on the risk of IVCF displacement.
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Hemodinámica , Filtros de Vena Cava , Humanos , Vena Cava Inferior , Simulación por Computador , Trombosis/prevención & control , Trombosis/etiología , Embolia Pulmonar/prevención & control , Modelos CardiovascularesRESUMEN
We present a 55-year-old male patient with right renal carcinoma with long inferior vena cava (IVC) tumor thrombus who underwent robot-assisted laparoscopic radical nephrectomy with extensive IVC resection and left renal vein ligation. The patient had a history of hematuria only prior to admission. Our case involved resection of the entire abdominal segment of the IVC and left renal vein without reconstruction. Unfortunately, the patient passed away over a year after the surgery due to brain metastasis.
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Carcinoma de Células Renales , Neoplasias Renales , Nefrectomía , Vena Cava Inferior , Humanos , Vena Cava Inferior/cirugía , Vena Cava Inferior/patología , Masculino , Persona de Mediana Edad , Neoplasias Renales/cirugía , Neoplasias Renales/patología , Carcinoma de Células Renales/cirugía , Carcinoma de Células Renales/patología , Venas Renales/cirugía , Venas Renales/patología , Venas Renales/diagnóstico por imagen , Trombosis de la Vena/cirugía , Trombosis de la Vena/etiología , Trombosis de la Vena/patologíaRESUMEN
BACKGROUND: The optimal assessment of systemic and lung decongestion during acute heart failure is not clearly defined. We evaluated whether inferior vena cava (IVC) and pulmonary ultrasound (CAVAL US) guided therapy is superior to standard care in reducing subclinical congestion at discharge in patients with AHF. METHODS: CAVAL US-AHF was an investigator-initiated, single-center, single-blind, randomized controlled trial. A daily quantitative ultrasound protocol using the 8-zone method was used and treatment was adjusted according to an algorithm. The primary endpoint was the presence of more than 5 B-lines and/or an increase in IVC diameter and collapsibility at discharge. And secondary endpoint exploratory outcome was the composite of readmission for HF, unplanned visit for worsening HF or death at 90 days RESULTS: Sixty patients were randomized to CAVAL US (n = 30) or control (n = 30). The primary endpoint was achieved in 4 patients (13.3%) in the CAVAL US group and 20 patients (66.6%) in the control group (P < .001). A significant reduction in HF readmission, unplanned visit for worsening HF or death at 90 days was seen in the CAVAL US group (13.3% vs 36.7%; log rank P = .038). Other endpoints such as NT-proBNP reduction at discharge showed a nonstatistically significant reduction in the CAVAL US group (48% IQR 27-67 vs 37% -3-59; P = .09). Safety outcomes were similar in both groups. CONCLUSION: IVC and lung ultrasound-guided therapy in AHF patients significantly reduced subclinical congestion at discharge. CAVAL US-AHF provides preliminary evidence for the potential use of a simple technique to guide decongestive therapy during hospitalization for AHF, which may reduce the composite outcome at 90 days.
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Insuficiencia Cardíaca , Ultrasonografía Intervencional , Vena Cava Inferior , Humanos , Vena Cava Inferior/diagnóstico por imagen , Insuficiencia Cardíaca/terapia , Masculino , Femenino , Proyectos Piloto , Método Simple Ciego , Anciano , Enfermedad Aguda , Ultrasonografía Intervencional/métodos , Pulmón/diagnóstico por imagen , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
IMPORTANCE: Maneuvers assessing fluid responsiveness before an intravascular volume expansion may limit useless fluid administration, which in turn may improve outcomes. OBJECTIVE: To describe maneuvers for assessing fluid responsiveness in mechanically ventilated patients. REGISTRATION: The protocol was registered at PROSPERO: CRD42019146781. INFORMATION SOURCES AND SEARCH: PubMed, EMBASE, CINAHL, SCOPUS, and Web of Science were search from inception to 08/08/2023. STUDY SELECTION AND DATA COLLECTION: Prospective and intervention studies were selected. STATISTICAL ANALYSIS: Data for each maneuver were reported individually and data from the five most employed maneuvers were aggregated. A traditional and a Bayesian meta-analysis approach were performed. RESULTS: A total of 69 studies, encompassing 3185 fluid challenges and 2711 patients were analyzed. The prevalence of fluid responsiveness was 49.9%. Pulse pressure variation (PPV) was studied in 40 studies, mean threshold with 95% confidence intervals (95% CI) = 11.5 (10.5-12.4)%, and area under the receiver operating characteristics curve (AUC) with 95% CI was 0.87 (0.84-0.90). Stroke volume variation (SVV) was studied in 24 studies, mean threshold with 95% CI = 12.1 (10.9-13.3)%, and AUC with 95% CI was 0.87 (0.84-0.91). The plethysmographic variability index (PVI) was studied in 17 studies, mean threshold = 13.8 (12.3-15.3)%, and AUC was 0.88 (0.82-0.94). Central venous pressure (CVP) was studied in 12 studies, mean threshold with 95% CI = 9.0 (7.7-10.1) mmHg, and AUC with 95% CI was 0.77 (0.69-0.87). Inferior vena cava variation (∆IVC) was studied in 8 studies, mean threshold = 15.4 (13.3-17.6)%, and AUC with 95% CI was 0.83 (0.78-0.89). CONCLUSIONS: Fluid responsiveness can be reliably assessed in adult patients under mechanical ventilation. Among the five maneuvers compared in predicting fluid responsiveness, PPV, SVV, and PVI were superior to CVP and ∆IVC. However, there is no data supporting any of the above mentioned as being the best maneuver. Additionally, other well-established tests, such as the passive leg raising test, end-expiratory occlusion test, and tidal volume challenge, are also reliable.
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Presión Venosa Central , Fluidoterapia , Pletismografía , Respiración Artificial , Volumen Sistólico , Vena Cava Inferior , Humanos , Respiración Artificial/métodos , Respiración Artificial/estadística & datos numéricos , Presión Venosa Central/fisiología , Fluidoterapia/métodos , Fluidoterapia/normas , Fluidoterapia/estadística & datos numéricos , Vena Cava Inferior/fisiología , Volumen Sistólico/fisiología , Pletismografía/métodos , Presión Sanguínea/fisiologíaAsunto(s)
Fibrosis Retroperitoneal , Vena Cava Inferior , Humanos , Fibrosis Retroperitoneal/complicaciones , Fibrosis Retroperitoneal/diagnóstico , Vena Cava Inferior/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Femenino , Anciano , Trombosis de la Vena/etiología , Trombosis de la Vena/diagnóstico por imagenRESUMEN
BACKGROUND: To report the diagnosis and treatment of a rare disease of intravenous leiomyomatosis (IVL) originating from the uterus, growing in the inferior vena cava (IVC) and extending into the right atrium (RA) associated with a pelvic arteriovenous fistula (AVF). This is the first reported case of IVL in the IVC and RA with pulmonary benign metastasizing leiomyoma (PBML) secondary to a pelvic AVF despite the use of GnRH agonists in a nonmenopausal woman. CASE PRESENTATION: The patient was a 50-year-old premenopausal woman with a history of surgical resection for and antiestrogen conservative drug for pulmonary benign metastasizing leiomyoma (PBML) 5 years. The patient nevertheless developed IVL in the IVC, internal iliac vein and RA accompanied by AVF. Vaginal ultrasound combined with echocardiography and computerized tomographic venography imaging assists in the diagnosis of IVL combined with AVF, with histopathology and immunohistochemistry ultimately confirming the diagnosis. The patient ultimately was performed with a combination of hysterectomy, bilateral adnexectomy, and resection of tumors in the IVC and RA without cardiopulmonary bypass and sternotomy. CONCLUSION: BML may be difficult to control with incomplete removal of the uterus and ovaries even with the use of antiestrogenic medications, and medically induced AVF resulting from fibroid surgery may accelerate this process and the development of IVL.
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Fístula Arteriovenosa , Atrios Cardíacos , Leiomiomatosis , Neoplasias Pulmonares , Neoplasias Uterinas , Neoplasias Vasculares , Vena Cava Inferior , Humanos , Femenino , Vena Cava Inferior/patología , Vena Cava Inferior/cirugía , Vena Cava Inferior/diagnóstico por imagen , Persona de Mediana Edad , Neoplasias Uterinas/patología , Neoplasias Uterinas/cirugía , Fístula Arteriovenosa/cirugía , Fístula Arteriovenosa/etiología , Fístula Arteriovenosa/diagnóstico por imagen , Fístula Arteriovenosa/patología , Atrios Cardíacos/patología , Atrios Cardíacos/cirugía , Atrios Cardíacos/diagnóstico por imagen , Leiomiomatosis/patología , Leiomiomatosis/cirugía , Leiomiomatosis/diagnóstico por imagen , Neoplasias Pulmonares/secundario , Neoplasias Pulmonares/patología , Neoplasias Vasculares/patología , Neoplasias Vasculares/cirugía , Neoplasias Vasculares/diagnóstico por imagen , Neoplasias Cardíacas/secundario , Neoplasias Cardíacas/patología , Neoplasias Cardíacas/cirugía , Neoplasias Cardíacas/complicaciones , Resultado del Tratamiento , Histerectomía , Vena Ilíaca/patología , Vena Ilíaca/diagnóstico por imagenRESUMEN
PURPOSE OF REVIEW: Renal Cell Carcinoma (RCC) with invasion into the inferior vena cava (IVC) is a rare and mortal condition. Patients with RCC have an average life expectancy of no more than six months, thus requiring an aggressive surgical approach. We analyze the outcomes of patients that underwent surgery at a single medical institution. RECENT FINDINGS: The analysis of recent series of successful treatment with radical nephrectomy and IVC thrombectomy shows a 5 year survival from 45 to 69%. We found in the analyzed series that the success of the treatment in these patients depends on the resection of the renal tumor and venous thrombectomy. We found that at our medical institution nephrectomy and IVC thrombectomy with primary repair have no intraoperative mortality and no pulmonary embolism. Nephrectomy and thrombectomy of IVC is a reliable approach for patients with advance RCC.
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Carcinoma de Células Renales , Neoplasias Renales , Nefrectomía , Trombectomía , Vena Cava Inferior , Humanos , Neoplasias Renales/cirugía , Vena Cava Inferior/cirugía , Nefrectomía/métodos , Trombectomía/métodos , Carcinoma de Células Renales/cirugía , Resultado del Tratamiento , Invasividad NeoplásicaRESUMEN
Background: Renal angiomyolipoma (AML) without local invasion is generally considered benign. However, it may extend to the renal sinus, even the renal vein, or the inferior vena cava (IVC). In patients with non-tuberous sclerosis complex, coexistence of renal cell carcinoma (RCC) and renal AML is uncommon. Case presentation: A 72-year-old woman was incidentally found to have a solitary right renal mass with an IVC thrombus extending into the right atrium during a routine health checkup. Robot-assisted laparoscopic radical nephrectomy and thrombectomy were successfully performed through adequate preoperative examination and preparation. Two tumor lesions were found and pathologically confirmed as renal AML and RCC, and the tumor thrombus was derived from the renal AML. During the one-year follow-up period, no signs of recurrence or metastatic disease were observed. Conclusions: Renal AML with a tumor thrombus in the IVC and right atrium accompanied by RCC may occur, although rarely. In clinical practice, if preoperative manifestations differ from those of common diseases, rare diseases must be considered to avoid missed diagnoses. In addition, adequate examination and multidisciplinary discussions before making a diagnosis are necessary. For a level 4 tumor thrombus with no infringement of the venous wall, adoption of robot-assisted minimally invasive surgery, without extracorporeal circulation technology, is feasible.
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Angiomiolipoma , Carcinoma de Células Renales , Atrios Cardíacos , Neoplasias Renales , Vena Cava Inferior , Humanos , Carcinoma de Células Renales/complicaciones , Carcinoma de Células Renales/cirugía , Femenino , Anciano , Vena Cava Inferior/diagnóstico por imagen , Neoplasias Renales/complicaciones , Neoplasias Renales/cirugía , Neoplasias Renales/patología , Angiomiolipoma/complicaciones , Angiomiolipoma/cirugía , Atrios Cardíacos/diagnóstico por imagen , Nefrectomía/métodos , Trombectomía/métodos , Trombosis/cirugía , Trombosis/complicaciones , Procedimientos Quirúrgicos Robotizados/métodosRESUMEN
Cancer-associated venous thromboembolism (CAT) poses a severe threat, disrupting ongoing cancer management and adversely impacting treatment outcomes. CAT often leads to a two- to six-fold increase in mortality rates when it progresses to venous total occlusion. The primary modalities employed in addressing this life-threatening complication include anticoagulant therapy only or coupled with strategic endovascular interventions. Aggressive endovascular interventions, such as mechanical thrombectomy and venous stent implantation, are crucial in mitigating thrombotic complications, relieving symptoms, and improving this vulnerable population's overall quality of life and life expectancy. This case report presents a CAT case extending to the total occlusion of the inferior vena cava. Our goal is to provide valuable insights into the evolving management of CAT and its sequelae, showcasing treatment approaches that lead to improved outcomes and a better quality of life for cancer patients facing these additional challenges.
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Procedimientos Endovasculares , Tromboembolia Venosa , Humanos , Tromboembolia Venosa/complicaciones , Tromboembolia Venosa/etiología , Procedimientos Endovasculares/métodos , Trombosis de la Vena/complicaciones , Trombosis de la Vena/etiología , Masculino , Vena Cava Inferior , Trombectomía/métodos , Persona de Mediana Edad , Calidad de Vida , Vena Ilíaca , Neoplasias/complicaciones , Stents , FemeninoRESUMEN
Patients with functionally univentricular hearts are usually palliated surgically. There have been several reports of successful attempts to complete the Fontan procedure without surgery. The pathways created at the time of the preconditioning were largely reminiscent of the lateral tunnel Fontan. However, this approach is still confidentially limited to a small number of centers. In 2013, we designed a circuit that mimics the actual surgical technique of extracardiac total cavopulmonary connection to allow for transcatheter completion in an animal study. A polytetrafluoroethylene conduit was connected between the pulmonary artery and the inferior vena cava (IVC). The superior anastomosis was occluded to avoid flow between IVC and superior vena cava (SVC). The conduit was connected to the right atrium (RA) and a large fenestration was created to allow free flow from the IVC to the RA. Extrapolating our approach, a center reported the successful transcatheter completion of an extracardiac Fontan in a 6-year-old child. However, this technique is not directly transposable to our population of patients who require preconditioning in infancy. We report here an innovative extension of this technique that may allow preparing patients in infancy, ideally at the time of the Glenn in the future, to receive an extracardiac Fontan at 2 years/11 kg without additional surgery.
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Cateterismo Cardíaco , Procedimiento de Fontan , Cardiopatías Congénitas , Procedimiento de Fontan/efectos adversos , Cateterismo Cardíaco/instrumentación , Humanos , Cardiopatías Congénitas/cirugía , Cardiopatías Congénitas/fisiopatología , Cardiopatías Congénitas/diagnóstico por imagen , Arteria Pulmonar/cirugía , Arteria Pulmonar/fisiopatología , Arteria Pulmonar/diagnóstico por imagen , Vena Cava Inferior/diagnóstico por imagen , Vena Cava Inferior/cirugía , Vena Cava Inferior/fisiopatología , Politetrafluoroetileno , Corazón Univentricular/cirugía , Corazón Univentricular/fisiopatología , Corazón Univentricular/diagnóstico por imagen , Diseño de Prótesis , Resultado del Tratamiento , Hemodinámica , Animales , Prótesis VascularRESUMEN
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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Procedimientos Endovasculares , Trombectomía , Vena Cava Inferior , Trombosis de la Vena , Humanos , Trombectomía/métodos , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Adulto , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/cirugía , Vena Cava Inferior/diagnóstico por imagen , Vena Cava Inferior/cirugía , Anciano , Procedimientos Endovasculares/métodos , Resultado del Tratamiento , Vena Ilíaca/diagnóstico por imagen , Vena Ilíaca/cirugía , Células Neoplásicas Circulantes , Adulto JovenRESUMEN
OBJECTIVE: To summarize the clinical characteristics of patients with renal angiomyolipoma (RAML) combined with inferior vena cava (IVC) tumor thrombus, and to explore the feasibility of partial nephrectomy and thrombectomy in this series of patients. METHODS: The clinical data of patients diagnosed with RAML combined with IVC tumor thrombus in the Department of Urology of the Peking University Third Hospital from April 2014 to March 2023 were retrospectively analyzed, and demographic and perioperative data of RAML patients with IVC tumor thrombus were recorded and collected from Electronic Medical Record System, including age, gender, surgical methods, and follow-up time, etc. The clinical characteristics between classic angiomyolipoma (CAML) patients with IVC tumor thrombus and epithelioid angiomyolipoma (EAML) patients with IVC tumor thrombus were compared to determine the clinical characteristics of these patients. RESULTS: A total of 11 patients were included in this study, including 7 patients with CAML with IVC tumor thrombus and 4 patients with EAML with IVC tumor thrombus. There were 9 females (9/11, 81.8%) and 2 males (2/11, 18.2%), with an average age of (44.0±17.1) years. 9 patients (9/11, 81.8%) experienced clinical symptoms, including local symptoms including abdominal pain, hematuria, abdominal masses, and systemic symptoms including weight loss and fever; 2 patients (2/11, 18.2%) with RAML and IVC tumor thrombus did not show clinical symptoms, which were discovered by physical examination. Among the 11 patients, 10 underwent radical nephrectomy with thrombectomy, of whom, 3 underwent open surgery (3/10, 30.0%), 2 underwent laparoscopic surgery (2/10, 20.0%), and 5 underwent robot-assisted laparoscopic surgery (5/10, 50.0%). In addition, 1 patient underwent open partial nephrectomy and thrombectomy. The patients with EAML combined with IVC tumor thrombus had a higher proportion of systemic clinical symptoms (100% vs. 0%, P=0.003), more intraoperative bleeding [400 (240, 3 050) mL vs. 50 (50, 300) mL, P =0.036], and a higher proportion of tumor necrosis (75% vs. 0%, P=0.024) compared to the patients with CAML combined with IVC tumor thrombus. However, there was no statistically significant difference in operation time [(415.8±201.2) min vs. (226.0±87.3) min, P=0.053] between the two groups. CONCLUSION: Compared with the patients with CAML and IVC tumor thrombus, the patients with EAML and IVC tumor thrombus had a higher rate of systemic symptoms and tumor necrosis. In addition, in the selected patients with CAML with IVC tumor thrombus, partial nephrectomy and tumor thrombectomy could be performed to better preserve renal function.
Asunto(s)
Angiomiolipoma , Neoplasias Renales , Nefrectomía , Trombectomía , Vena Cava Inferior , Humanos , Angiomiolipoma/cirugía , Angiomiolipoma/diagnóstico , Angiomiolipoma/patología , Angiomiolipoma/complicaciones , Neoplasias Renales/cirugía , Neoplasias Renales/patología , Neoplasias Renales/diagnóstico , Femenino , Masculino , Vena Cava Inferior/cirugía , Vena Cava Inferior/patología , Estudios Retrospectivos , Nefrectomía/métodos , Trombectomía/métodos , Adulto , Persona de Mediana Edad , Trombosis de la Vena/cirugía , Trombosis de la Vena/etiología , Laparoscopía/métodos , Trombosis/cirugía , Trombosis/diagnósticoRESUMEN
OBJECTIVE: To analyze the clinical effects of intraoperative transesophageal echocardiography (TEE) in different surgical methods for nephrectomy combined with Mayo â ¢-â £ inferior vena cave (IVC) tumor thrombectomy. METHODS: In the study, 28 patients who did surgery of nephrectomy and Mayo â ¢-â £ IVC thrombectomys in Peking University Third Hospital from 2022 January to 2024 February were included. Of the 28 patients, 16 patients did robotic surgery, 2 patients did laparoscopic surgery, and 10 patients did open surgery. All patients' clinical data were collected. RESULTS: Intra-operative TEE was used in 9 robotic surgeries, of which 7 cases showed image changes compared with preoperative image results. Intraoperative TEE indicated that tumor thrombus entered the right atrium in 2 cases, showed that tumor thrombus grade rose from Mayo â ¢ to Mayo â £ in 2 cases, and indicated that tumor thrombus adhered to IVC wall in 3 cases. All of these surgical plans were timely adjusted. Intra-operative TEE was used in 6 cases of open surgery, and 4 cases of them showed Mayo grade changes compared with preoperative image results. Intraoperative TEE indicated that tumor thrombus adhered to the IVC wall in 3 cases, and tumor thrombus adhered to the IVC wall with thrombus in one case. The surgical plans were adjusted, and the tumor thrombus was left or segmentally removed. Laparoscopic surgery did not use intraoperative TEE. The effects of intraoperative TEE included: the combination of exploration and TEE monitoring was used in open surgery, and tumor thrombus removal process was fully monitored by intraoperative TEE in the robotic surgery. Intraoperative TEE real-time monitored circulatory status and cardiac function changes. CONCLUSION: In different surgical methods for nephrectomy combined with Mayo â ¢-â £ tumor thrombectomy, intraoperative TEE can re-determine the tumor thrombus grade and degree of tumor thrombus adhered to IVC, track the tumor thrombus removal process in real-time, and monitor circulatory status and cardiac function changes. Intraoperative TEE plays an important role in different surgical methods, but its clinical application is still insufficient. Intraoperative TEE is recommended to such type of surgeries.
Asunto(s)
Ecocardiografía Transesofágica , Neoplasias Renales , Laparoscopía , Nefrectomía , Procedimientos Quirúrgicos Robotizados , Trombectomía , Vena Cava Inferior , Humanos , Ecocardiografía Transesofágica/métodos , Nefrectomía/métodos , Trombectomía/métodos , Vena Cava Inferior/cirugía , Vena Cava Inferior/diagnóstico por imagen , Neoplasias Renales/cirugía , Neoplasias Renales/diagnóstico por imagen , Neoplasias Renales/patología , Procedimientos Quirúrgicos Robotizados/métodos , Laparoscopía/métodos , Masculino , Femenino , Persona de Mediana EdadRESUMEN
OBJECTIVE: To analyze the clinicopathological features, prognostic value and surgical treatment experience in patients with adrenocortical carcinoma with venous tumor thrombus. METHODS: We collected relevant data of the patients with adrenocortical carcinoma who had undergone surgery in Peking University Third Hospital from 2018 to 2023. The patients were divided into venous tumor thrombus group and non-tumor thrombus group. The Wilcoxon rank sum test was used to compare the quantitative variables. The chi-squared test and Fisher's exact test were used to compare the categorical variables. The Kaplan-Meier method was used to estimate the survival rate. RESULTS: A total of 27 patients with adrenocortical carcinoma were included, of whom 11 cases (40.7%) had venous tumor thrombus. In the patients with venous tumor thrombus, 8 patients were female and 3 were male. The median age was 49 (36, 58) years. The median body mass index was 26.0 (24.1, 30.4) kg/m2. Seven patients presented with symptoms at their initial visit. Six patients had a history of hypertension. Elevated levels of cortisol were observed in 2 cases. Three tumors were found on the left side, while 8 were found on the right side. Median tumor diameter was 9.4 (6.5, 12.5) cm. On the left, there was a case of tumor thrombus limited to the central vein of the left adrenal gland without invasion into the left renal vein, and two cases of tumor thrombus growth extending into the inferior vena cava below the liver. One case of tumor thrombus on the right adrenal central vein did not invade the inferior vena cava. Four cases of tumor thrombus invaded the inferior vena cava below the liver and three cases extended to the posterior of the liver. Ten patients were in European Network for the Study of Adrenal Tumors (ENSAT) stage â ¢ and one was in ENSAT stage â £. Open surgery was performed in 6 cases, laparoscopic surgery alone in 4 cases and robot-assisted laparoscopic surgery in 1 case. Two patients underwent ipsilateral kidney resection. Median operative time was 332 (261, 440) min. Median intraoperative bleeding was 900 (700, 2 200) mL. Median hospital stay was 9 (5, 10) days. Median survival time for the patients with tumor thrombus was 24.0 months and median time to recurrence was 7.0 months. The median survival and recurrence time of 16 patients without tumor thrombus were not reached. The patients with tumor thrombus had worse 3-year overall survival (OS) rate (40.9% vs. 71.4%; Log-rank, P=0.038) and 2-year recurrence-free survival (RFS) (9.1% vs.53.7%; Log-rank, P=0.015) rates compared with the patients with non-tumor thrombus. CONCLUSION: Patients with adrenocortical carcinoma with venous tumor thrombus have poor prognosis. Different adrenal tumor resections and venous tumor thrombus removal procedures based on different tumor thrombus locations are safe and effective in treating this disease.
Asunto(s)
Neoplasias de la Corteza Suprarrenal , Adrenalectomía , Carcinoma Corticosuprarrenal , Humanos , Masculino , Femenino , Persona de Mediana Edad , Carcinoma Corticosuprarrenal/cirugía , Carcinoma Corticosuprarrenal/complicaciones , Carcinoma Corticosuprarrenal/patología , Neoplasias de la Corteza Suprarrenal/cirugía , Neoplasias de la Corteza Suprarrenal/complicaciones , Neoplasias de la Corteza Suprarrenal/patología , Adulto , Pronóstico , Adrenalectomía/métodos , Tasa de Supervivencia , Trombosis de la Vena/etiología , Trombosis de la Vena/cirugía , Vena Cava Inferior/patologíaRESUMEN
BACKGROUND: 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. 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 inferior vena cava wall and long indwelling time may complicate retrieval. The vena cava diameter is also closely related to the degree of filter tilt.