Endovascular treatment of intrahepatic inferior vena cava obstruction from malignant hepatocellular tumor thrombus utilizing Luminexx self-expanding nitinol stents.

To The Editor: We report on a 64-year-old male with a past medical history of hepatocellular carcinoma partially resected at an outside institution, who presented with recurrent tumor in the left lobe of the liver for a scheduled transarterial chemoembolization (TACE). He demonstrated marked scrotal edema, lower body edema and extensive ascites consistent with inferior vena caval syndrome. Contrast enhanced computed tomography of the abdomen demonstrated an enhancing left lobe liver tumor with extension into the hepatic portion of the inferior vena cava (IVC). Selective hepatic arteriogram demonstrated a highly vascular neoplasm involving the left lobe of the liver consistent with recurrent hepatoma. The venous phase demonstrated bulky filling defects within the IVC consistent with thrombus. Subsequently, a venacavagram was performed with the intent to dissolve the thrombus utilizing pharmacological thrombolysis. Extensive thrombus was identified on the venacavagram from the renal veins to the right atrium. An infusion catheter (Angiodynamics, Queensbury, NY) was easily advanced through the occluded IVC and into the origin of the right atrium. Tenecteplace (TNKase) (Gene-tech, San Francisco, CA) was infused overnight at 0.5 mg/h (5 cc/h). Following overnight infusion therapy, there was no significant change in the occluding IVC thrombus. Utilizing standard interventional and endovascular techniques, tandem 14 mm X 60 mm Luminexx (Bard Peripheral Vascular, Tempe, AZ) self-expanding nitinol stents were deployed from the right atrium to the level of the renal veins. Final images demonstrated good flow from the iliac veins to the right atrium. On the next day, the patient was doing well with improved appetite, reduced scrotal edema, and improved lower body edema. The patient was sent home post procedure Day 2 with the possibility of performing the intended chemoembolization of the recurrent hepatoma in the future as an outpatient.

Inferior vena cava obstruction is a well-described clinical entity. It is caused by multiple etiologies including propagation of deep venous thrombosis, IVC filter thrombosis, radiation fibrosis, hemodialysis-related factors and extrinsic compression by adjacent tumor. (1-3) The symptoms of IVC obstruction include progressive ascites, scrotal edema and lower body edema. (4) These constellations of symptoms are devastating to a patient with end-stage cancer. Various surgical and nonsurgical therapies have been described relating to the treatment of IVC obstruction including IVC resection, radiation and chemotherapy. (5)

Our case describes a concise technique for the endovascular treatment of hepatoma-induced IVC occlusion utilizing venography, venous thrombolysis and the latest stent technology. The combination of venography and IVC pharmacological thrombolysis with TNKase confirmed the diagnosis of intracaval tumor thrombus amenable to stent placement. Venous stenting is a common endovascular therapy performed by interventional radiologists for various venous territories including axillary vein thrombosis (Paget-Schrotter syndrome), iliofemoral stenosis (May-Thumer syndrome), arteriovenous fistula anastomosis stenosis, and superior vena cava (SVC) syndrome. (3) Presently, modern stent technology allows for various sizes and lengths of venous territories to be treated through very small entrance sites. These newer designs help interventionalists pursue many more endovascular options in patients with various vascular conditions. We feel that endovascular treatment of malignant IVC obstruction is a safe and effective palliative therapy which rapidly resolves the clinical manifestations of IVC syndrome in patients with end-stage cancer.

Acknowledgments

We wish to thank Valerie Bryant, Administrative Assistant, Department of Radiology, St. Joseph's Hospital and Medical Center, for her assistance in preparation of the manuscript.

Glenn W. Stambo, MD

John Leto, RT

Kelly Van Epps, MD

Troy Woeste, MD

Division of Vascular and Interventional

Radiology, Department of Radiology

St. Joseph's Hospital and Medical Center

Tampa, FL

Christopher George, MD

Department of Hematology and Oncology

St. Joseph's Hospital and Medical Center

Tampa, FL

References

1. Oviedo J, Cerda S. Vascular invasion by hepatocellular carcinoma. Arch Pathol Lab Med 2001;125:454-455.

2. Furui S, Sawada S, Kuramoto K, et al. Gianturco stent placement in malignant caval obstruction: analysis of factors for predicting the outcome. Radiology 1995;195:147-152.

3. Bondelinger RF, Goffette P, et al. Expandable Metal Stents for Stenoses of the Vena Cava and Large Veins. Seminars in Interventional Radiology 1991;8:252-263.

4. Fletcher WS, Lakin PC, Pommier RF, et al. Results of treatment of inferior vena cava syndrome with expandable metallic stents. Arch Surg 1998;133:935-938.

5. Ohwada S, Kawashima Y. Extended hepatectomy with ePTFE graft vena caval replacement and hepatic vein reconstruction: a case report. Hepatogastroenterology 1999;46:1151-1155.