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Objective: The aim of this study was to assess management and determine outcomes of renal tumors with inferior vena cava (IVC) and intracardiac (IC) extension in a tertiary care center in Pakistan. Methods: A retrospective chart review was conducted at the Aga Khan University Hospital, Karachi, Pakistan. All patients from 1 to 18 years of age with renal tumors with intravascular extensions, surgically managed from January 1988 till June 2016, were included. Data was extracted by reviewing medical records, and the tumor details, treatment and outcomes were analyzed. Results: A total of 18 patients out of the total 61 patients with renal tumors, presented with IVC and/or IC extension, with the majority involving the right kidney. Mean age was 5.9 (SD:4.9) and a female preponderance (56%) was seen. Wilms tumor (77%) was the most common tumor type, with the level of tumor extension into IVC predominantly being below the diaphragm (55.5%). Fourteen patients received preoperative chemotherapy, with tumor regression, seen in 10. Most patients underwent thrombectomy through the renal vein (56%). Regarding outcomes, frequency of mortality and morbidity was 1 and 2, respectively, with 7 patients having no recurrent 5 years post-surgery. Conclusion: A greater incidence (29.5%) of IVC and or IC Tumor extension was found compared to existing literature, which could likely be due to a higher referral rate to the center. Moreover, this is a single-center study and so a multi-center study is crucial to form an assessment of surgical management in resource-limited settings. Our study is the first from Pakistan on this particular renal tumor presentation. Considering the varying case presentations and surgical techniques used, further studies are needed to standardize surgical management and optimize patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Hydatid disease is a zoonotic infection caused by the species Echinococcus that typically affects the liver. Most liver hydatid cysts are asymptomatic at first, but as the cyst grows larger, symptoms, such as compression effects, start to appear. Ultrasonography and computed tomography scans are the widely used diagnostic tools, and surgery is considered the mainstay of treatment. Case presentation: We present an unusual case of a giant pedunculated hydatid cyst causing inferior vena cava syndrome in a 20-year-old male patient from the Oromo ethnic group from a rural area of the country. Abdominal ultrasound and computed tomography scan confirmed the diagnosis. Our patient underwent radical surgical resection of the cyst and had a good outcome. Conclusion: Hydatid liver cyst diagnosis needs a high index of suspicion for echinococcal etiology when dealing with a giant liver cyst as it results in grave complications without any manifestations. [ABSTRACT FROM AUTHOR]

Background: To assess thoracic vascular computed tomography (CT) contrast enhancement of a novel intravenous tantalum oxide nanoparticle contrast agent (carboxybetaine zwitterionic tantalum oxide, TaCZ) compared to a conventional iodinated contrast agent (Iopamidol) in a rabbit multiphase protocol. Methods: Five rabbits were scanned inside a human-torso-sized encasement on a clinical CT system at various scan delays after intravenous injection of 540 mg element (Ta or I) per kg of bodyweight of TaCZ or Iopamidol. Net contrast enhancement of various arteries and veins, as well as image noise, were measured. Randomized scan series were reviewed by three independent readers on a clinical workstation and assessed for vascular conspicuity and image artifacts on 5-point Likert scales. Results: Overall, net vascular contrast enhancement achieved with TaCZ was superior to Iopamidol (p ≤ 0.036 with the exception of the inferior vena cava at 6 s (p = 0.131). Vascular contrast enhancement achieved with TaCZ at delays of 6 s, 40 s, and 75 s was superior to optimum achieved Iopamidol contrast enhancement at 6 s (p ≤ 0.036. Vascular conspicuity was higher for TaCZ in 269 of 300 (89.7%) arterial and 269 of 300 (89.7%) venous vessel assessments, respectively (p ≤ 0.005), with substantial inter-reader reliability (κ = 0.61; p < 0.001) and strong positive monotonic correlation between conspicuity scores and contrast enhancement measurements (ρ = 0.828; p < 0.001). Conclusion: TaCZ provides absolute and relative contrast advantages compared to Iopamidol for improved visualization of thoracic arteries and veins in a multiphase CT protocol. Relevance statement: The tantalum-oxide nanoparticle is an experimental intravenous CT contrast agent with superior cardiovascular and venous contrast capacity per injected elemental mass in an animal model, providing improved maximum contrast enhancement and prolonged contrast conspicuity. Further translational research on promising high-Z and nanoparticle contrast agents is warranted. Key Points: There have been no major advancements in intravenous CT contrast agents over decades. Iodinated CT contrast agents require optimal timing for angiography and phlebography. Tantalum-oxide demonstrated increased CT attenuation per elemental mass compared to Iopamidol. Nanoparticle contrast agent design facilitates prolonged vascular conspicuity. [ABSTRACT FROM AUTHOR]

Background: Inferior vena cava filter (IVC) retrieval is most often routine but can be challenging with high morbidity in complex cases, especially those with an extended dwelling time. While risk of morbidity in complex retrievals is decreased with advanced filter retrieval techniques, deciding when and which to use these requires detailed pre-procedural planning. The purpose of our study was to evaluate patient-specific 3D printed anatomic IVC filter models for aiding complex IVC filter retrievals. Methods: All IVC filter retrieval patients between June 2021 and September 2022 at one academic medical hospital were prospectively screened. Nine met criteria for complex retrieval, and their CT images were used to 3D print patient-specific IVC and filter models. Models were used in pre-procedural planning and clinical utility was assessed using the Anatomic Model Utility Likert Questionnaire and estimations of the procedural and fluoroscopy time saved. Results: The usage of 3D printed models in pre-procedural planning had high clinical utility based on the Likert questionnaire (Anatomic Model Utility Points 366.7 ± 103.1). Using a model significantly increased confidence in planning (p = 0.03) and modified the treatment plan in seven cases. It also led to cost-efficient use of resources in the procedure suite with estimated reduction in procedure and fluoroscopy time of 29.0 [20.3] (p = 0.003) and 10.2 [6.7] (p = 0.002) minutes, respectively. Conclusion: 3D printed anatomic models for patients who require complex IVC filter retrieval demonstrated Likert-based high clinical utility and led to estimated reductions of procedural and fluoroscopy time. [ABSTRACT FROM AUTHOR]

Background: Whether immune checkpoint inhibitor (ICI) plus ICI combination therapy or ICI plus tyrosine kinase inhibitor (TKI) combination therapy is useful for renal cell carcinoma (RCC) with inferior vena cava tumor thrombosis (IVCTT) remains unclear. Methods: We retrospectively evaluated the therapeutic effects and incidence of treatment-related adverse events (TRAEs) associated with ICI-based combination therapy in 36 patients with advanced RCC with IVCTT. Results: The median age at initiation of treatment was 71 years; the IVCTT stages were cT3b in 22 patients and cT3c in 14. The ICI–ICI and ICI–TKI groups comprised 15 and 21 patients, respectively. Median tumor shrinkage at the best response showed that the primary tumor diameter decreased by 1.8 cm (22%), and the IVCTT height decreased by 1.5 cm (26%). A higher proportion of patients in the ICI–TKI group experienced tumor shrinkage than those in the ICI–ICI group (primary tumor, p = 0.0325; IVCTT, p = 0.0112). Approximately 27% of patients experienced an increase in the IVCTT height with ICI–ICI combination therapy. No significant difference was observed in the relative tumor shrinkage of IVCTT, primary or level-down staging of IVCTT, other treatment effects, incidence of TRAEs, surgical outcomes, or prognosis between the groups. Conclusion: ICI-based combination therapy is effective against IVCTT and primary RCC. Although ICI–ICI is associated with a higher probability of tumor growth compared with ICI–TKI in the frequency of tumor regression, both therapies may be almost equally effective against primary RCC with IVCTT. [ABSTRACT FROM AUTHOR]

Objectives: To develop and validate an open-source artificial intelligence (AI) algorithm to accurately detect contrast phases in abdominal CT scans. Materials and methods: Retrospective study aimed to develop an AI algorithm trained on 739 abdominal CT exams from 2016 to 2021, from 200 unique patients, covering 1545 axial series. We performed segmentation of five key anatomic structures—aorta, portal vein, inferior vena cava, renal parenchyma, and renal pelvis—using TotalSegmentator, a deep learning-based tool for multi-organ segmentation, and a rule-based approach to extract the renal pelvis. Radiomics features were extracted from the anatomical structures for use in a gradient-boosting classifier to identify four contrast phases: non-contrast, arterial, venous, and delayed. Internal and external validation was performed using the F1 score and other classification metrics, on the external dataset "VinDr-Multiphase CT". Results: The training dataset consisted of 172 patients (mean age, 70 years ± 8, 22% women), and the internal test set included 28 patients (mean age, 68 years ± 8, 14% women). In internal validation, the classifier achieved an accuracy of 92.3%, with an average F1 score of 90.7%. During external validation, the algorithm maintained an accuracy of 90.1%, with an average F1 score of 82.6%. Shapley feature attribution analysis indicated that renal and vascular radiodensity values were the most important for phase classification. Conclusion: An open-source and interpretable AI algorithm accurately detects contrast phases in abdominal CT scans, with high accuracy and F1 scores in internal and external validation, confirming its generalization capability. Clinical relevance statement: Contrast phase detection in abdominal CT scans is a critical step for downstream AI applications, deploying algorithms in the clinical setting, and for quantifying imaging biomarkers, ultimately allowing for better diagnostics and increased access to diagnostic imaging. Key Points: Digital Imaging and Communications in Medicine labels are inaccurate for determining the abdominal CT scan phase. AI provides great help in accurately discriminating the contrast phase. Accurate contrast phase determination aids downstream AI applications and biomarker quantification. [ABSTRACT FROM AUTHOR]

Background: Cardiac point-of-care ultrasound (cPOCUS) can aid in the diagnosis and treatment of cardiac disorders. Such disorders can arise as complications of acute brain injury, but most neurologic intensive care unit (NICU) providers do not receive formal training in cPOCUS. Caption artificial intelligence (AI) uses a novel deep learning (DL) algorithm to guide novice cPOCUS users in obtaining diagnostic-quality cardiac images. The primary objective of this study was to determine how often NICU providers with minimal cPOCUS experience capture quality images using DL-guided cPOCUS as well as the association between DL-guided cPOCUS and change in management and time to formal echocardiograms in the NICU. Methods: From September 2020 to November 2021, neurology-trained physician assistants, residents, and fellows used DL software to perform clinically indicated cPOCUS scans in an academic tertiary NICU. Certified echocardiographers evaluated each scan independently to assess the quality of images and global interpretability of left ventricular function, right ventricular function, inferior vena cava size, and presence of pericardial effusion. Descriptive statistics with exact confidence intervals were used to calculate proportions of obtained images that were of adequate quality and that changed management. Time to first adequate cardiac images (either cPOCUS or formal echocardiography) was compared using a similar population from 2018. Results: In 153 patients, 184 scans were performed for a total of 943 image views. Three certified echocardiographers deemed 63.4% of scans as interpretable for a qualitative assessment of left ventricular size and function, 52.6% of scans as interpretable for right ventricular size and function, 34.8% of scans as interpretable for inferior vena cava size and variability, and 47.2% of scans as interpretable for the presence of pericardial effusion. Thirty-seven percent of screening scans changed management, most commonly adjusting fluid goals (81.2%). Time to first adequate cardiac images decreased significantly from 3.1 to 1.7 days (p < 0.001). Conclusions: With DL guidance, neurology providers with minimal to no cPOCUS training were often able to obtain diagnostic-quality cardiac images, which informed management changes and significantly decreased time to cardiac imaging. [ABSTRACT FROM AUTHOR]

Background: Accurate volume status assessment and dry weight achievement are the most challenging goals for a nephrologist. We aimed to evaluate the role of ultrasonographic parameters including lung ultrasound and inferior vena cava (IVC) measurements as practical methods of volume status assessment in children on hemodialysis by comparing them with established techniques, such as clinical evaluation and bioimpedance spectroscopy. Methods: A prospective cross-sectional study compared pre- and post-dialysis volume status using bioimpedance spectroscopy (BIS) parameters and clinical data with ultrasonographic lung B-lines and IVC parameters in children on regular hemodialysis. Results: A total 60 children (mean age 9.4 ± 2.8 years) were enrolled. Twenty patients (33.3%) were clinically overloaded to varying degrees (17 patients had mild to moderate signs of fluid overload and 3 patients had moderate to severe signs of fluid overload). All other patients (66.7%) were clinically euvolemic. Sonographic parameters were significantly lower post-dialysis than pre-dialysis, including lung B-line count and IVC diameter. IVC collapsibility index mean was significantly higher post-dialysis than pre-dialysis. There was a significant correlation between the lung B-line count, IVC parameters, and BIS-measured overhydration both before and after hemodialysis. Nine patients had ≥ 8 B-lines post-dialysis, only three of them were hypertensive. Conclusions: Clinical criteria alone are not specific for determining accurate fluid status in pediatric hemodialysis patients. Lung B-line score, IVC parameters, and BIS may be complementary to each other and to clinical data. Lung B-lines outperform IVC measurements and BIS in subclinical volume overload detection in pediatric hemodialysis patients. [ABSTRACT FROM AUTHOR]

Patients with tumor thrombosis in the portal vein due to hepatocellular carcinoma (HCC) are uncommon, and the majority of these cases is thought to be in an advanced stage with a bad prognosis. The right atrium and the inferior vena cava may be impacted by the intravascular tumor thrombus, with the latter having a bad prognosis. Portal vein involvement is one of the most serious consequences of HCC. For both systemic and locoregional therapy, targeting many pathways in the HCC cascade using a mix of medications and additional modalities like transarterial chemoembolization, transarterial radioembolization, radiation, and hepatic arterial infusion chemotherapy appears to be helpful. Portal vein tumor thrombosis, which affects 35 to 50% of patients, is a strong predictor of poor prognosis due to the higher likelihood of tumor migration into the bloodstream and the subsequent increased risk of recurrence. This case report highlights about a 60-year-old female who presented with HCC with portal vein tumor thrombosis not willing for chemo- and radiotherapy successfully treated with transarterial chemoembolization as a palliative management. [ABSTRACT FROM AUTHOR]

Background: Uterine Fibroids (UFs) are common benign tumors in the female reproductive tract, but their progression to intravascular leiomyomatosis (IVL) is rare. Presently, there are few reports on single-stage resection of UFs and IVL. Case presentation: A 47-year-old woman, G2P2, had been diagnosed multiple UFs four years ago and now developed heart failure. Imaging examinations revealed that UFs had invaded the right iliac vein and extended into the right atrium through the inferior vena cava. Through multidisciplinary collaboration and a single-stage resection, the patient has survived for over 24 months post-surgery, and her heart function has significantly improved compared to preoperative levels, with no recurrence of UFs observed. Conclusions: Single-stage resection of IVL and UF is feasible and advantageous for this case, and selecting the appropriate surgical approach is crucial. [ABSTRACT FROM AUTHOR]

Aims Methods and results Conclusion To investigate the changes in retinal microvasculature by contemporary imaging techniques during episodes of acute decompensated heart failure (ADHF) and following recompensation compared to age‐matched controls without known cardiac or retinal disease.Adult patients hospitalized with a primary diagnosis of ADHF, regardless of left ventricular ejection fraction (LVEF) and treated with a minimum dose of 40 mg of intravenous furosemide or equivalent were included. Transthoracic echocardiography was conducted in all patients. Eye examinations were performed out within the initial 24 h after admission and after recompensation before discharge. All eyes underwent a general examination, including a best corrected visual acuity test, dilated fundoscopy, spectral‐domain optical coherence tomography (OCT) as well as OCT angiography (OCT‐A). In addition, 40 participants without documented cardiac or retinal diseases served as controls. Forty patients with ADHF (mean age 78.9 ± 8.8 years; 32% female) with a mean LVEF of 43 ± 12.8% were included. All patients were treated with intravenous diuretics for a median of 4.3 ± 2.8 days. There was a significant reduction in N‐terminal pro‐B‐type natriuretic peptide from baseline up to discharge (10 396 [interquartile range 6410] vs. 6380 [interquartile range 3933] pg/ml, p ≤ 0.001) and inferior vena cava diameters (2.13 ± 0.4 vs. 1.63 ± 0.3 cm, p = 0.003). Compared to the control group, patients with ADHF showed on admission impaired visual acuity (0.15 ± 0.1 vs. 0.35 ± 0.1 logMAR, p < 0.001), reduced macular vessel density (18.0 ± 1.9 vs. 14.3 ± 3.6 mm/mm2, p < 0.001) and perfusion density (42.6 ± 3.2 vs. 35.2 ± 9.7%, p < 0.001). After recompensation, the mean overall vessel density and mean overall perfusion density were markedly increased at discharge (14.3 ± 3.6 vs. 19.7 ± 2.6 mm/mm2, p = 0.001, and 35.2 ± 9.7 vs. 39.2 ± 6.5%, p = 0.005, respectively). The mean diameter of the superior temporal retinal vein at admission was significantly larger compared to the control group (136 ± 19 vs. 124 ± 22 μm, p = 0.008) and decreased significantly to 122 ± 15 μm at discharge (p < 0.001).This analysis revealed a remarkable reversible change in retinal microvasculature after ADHF. This could provide a valuable evidence for use of OCT‐A in the assessment of overall microperfusion and haemodynamic status in patients with acute heart failure. [ABSTRACT FROM AUTHOR]

Background: The severity of systemic congestion is associated with increased portal vein flow pulsatility (PVP). Aim: To determine the usefulness of PVP as a marker of decongestion and prognosis in acute decompensated heart failure (ADHF) patients. Methods: 105 patients, 60% of whom were men, were hospitalized with ADHF, and their PVP index (PVPI) was calculated (maximum velocity–minimum velocity/maximum velocity) × 100 on admission and before discharge, along with their EVEREST score, inferior vena cava diameter (IVC), NT-proBNP, serum sodium, and glomerular filtration rate. A PVPI ≥ 50% was defined as a marker of systemic congestion. After treatment with loop diuretics, a decrease in PVPI of >50% before discharge was considered a marker of decongestion The patients were classified into two groups (G): G1-PVPI decrease ≥ 50% (54 patients) and G2-PVPI decrease < 50% (51 patients). Results: At discharge, compared to G2, G1 patients had lower mean PVPI (14.2 vs. 38.9; p < 0.001), higher serum Na (138 vs. 132 mmol/L, p = 0.03), and a higher number of patients with a significant (>30%) NT-proBNP decrease (42 vs. 27, p = 0.007). PVPI correlated with IVC (r = 0.55, p < 0.001), NT-proBNP (r = 0.21, p = 0.04), and serum Na (r = −0.202, p = 0.04). A total of 55% of patients had worsening renal failure (G1 63% vs. G2 48%, p = 0.17). After 90 days, G2 patients had higher mortality (27.45% vs. 3.7 p = 0.001) and rehospitalization (49.01% vs. 33.33%, p < 0.001). In multivariate regression analysis, PVPI was an independent predictor of rehospitalization (OR 1.05, 95% CI 1.00–1.10, p = 0.048). Conclusions: Portal vein flow pulsatility, a meaningful marker of persistent subclinical congestion, is related to short-term prognosis in ADHF patients. [ABSTRACT FROM AUTHOR]

Introduction: The trend of human migration to terrestrial high altitudes (HA) has been increasing over the years. However, no published prospective studies exist with follow-up periods exceeding 1 month to investigate the cardiac change. This prospective study aimed to investigate the changes in cardiac structure and function in healthy young male lowlanders following long-term migration to HA. Methods: A total of 122 Chinese healthy young males were divided into 2 groups: those migrating to altitudes between 3600 m and 4000 m (low HA group, n = 65) and those migrating to altitudes between 4000 m and 4700 m (high HA group, n = 57). Traditional echocardiographic parameters were measured at sea level, 1 month and 1 year after migration to HA. Results: All 4 cardiac chamber dimensions, areas, and volumes decreased after both 1 month and 1 year of HA exposure. This reduction was more pronounced in the high HA group than in the low HA group. Bi-ventricular diastolic function decreased after 1 month of HA exposure, while systolic function decreased after 1 year. Notably, these functional changes were not significantly influenced by altitude differences. Dilation of the pulmonary artery and a progressive increase in pulmonary artery systolic pressure were observed with both increasing exposure time and altitude. Additionally, a decreased diameter of the inferior vena cava and reduced bicuspid and tricuspid blood flow velocity indicated reduced blood flow following migration to the HA. Discussion: 1 year of migration to HA is associated with decreased blood volume and enhanced hypoxic pulmonary vasoconstriction. These factors contribute to reduced cardiac chamber size and slight declines in biventricular function. [ABSTRACT FROM AUTHOR]

Background: Russo-Ukrainian war is associated with severe traumas, including injuries to the major vessels. Penetrating aortic injury remains one of the most difficult injuries; the mortality rate is 90–100% in case of gunshot wounds, associated with frequent lethal outcomes due to uncontrolled bleeding. Of the three main abdominal veins, the inferior vena cava (IVC) is the most frequently damaged, which is required quick and appropriate surgical decisions to be made. Little is known about the management of gunshot injuries to such major vessels as the aorta and IVC. It is also worth mentioning about the importance to share our practical experience from the ongoing war for better understanding and future considerations by war surgeons of the vascular trauma management. The aim of the study was to demonstrate the specific features of the diagnosis and management of a gunshot shrapnel blind penetrating wound to the abdomen with injury to the aortic bifurcation level and the infrarenal section of the inferior vena cava. Case presentation: A 44-year-old male soldier of the Armed Forces of Ukraine received a gunshot injury to the abdomen from a mortars' explosive shelling. The patient was evacuated to the Forward Surgical Team (Role 1) and received primary surgical treatment within one hour after the injury according to the "golden hour" principle. Then, evacuated was performed to the Role 3 hospital in Kharkiv. At the Role 3 hospital, the patient underwent second-look surgery as well as damage control surgery. At revision, no active bleeding was observed, and the surgical pads (packed previously by the Forward Surgical Team) were removed. Further revision showed a metal projectile within the aortic wall at the level of aortic bifurcation and wall defects were also detected for inferior vena cava. This metal projectile was removed by using the multifunctional surgical magnetic tool followed by suturing of the aortic wall defect as well as defects of the inferior vena cava. Conclusions: Application of Damage Control Surgery is a useful approach in the management of severe vascular injury as well as useful to stop abdominal contamination by intestinal contents. The application of a surgical magnetic tool for the searching and removal of ferromagnetic foreign bodies reduces operative trauma and reduces the time for identification of foreign bodies. [ABSTRACT FROM AUTHOR]

Background: Sympathetic nerve activity (SNA) plays a central role in the pathogenesis of several diseases such as sepsis and chronic kidney disease (CKD). Activation of microglia in the paraventricular nucleus of the hypothalamus (PVN) has been implicated in SNA. The mechanisms responsible for the adverse prognosis observed in sepsis associated with CKD remain to be determined. Therefore, we aimed to clarify the impact of increased SNA resulting from microglial activation on hemodynamics and organ damage in sepsis associated with CKD. Methods and results: In protocol 1, male Sprague–Dawley rats underwent either nephrectomy (Nx) or sham surgery followed by cecal ligation and puncture (CLP) or sham surgery. After CLP, Nx-CLP rats exhibited decreased blood pressure, increased heart rate, elevated serum creatinine and bilirubin levels, and decreased platelet count compared to Nx-Sham rats. Heart rate variability analysis revealed an increased low to high frequency (LF/HF) ratio in Nx-CLP rats, indicating increased SNA. Nx-CLP rats also had higher creatinine and bilirubin levels and lower platelet counts than sham-CLP rats after CLP. In protocol 2, Nx-CLP rats were divided into two subgroups: one received minocycline, an inhibitor of microglial activation, while the other received artificial cerebrospinal fluid (CSF) intracerebroventricularly via an osmotic minipump. The minocycline-treated group (Nx-mino-CLP) showed attenuated hypotensive and increased heart rate responses compared to the CSF-treated group (Nx-CSF-CLP), and the LF/HF ratio was also decreased. Echocardiography showed larger left ventricular dimensions and inferior vena cava in the Nx-mino-CLP group. In addition, creatinine and bilirubin levels were lower and platelet counts were higher in the Nx-mino-CLP group compared to the Nx-CSF-CLP group. Conclusions: In septic rats with concomitant CKD, SNA was significantly enhanced and organ dysfunction was increased. It has been suggested that the mechanism of exacerbated organ dysfunction in these models may involve abnormal systemic hemodynamics, possibly triggered by activation of the central sympathetic nervous system through activation of microglia in the PVN. [ABSTRACT FROM AUTHOR]

The article discusses a case study of a laparoscopic right anterior inferior segmentectomy performed on a patient with hepatocellular carcinoma (HCC) and congenital absence of the portal vein (CAPV). CAPV is a rare condition that can lead to various hepatic tumors. Typically, anatomical liver resection uses the intrahepatic portal vein as a landmark, but in patients with CAPV, the intrahepatic artery can be used instead. The study demonstrates that laparoscopic right anterior inferior segmentectomy is a safe procedure for patients with CAPV, and the intrahepatic artery is a useful landmark for anatomical liver resection in these cases. [Extracted from the article]

Renal cell carcinoma (RCC) often presents with tumor thrombus (TT) in the inferior vena cava (IVC), posing significant therapeutic challenges, particularly in cases of metastatic or inoperable disease. While surgical excision remains the standard treatment approach, recent advancements in radiotherapy techniques may offer alternative strategies. We present the clinical picture of a 74-year-old male with metastatic RCC, who presented with recurrent IVC-TT, detected by surveillance computed tomography imaging, and complained of mild lower leg edema. This was successfully managed with stereotactic body radiotherapy (SBRT), resulting in a slow but continuous shrinkage of the IVC-TT with almost complete regression of most lung, liver, and lymph node metastases, obtaining a full resolution of the mild bilateral leg edema. The case described here highlights the possibility of using radiotherapy as a safe and tolerable treatment for inoperable or metastatic patients with IVC-TT. Additionally, we conducted a literature review looking for evidence of the effectiveness of radiotherapy in RCC patients with IVC-TT across different treatment settings. This case-based review ultimately aims to shed light on the emerging evidence supporting the usefulness of radiotherapy in such complex clinical challenges, hopefully paving the way for well-organized trials. [ABSTRACT FROM AUTHOR]

Apparent bilateral adrenal suppression (ABAS), where aldosterone/cortisol ratios in both adrenal veins are lower than in the inferior vena cava, yields uninterpretable adrenal venous sampling (AVS) results and is poorly understood. A 57-year-old male with hypertension and spontaneous hypokalemia was admitted to our hospital. Confirmatory tests established a diagnosis of primary aldosteronism (PA). Initial AVS indicated ABAS, but unilateral PA remained possible due to elevated aldosterone, low renin, hypokalemia, and a right adrenal nodule (8 × 7 mm) on computed tomography. Subsequently, a second, super-selective AVS identified tributaries from areas of aldosterone hypersecretion, enabling accurate localization of unilateral PA. ABAS may occur due to anatomical factors such as dilution by tributaries from nonaldosterone-producing adenoma (APA) areas with suppressed aldosterone production. Super-selective AVS proves beneficial in diagnosing unilateral PA concealed within ABAS by pinpointing tributaries from APA regions. [ABSTRACT FROM AUTHOR]

Pheochromocytoma and paragangliomas (PPGLs) are rare chromaffin cell tumors arising from neural crest tissue. The majority of these tumors are nonmetastatic, with complete cure achieved through surgical resection. PPGLs have been associated with several hereditary cancer syndromes, including von Hippel-Lindau (VHL). We present the case of a 10-year-old patient with VHL and a history of 2 asynchronous pheochromocytomas requiring bilateral adrenalectomies who presented with a new 1.2 cm × 1.3 cm × 1.5 cm nodular structure between the superior pole of the right kidney and the intrahepatic inferior vena cava. The patient was noted to have hypertension but was otherwise asymptomatic. Positron emission tomography-DOTA-(Tyr)3-octreotate revealed a metabolically active retrocrural lymph node. Based on these imaging findings and laboratory studies showing elevated plasma normetanephrine, clinical suspicion was highest for metastatic pheochromocytoma. The patient underwent surgical resection of multiple abdominal tumors. Pathology ultimately favored a diagnosis of multiple primary paragangliomas rather than metastatic disease. With this shift in diagnosis, the patient was managed with surgery alone. One year later, he has no signs of disease recurrence. Long-term surveillance imaging and screening with fractionated plasma metanephrines is indicated to monitor for new tumors in the setting of VHL and 3 prior endocrine tumors. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Superior vena cava syndrome (SVCS) is commonly caused by mediastinal malignancies. Early identification through clinical signs and imaging is critical to avoid complications including cerebral and laryngeal edema, and cardiogenic shock. We present a case of large cell neuroendocrine carcinoma causing superior and inferior vena cava compression that responded well to radiotherapy and chemotherapy. [ABSTRACT FROM AUTHOR]

Background Spinal anesthesia is commonly used in various surgical procedures but is often associated with hypotension, which can lead to significant complications. The Inferior Vena Cava Collapsibility Index (IVCCI) and Caval Aorta Index (CAI) are potential predictors of fluid responsiveness and can help anticipate hypotension after spinal anesthesia. This study aims to evaluate the efficacy of IVCCI and CAI in predicting hypotension following spinal anesthesia. Materials and Methods A total of 100 patients scheduled for elective surgeries under spinal anesthesia were enrolled in this prospective clinical study. Preoperative IVCCI and CAI measurements were obtained using ultrasound. Spinal anesthesia was administered using 0.5% bupivacaine. Blood pressure was monitored every 5 minutes for 30 minutes post-anesthesia. Hypotension was defined as a systolic blood pressure decrease of more than 20% from baseline or below 90 mmHg. Statistical analysis was performed using logistic regression to assess the predictive value of IVCCI and CAI for hypotension. Results Out of 100 patients, 35 developed hypotension after spinal anesthesia. The mean IVCCI for the hypotensive group was 45%, compared to 25% in the non-hypotensive group (p < 0.01). The mean CAI was 0.8 in the hypotensive group and 0.6 in the non-hypotensive group (p < 0.05). Logistic regression analysis revealed that both IVCCI and CAI were significant predictors of hypotension, with IVCCI having a higher predictive accuracy (AUC = 0.85) compared to CAI (AUC = 0.78). Conclusion The Inferior Vena Cava Collapsibility Index and Caval Aorta Index are effective predictors of hypotension following spinal anesthesia. IVCCI, in particular, demonstrates superior predictive accuracy. Incorporating these indices into preoperative assessments may enhance the management and prevention of hypotension, improving patient outcomes. [ABSTRACT FROM AUTHOR]

Introduction: This study introduces and compares a new intraperitoneal laparoscopic para‐aortic lymphadenectomy method to reach the level of the renal vein, the "tent‐pitching" antegrade approach with the retrograde approach in gynecological malignancy surgeries in terms of success rate, complication incidence, and the number of lymph nodes removed. It focuses on the feasibility, safety, and effectiveness. Meanwhile, this article reports on the vascular anatomical variations discovered in the para‐aortic region to enhance surgical safety. Material and Methods: This was a retrospective cohort study including patients undergone laparoscopic para‐aortic lymphadenectomy at a single center from January 2020 to December 2023 for high‐risk endometrial and early‐stage ovarian cancer. Patient charts were reviewed for mode of operation, perioperative complications, operative details, and histopathology. The patients were divided into anterograde group and retrograde group according to the operation mode. The two groups were further compared based on the success rate of lymph node clearance at the renal vein level, perioperative complications, and the number of removed lymph nodes. Quantitative data were analyzed using the t‐test, non‐normally distributed data using the rank‐sum test, and categorical data using Fisher's exact test and the chi‐square test, with statistical significance defined as P < 0.05. Results: Among 173 patients, the antegrade group showed higher surgery success (97.5% vs 68.82%), more lymph nodes removed (median 14 vs 7), and less median blood loss. The operation time was shorter in the antegrade group. Postoperative complications like lymphocele and venous thrombosis were lower in the antegrade group. Vascular abnormalities were found in 28.9% of patients, with accessory lumbar vein routing anomaly and accessory renal arteries being most common. Conclusions: The antegrade approach is feasible, safe, and effective, improving surgical exposure, reducing difficulty without additional instruments or puncture sites, and minimizing organ damage risk. It is effective in achieving better access to the renal vein and removing more para‐aortic lymph nodes than the retrograde method. Recognizing and carefully managing the diverse vascular abnormalities in the para‐aortic area, including variations in renal arteries, veins, and the inferior vena cava, is essential to reduce intraoperative bleeding and the likelihood of converting to open surgery. [ABSTRACT FROM AUTHOR]

Blood flow in the hepatic veins and superior vena cava (SVC) reflects right heart filling; however, their Doppler profiles are often not identical, and no studies have compared their diagnostic efficacies. We aimed to determine which venous Doppler profile is reliable for detecting elevated right atrial pressure (RAP). In 193 patients with cardiovascular diseases who underwent cardiac catheterization within 2 d of echocardiography, the hepatic vein systolic filling fraction (HV-SFF) and the ratio of the peak systolic to diastolic forward velocities of the SVC (SVC-S/D) were measured. HV-SFF < 55% and SVC-S/D < 1.9 were regarded as elevated RAP. We also calculated the fibrosis 4 index (FIB-4) as a serum liver fibrosis marker. HV-SFF and SVC-S/D were feasible in 177 (92%) and 173 (90%) patients, respectively. In the 161 patients in whom both venous Doppler waveforms could be measured, HV-SFF and SVC-S/D were inversely correlated with RAP (r = −0.350, p < 0.001; r = −0.430, p < 0.001, respectively). SVC-S/D > 1.9 showed a significantly higher diagnostic accuracy of RAP elevation compared with HV-SFF < 55% (area under the curve, 0.842 vs. 0.614, p < 0.001). Multivariate analyses showed that both FIB-4 (β = −0.211, p = 0.013) and mean RAP (β = −0.319, p < 0.001) were independent determinants of HV-SFF. In contrast, not FIB-4 but mean RAP (β = −0.471, p < 0.001) was an independent determinant of SVC-S/D. The diagnostic accuracy remained unchanged when HV-SFF < 55% was considered in conjunction with the estimated RAP based on the inferior vena cava morphology. Conversely, SVC-S/D showed an incremental diagnostic value over the estimated RAP. SVC-S/D enabled a more accurate diagnosis of RAP elevation than HV-SFF. [ABSTRACT FROM AUTHOR]

Context The role of hormone parameters at adrenal venous sampling (AVS) in predicting clinical and biochemical outcomes remains controversial. Objective To investigate the impact of hormone parameters at AVS under cosyntropin stimulation on lateralization and on complete biochemical and clinical outcomes. Methods We retrospectively evaluated 150 sequential AVS under cosyntropin infusion. The bilateral successful cannulation rate was 83.3% (n = 140), 47.9% bilateral and 52.1% unilateral. The lateralization index, aldosterone/cortisol ratio (A/C) in the dominant adrenal vein (AV), and relative aldosterone secretion index (RASI = A/C in AV divided by A/C in inferior vena cava) were assessed. The contralateral suppression (CS) percentage was defined by (1 − nondominant RASI) * 100. Results A nondominant RASI <0.5 (CS >50%) had 86.84% sensitivity and 92.96% specificity to predict contralateral lateralization. An A/C ratio in dominant AV >5.9 (74.67% sensitivity and 80% specificity) and dominant RASI >4.7 (35.21% sensitivity and 88.06% specificity) had the worst performance to predict ipsilateral lateralization. Complete biochemical and clinical cure was significantly more frequent in the patients with CS >50% [98.41% vs 42.86% (P <.001) and 41.94% vs 0% (P <.001)]. CS correlated with high aldosterone at diagnosis (P <.001) and low postoperative aldosterone levels at 1 month (P =.019). Postoperative biochemical hypoaldosteronism was more frequent in patients with CS >50% (70% vs 16.67%, P =.014). In multivariable analysis, a CS >50% was associated with complete biochemical cure [odds ratio (OR) 125, 95% confidence interval (CI) 11.904-5000; P =.001] and hypertension remission (OR 12.19, 95% CI 2.074-250; P =.023). Conclusion A CS >50% was an independent predictor of complete clinical and biochemical cure. Moreover, it can predict unilateral primary aldosteronism and postoperative biochemical hypoaldosteronism. Our findings underscore the usefulness of CS for clinical decision-making. [ABSTRACT FROM AUTHOR]

Ultrasound (US) scans of the inferior vena cava (IVC) provide useful information on the volume status of a patient. However, their investigation is user-dependent and prone to measurement errors. An important technical problem is the objective difficulty in studying a very compliant blood vessel like IVC, which makes large respirophasic movements and shows a complicated three-dimensional geometry. Using bi-dimensional (2D) B-mode views either in a long or short axis has improved the characterization of IVC dynamics compared to measurements along a single direction (M-mode). However, specific movements of the IVC can also challenge the information provided by these 2D sections. Thus, these two orthogonal views, provided by an US system in the X-plane, are integrated here using an innovative method. It is tested on simulated videos of the IVC by performing complicated movements, which are compensated by the new method, overcoming the biased measurements provided by 2D scans. The method is then applied on example experimental data. [ABSTRACT FROM AUTHOR]

Background and Objectives: PoCUS ultrasound applications are widely used in everyday work, especially in the field of emergency medicine. The main goal of this research was to create a diagnostic and therapeutic protocol that will integrate ultrasound examination of the lungs, ultrasound measurements of the inferior vena cava (assessment of central venous pressure) and BREST scores (risk stratification for heart failure), with the aim of establishing a more effective differential diagnostic approach for dyspneic patients. Materials and Methods: A cross-sectional study was conducted in the emergency medicine department with the educational center of the community health center of Banja Luka. Eighty patients of both sexes were included and divided into experimental and control groups based on the presence or absence of dyspnea as a dominant subjective complaint. Based on the abovementioned variables, the LUSBI protocol (lung ultrasound/BREST score/inferior vena cava) was created, including profiles to determine the nature of the origin of complaints. The biochemical marker of heart failure NT pro-BNP served as a laboratory confirmation of the cardiac origin of the complaints. Results: The distribution of NT pro BNP values in the experimental group showed statistically significant differences between individual profiles of the LUSBI protocol (p < 0.001). Patients assigned to group B PLAPS 2 had significantly higher average values of NT pro-BNP (20159.00 ± 3114.02 pg/mL) compared to other LUSBI profiles. Patients from the experimental group who had a high risk of heart failure according to their BREST scores also had a significantly higher average maximum expiratory diameter compared to those without heart failure (p = 0.004). A statistically significant difference (p = 0.001) in LUSBI profiles was observed between the groups of patients divided according to CVP categories. Conclusion: The integration of the LUSBI protocol into the differential diagnosis of dyspnea has been shown to be very effective in confirming or excluding a cardiac cause of the disease in patients. [ABSTRACT FROM AUTHOR]

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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. [ABSTRACT FROM AUTHOR]

Catheter ablation for tachyarrhythmia via superior approach has been used in patients without possible inferior vena cava access such as in cases of venous occlusion or complex anomaly. Difficulty in catheter manipulation, instability, number of required vascular access, and radiation exposure of operator had been described in the procedure. Application of three‐dimensional (3‐D) mapping system in catheter ablation via superior approach could navigate the guiding catheter and provide more precise ablation. We reported four cases receiving catheter ablation due to atrioventricular nodal reentry tachycardia, atrial fibrillation, and right ventricular arrhythmia via superior approach facilitated by 3‐D mapping system with fewer vascular access and catheters. [ABSTRACT FROM AUTHOR]

Background: Heart transplantation in patients with situs inversus is challenging, especially in terms of reconstruction of the systemic venous return. Several rerouting techniques have been presented but are associated with vulnerability to external compression, which might cause hemodynamic instability, especially in the presence of chest deformity. In this study, we report a rare case of successful heart transplantation in the presence of situs inversus and pectus excavatum. Case presentation: A 55-year-old man, with a history of surgeries for corrected transposition of the great arteries with ventricular septal defect, was registered for heart transplantation owing to progression of heart failure. Subsequently, he had undergone a left ventricular assist device implantation; 14 years after registration, he underwent transplantation of the heart with normal anatomy. The inferior vena cava was reconstructed by anastomosing the left atria with a counterclockwise rotation of the donor heart and by lengthening the recipient inferior vena cava with a conduit made of the residual right atrial tissue. The superior vena cava was reconstructed using a donor innominate vein harvested with sufficient length. After successful weaning from cardiopulmonary bypass, the chest could not be closed because the heart was compressed owing to chest deformity, resulting in hemodynamic instability. Therefore, to exclude the left lung, a left pericardial screen was created using a bovine pericardium, allowing the chest to be closed with acceptable hemodynamics. The patient suffered postoperatively from a higher venous pressure, suggesting an obstruction of venous return early after surgery. The obstruction gradually resolved, and the patient was transferred for rehabilitation. Conclusions: Heart transplantation in the presence of situs inversus is challenging; moreover, the presence of pectus excavatum further complicates the procedure. The paradoxically larger left lung and chest deformity compressed and impaired reconstructed systemic venous return. Although intrathoracic exclusion of the left lung was effective, an intraoperative or early postoperative thoracoplasty for pectus excavatum was also a viable option. Patient-specific management is mandatory, depending on the anatomy. [ABSTRACT FROM AUTHOR]

Introduction: Leiomyosarcoma (LMS) is a malignancy with smooth muscle differentiation. Metastatic LMS is associated with poor prognosis and limited efficacy of systemic treatment. Novel treatment modalities are desperately needed for this entity. Case Presentation: We report the first use of pembrolizumab plus pharmacologic ascorbate in 3 patients with metastatic LMS. All cases resulted in persistent objective responses and disease control significantly better than has been reported with chemotherapy or other immunotherapeutic approaches. Three patients with metastatic LMS, one each of uterine, vascular, and soft tissue origin, were treated with pembrolizumab plus pharmacologic ascorbate. The patient with uterine LMS received combination therapy at presentation and had persistent response for 12 months, which is ongoing. The patient with metastatic LMS of the inferior vena cava received combination therapy at presentation and had persistent response for 12 months, at which time new metastases were found. The patient with soft tissue LMS had disease progression on pembrolizumab monotherapy prior to the addition of ascorbate, after which she had a 17-month response, which is ongoing. No side effects attributed to treatment were reported. Conclusion: Pembrolizumab plus pharmacologic ascorbate is a novel immunotherapeutic approach and warrants further study in LMS. [ABSTRACT FROM AUTHOR]

Background: Redo isolated tricuspid valve surgery has high in-hospital mortality and morbidity and is a challenging procedure. We report a successful case of redo isolated tricuspid valve replacement for structural valve deterioration of a bioprosthesis in a patient with isolated persistent left superior vena cava (PLSVC). Case presentation: An 81-year-old man with a history of tricuspid valve replacement using a porcine bioprosthetic valve 9 years previously presented with dyspnea on exertion. Right heart failure due to worsening transvalvular leakage in the bioprosthetic tricuspid valve was considered to be the cause of his symptoms, and the decision was made to replace the tricuspid valve. An isolated PLSVC is considered to be an obstacle in right-sided heart valve surgery. The PLSVC was located deep to the left of the pulmonary artery and, after some effort, was cannulated by obtaining an excellent surgical view using retraction sutures on the left side of the pericardium. Cardiopulmonary bypass was initiated after cannulation of the ascending aorta, PLSVC, and femoral vein. After cross-clamping of the ascending aorta, cold blood cardioplegic arrest was induced under moderate hypothermia, and the PLSVC and inferior vena cava were snared. The right atrium was opened and the prosthetic tricuspid valve was examined. One of the leaflets was shortened, which appeared to cause the transvalvular leak. The prosthetic valve was explanted, the annulus was trimmed, and a new bioprosthetic valve was implanted. The postoperative course was uneventful. Conclusions: It is important to treat structural valve deterioration of a prosthetic tricuspid valve in a timely manner. We hope that our intervention timing and surgical strategy can help surgeons to consider early intervention in similar cases, even if there are surgical obstacles such as isolated PLSVC. [ABSTRACT FROM AUTHOR]

Background: Supine hypotension syndrome (SHS) has been reported to occur due to compression by a giant tumor such as ovarian tumor. We herein report a case of retroperitoneal ganglioneuroma with SHS treated with laparoscopic resection. Case presentation: The patient was an 11-year-old male with right-sided abdominal pain. He had a pale complexion and tachycardia while falling asleep. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a giant mass lesion (60 × 35 mm) with compression of the inferior vena cava (IVC) and duodenum ventrally and the right kidney caudally. The IVC was flattened by mass compression. Abdominal ultrasonography (US) revealed narrowing of the IVC due to the mass and accelerated blood flow after IVC stenosis in the supine and left lateral recumbent position. His pale complexion and tachycardia while falling asleep was thought to be due to decreased venous return caused by the tumor compressing the IVC, resulting hypotension. 123I-MIBG scintigraphy revealed no abnormal findings. Tumor markers were normal. He was diagnosed with SHS due to a right adrenal gland tumor. The tumor compressed the IVC from the dorsal side, and hemostasis was expected to be difficult during bleeding. Therefore, a guidewire was inserted from the right femoral vein into the IVC for emergency balloon insertion during bleeding. A laparoscopic tumor resection was performed. A histopathological examination confirmed the diagnosis of primary retroperitoneal ganglioneuroma. Conclusions: The treatment of symptomatic retroperitoneal tumors requires a multidisciplinary approach. [ABSTRACT FROM AUTHOR]

Aim Methods Results Conclusion This study aims to evaluate the impact of frailty on the outcomes of older patients with pulmonary embolism (PE).Using the National Inpatient Sample database, we identified 288 070 patients aged 65 or older who were admitted with a primary diagnosis of PE from 2017 to 2019. Frailty was assessed using the Hospital Frailty Risk Score (HFRS), and patients were categorized into low‐, intermediate‐, and high‐frailty‐risk groups. Multivariate logistic regression was used to calculate adjusted odds ratios for all outcomes.These patients were categorized into low‐risk (57.6%, 161 420), medium‐risk (39.9%, 111 805), and high‐risk (2.5%, 7075) groups. High‐risk patients, predominantly females with multiple comorbidities, exhibited significantly higher mortality rates and adverse outcomes. The HFRS showed a good discriminating ability in predicting mortality (area under the receiver operating characteristic curve = 0.7796). Frailty was associated with increased use of advanced therapeutic interventions and critical care resources such as thrombolysis, catheter‐directed therapies, inferior vena cava filter placement, mechanical ventilation, vasopressor use, and intensive care unit admission.Frailty markedly affects outcomes in older PE patients. The HFRS offers a valuable prognostic tool in this population, suggesting that integrating frailty assessments into clinical practice could enhance care strategies and improve patient outcomes. Our findings underscore the need for further research to refine frailty‐based care paradigms. Geriatr Gerontol Int 2024; ••: ••–••. [ABSTRACT FROM AUTHOR]

Background: Atresia of the infrarenal inferior vena cava (IVC) is associated with thrombophilia and antithrombin (AT) deficiency (ATD) due to homozygosity for the so-called Budapest 3 variant, c.391C > T, in the gene, SERPINC1. Case presentation: We report on a father and his two sons that had severe thrombosis at a young age. One son had absence of, and the other had very gracile infrarenal IVC. The father had gracile vena iliaca. All had significant collateral building. AT activity was determined with four different methods and varied between moderately reduced and borderline normal values, depending on the method. While all were heterozygous for c.391C > T, the father was also heterozygous for a variant of uncertain significance in SERPINC1. Conclusions: The findings support the association between c.391C > T in SERPINC1, thrombophilia, and atresia of the IVC system and indicate that even heterozygosity for c.391C > T may contribute to such anomalies. ATD detection was hampered by the varying sensitivity of methods used for AT activity measurement. [ABSTRACT FROM AUTHOR]

Background: An aorto-caval fistula is a rare but critical complication of abdominal aortic aneurysm (AAA) rupture, leading to high-output heart failure and increased venous pressure. The anesthetic management of such cases, particularly when complicated by an intraoperative right-to-left shunt, is seldom reported. Case presentation: A 71-year-old man with a history of atrial fibrillation and catheter ablation presented with heart failure and abdominal pain, leading to cardiac arrest. Imaging revealed an AAA rupture into the inferior vena cava. During emergency surgery, severe venous bleeding was managed using intra-aortic balloon occlusion (IABO). Transesophageal echocardiography (TEE) identified a right-to-left shunt due to an iatrogenic atrial septal defect. Conclusion: Early TEE recognition and timely IABO intervention were crucial in managing this complex case, underscoring the importance of these techniques in similar emergency scenarios. [ABSTRACT FROM AUTHOR]

This article discusses the use of transvaginal SlowflowHD imaging technology to examine the development of embryonic and fetal hearts in the first trimester of pregnancy. The study found that by the 11th week of gestation, all major structures of the heart had developed. The article also mentions previous studies that used older technology to visualize cardiac structures, but the quality of the images was poor. The authors conclude that transvaginal SlowflowHD imaging provides a high-resolution and sensitive method for assessing cardiac structures in early pregnancy. The use of SlowflowHD has the potential to diagnose congenital heart anomalies and provide valuable diagnostic information on various heart conditions. However, it cannot determine flow direction and velocity, and further research is needed to explore its potential role in early fetal cardiac diagnosis. [Extracted from the article]

Introduction and Hypothesis: This study was aimed at exploring the immediate impacts of pelvic floor muscle exercises (PFMEs) on various maternal physiological parameters in pregnant women. Methods: The study included a total of 52 women, 26 pregnant (Pregnant group: 28.04±6.01 years; 26.83±3.81 kg/m2) and 26 nonpregnant (Control group: 29.42±5.73 years; 25.41±3.03 kg/m2) individuals. All women received PFME as follows: PFME was performed for 5 min (6-s holding contraction, 10 s of relaxation, 3 rapid PFM contractions). Evaluations were conducted before, immediately after, and 5 min post-exercise, with measurements including inferior vena cava (IVC) diameters and pulsatility index, blood pressure, oxygen saturation, and heart rates. Two-way analysis of variance was performed for group and time comparisons in repeated measurements. Results: In both groups, the IVC collapsibility index values were lower 5 min after exercise, although this decrease, although clinically significant, did not reach statistical significance (p = 0.057). Post-exercise systolic blood pressure significantly decreased in both groups, whereas diastolic blood pressure decreased significantly in the pregnant group (p = 0.001, p = 0.023). Conclusions: The study found no statistically significant changes in the collapsibility index of the IVC after PFME but observed a clinically suggestive decrease. The clinical decrease in the collapsibility index can be interpreted as PFME in the supine position increasing venous return. Additionally, PFME was found not to alter maternal and fetal heart rates but contributed to the decrease in maternal systolic and diastolic blood pressure. Our study supports the view that the acute effects of PFME neither induce fetal stress nor pose maternal risks. [ABSTRACT FROM AUTHOR]

Venöse Thromboembolien (VTE), zu denen die tiefe Venenthrombose (TVT) und die Lungenembolie (LE) gehören, sind eine weit verbreitete Herz-Kreislauf-Erkrankung, die weltweit an dritter Stelle nach Herzinfarkt und Schlaganfall steht. Das VTE-Risiko nimmt mit dem Alter zu und stellt in der alternden Bevölkerung ein wachsendes Problem dar. Die akute LE mit ihrer hohen Morbidität und Mortalität unterstreicht die Notwendigkeit einer frühzeitigen Diagnose und Intervention. In dieser Übersichtsarbeit werden prognostische Faktoren für die akute LE untersucht, um die LE anhand der hämodynamischen Stabilität und der rechtsventrikulären Belastung in die Kategorien geringes, mittleres und hohes Risiko einzuteilen. Die rechtzeitige Klassifizierung ist entscheidend für Triage- und Behandlungsentscheidungen. Heutzutage werden LE-Patienten mit geringem Risiko häufig mit direkten oralen Antikoagulanzien (direct oral anticoagulants, DOACS) behandelt und anschließend umgehend zur ambulanten Weiterbehandlung entlassen. Bei Patienten mit mittlerem und hohem Risiko können fortgeschrittene Therapien erforderlich sein, wie z.B. systemische Thrombolyse, kathetergeführte Thrombolyse, mechanische Thrombektomie und das Einsetzen eines Filters in die untere Hohlvene (Vena cava inferior, VCI). Letztere, insbesondere VCI-Filter, werden immer häufiger eingesetzt, wobei es neue Typen wie rückholbare und konvertierbare Filter gibt. Es gibt jedoch Bedenken hinsichtlich Komplikationen und der Notwendigkeit einer rechtzeitigen Entfernung. Diese Übersichtsarbeit befasst sich mit der Rolle von VCI-Filtern bei der Behandlung der akuten LE und geht auf ihre Indikationen, Typen, Komplikationen und Überlegungen zur Entfernung ein. Die anhaltende Debatte über den Einsatz von VCI-Filtern, insbesondere bei Patienten mit weniger konventionellen Indikationen, zeigt, dass weitere Forschung und Daten erforderlich sind. Trotz der Komplikationen deuten neuere Studien darauf hin, dass klinisch bedeutsame Probleme selten sind, was zu Diskussionen über den angemessenen und sicheren Einsatz von VCI-Filtern bei ausgewählten LE-Fällen geführt hat. Die Übersichtsarbeit umfasst abschließend aktuelle Trends, Wissenslücken und potenzielle Möglichkeiten zur Weiterentwicklung der Rolle von VCI-Filtern in der zukünftigen Behandlung der akuten LE. [ABSTRACT FROM AUTHOR]

Inferior vena cava (IVC) filters are used to prevent fatal and nonfatal pulmonary embolism in patients who otherwise cannot receive anticoagulation for venous thrombosis. While generally safe and effective, complications can arise, especially after prolonged implantation. Timely retrieval is essential once the indication for insertion has resolved. However, encountering patients with long-standing embedded filters is not uncommon. This case report discusses the successful retrieval of a permanent Greenfield IVC filter after 29 years. [ABSTRACT FROM AUTHOR]

Background: Inferior Vena Cava (IVC) filters have become an advantageous treatment modality for patients with venous thromboembolism. As the use of these filters continues to grow, it is imperative for providers to appropriately educate patients in a comprehensive yet understandable manner. Likewise, generative artificial intelligence models are a growing tool in patient education, but there is little understanding of the readability of these tools on IVC filters. Methods: This study aimed to determine the Flesch Reading Ease (FRE), Flesch–Kincaid, and Gunning Fog readability of IVC Filter patient educational materials generated by these artificial intelligence models. Results: The ChatGPT cohort had the highest mean Gunning Fog score at 17.76 ± 1.62 and the lowest at 11.58 ± 1.55 among the Copilot cohort. The difference between groups for Flesch Reading Ease scores (p = 8.70408 × 10−8) was found to be statistically significant albeit with priori power found to be low at 0.392. Conclusions: The results of this study indicate that the answers generated by the Microsoft Copilot cohort offers a greater degree of readability compared to ChatGPT cohort regarding IVC filters. Nevertheless, the mean Flesch–Kincaid readability for both cohorts does not meet the recommended U.S. grade reading levels. [ABSTRACT FROM AUTHOR]

Introduction: Transvenous lead extractions (TLEs) for cardiac implantable electronic device complications often encounter difficulties with strong adhesions to the myocardium or vessels. In this report, we introduce a novel "Four‐Stage Rocket" technique for effective TLE in cases where conventional methods fail. Methods and Results: Two challenging cases where conventional TLE methods failed were treated using a combination of four devices: Needle's Eye Snare, Agilis NxT Steerable Introducer, GlideLight Laser sheath, and GORE® DrySeal Flex Introducer sheath, employed via the inferior vena cava. The "Four‐Stage Rocket" technique successfully detached firmly adhered leads near the tricuspid valve annulus, where the traditional superior vena cava approach was inadequate. Conclusion: The "Four‐Stage Rocket" technique offers a potential alternative in complex TLE cases, aligning the laser direction with the adhesion detachment and reducing the tissue damage risk. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Adrenocortical carcinoma (ACC) is a rare form of cancer that primarily affects individuals in their fifth or sixth decade of life, with a slightly higher incidence in females. While most cases are sporadic, ACC can also be associated with certain hereditary syndromes. The prognosis for ACC is variable, with a median overall survival of 3 years. Surgery is currently the only curative treatment option for ACC. Diagnosing ACC can be challenging, especially when it presents as an adrenal incidentaloma. A multidisciplinary approach involving surgeons, endocrinologists, pathologists, nuclear medicine physicians, and radiologists is necessary for managing ACC. The article provides information on when to suspect and how to diagnose ACC, including the clinical presentation, biological assessment, and imaging techniques. The recommended surgical approach for ACC depends on various factors, such as tumor size and invasion of adjacent organs. Adjuvant mitotane treatment is standard after ACC resection, and long-term follow-up is crucial for monitoring recurrence. [Extracted from the article]

Proper assessment of fluid responsiveness using accurate predictors is crucial to guide fluid therapy and avoid the serious adverse effects of fluid overload. The main objective of this study was to investigate the accuracy of respiratory variations in inferior vena cava diameter (∆IVC) to predict fluid responsiveness in mechanically ventilated children. This prospective single-center study included 32 children (median age and weight of 17 months and 10 kg, respectively) who received a fluid infusion of 10 ml kg–1 of crystalloid solutions over 10 min. ∆IVC and respiratory variation in aortic blood flow peak velocity (∆Vpeak) were determined over one controlled respiratory cycle before and after fluid loading. Thirteen (41%) participants were fluid-responders. ∆IVC, ∆Vpeak, stroke volume index, and cardiac index were found to be predictors of fluid responsiveness. However, the area under the ROC curve of ∆IVC was smaller when compared to ∆Vpeak (0.709 vs. 0.935, p < 0.012). The best cut-off values were 7.7% for ∆IVC (sensitivity, 69.2%; specificity 78.9%, positive predictive value, 69.2%; and negative predictive value, 78.9%) and 18.2% for ∆Vpeak (sensitivity, 84.6%; specificity, 89.5%; positive predictive value, 84.6%; negative predictive value, 89.5%). Changes in stroke volume were positively correlated with ∆IVC (ρ = 0.566, p < 0.001) and ∆Vpeak (ρ = 0.603, p < 0.001). A significant correlation was also found between changes in MAP and ∆Vpeak (ρ = 0.382; p = 0.031), but the same was not observed with ∆IVC (ρ = 0.011; p = 0.951). In conclusion, ∆IVC was found to have a moderate accuracy in predicting fluid responsiveness in mechanically ventilated children and is an inferior predictor when compared to ∆Vpeak. [ABSTRACT FROM AUTHOR]

Key Clinical Message: LMS of IVC needs a multidisciplinary approach. Surgical excision with free margin is the cornerstone of management. Upon case‐by‐case selection, adjuvant chemotherapy may play a role in better oncologic outcome. Leiomyosarcoma (LMS) of the inferior vena cava (IVC) is a rare form of mesenchymal origin malignancy with less than 400 cases reported to date. Surgery is the mainstay of management but it requires vast experience in vascular and visceral surgery to attain a free tumor margin. Subsequent adjuvant treatment with chemotherapy and radiation remains as an area of gray zone. We report the case of a 61‐year‐old man with an 8‐month history of abdominal pain. Upon physical examination, an ill‐defined mass over the right side of the lower abdomen and bilateral lower extremity edema were detected. Abdominal ultrasound with Doppler revealed a right‐side retroperitoneal mass invading the IVC with extensive venous thrombosis for which anticoagulation was initiated. Computed Tomography of the abdomen revealed a huge heterogeneously enhancing mass involving the whole length of the infrarenal IVC obstructing the IVC lumen with collateral veins draining through the paralumbar veins and inferior epigastric veins bilaterally. With a top differential of primary IVC LMS, a midline longitudinal laparotomy was performed with an intraoperative finding of a tumor arising from the infra‐renal IVC which was excised. Gore‐Tex graft was used to reconstruct the IVC. There was an injury to the right common iliac artery and it was repaired by end‐to‐end anastomosis. Histopathology confirmed a high‐grade LMS of the IVC and surgical margin status was unknown. He was given adjuvant Chemotherapy consisting of Doxorubicin and Dacarbazine. He has been on follow‐up at the Oncology side with a good performance status. [ABSTRACT FROM AUTHOR]

The inferior vena cava filter (IVCF) has been used in clinical practice for decades to prevent fatal pulmonary embolism. One of the most commonly used types of IVCFs features a conical umbrella-like design. The geometric similarity among these umbrella-shaped IVCFs suggests a potential commonality in their hemodynamic behavior. However, many previous studies have primarily analyzed the blood flow around a single umbrella-shaped IVCF, failing to capture the general hemodynamic characteristics of this filter type. This paper uses computational fluid dynamics to simulate the blood flow around five typical umbrella-shaped IVCFs, aiming to investigate their hemodynamic commonality. For all five IVCFs, prothrombotic stagnation zones are observed downstream of the filter head, extending nearly 12 times the diameter of the inferior vena cava (IVC). The "viscous block" effect of the filter wires accelerates blood flow within the conical region of the filter, enhancing the potential for clot capture and dissolution. The deployment of umbrella-shaped IVCF remarkably increases the wall shear stress (WSS) on the IVC wall, and the WSS on the filter wire continuously increases in the flow direction. Additionally, the viscous resistance of each umbrella-shaped IVCF contributes several times more to the total flow resistance than the pressure resistance. Our results suggest that alterations in the morphology of the filter wires of umbrella-shaped IVCFs significantly impact the flow resistance of the filter and the WSS distribution pattern of the IVC. These hemodynamic changes may lead to life-threatening conditions, such as IVC lesions, filter rupture, and displacement. [ABSTRACT FROM AUTHOR]

Background: The placement of inferior vena cava (IVC) filters often emerges as an alternative preventative measure against pulmonary embolism in patients with upper gastrointestinal (GI) bleeding and isolated distal deep vein thrombosis (DVT). We aimed to investigate the association of IVC filter placement and the incidence of venous thromboembolism (VTE) recurrence in this patient population. Methods: We performed a retrospective cohort study including 450 patients with upper GI bleeding and isolated distal DVT. Propensity score matching using logistic regression was conducted to mitigate potential selection bias. Logistic regression models and additional sensitivity analyses were conducted to estimate the association between IVC filter implantation and VTE recurrence. Interaction and stratified analyses were also performed according to the background covariates. Results: Patients who underwent IVC filter placement were significantly younger than patients in the surveillance group (55.8 ± 9.0 vs 58.4 ± 11.2 years, p = 0.034). Patients in the IVC filter group demonstrated a higher distal thrombus burden. The VTE recurrence composite was significantly higher in patients who underwent IVC filter placement (44.1% [45/102] vs 25% [87/348], p < 0.001). Unmatched crude logistic regression analysis identified a significant association between IVC filter placement and VTE recurrence composite (OR = 2.37; 95% CI, 1.50–3.75). Sensitivity analyses yielded congruent outcomes. Conclusion: This study revealed an increased risk of VTE recurrence among patients receiving IVC filter placement, suggesting that IVC filter placement may not be suitable as a primary treatment for patients with upper GI bleeding and isolated distal DVT. [ABSTRACT FROM AUTHOR]

This article provides a summary of current data on the use of diuretic therapy in critically ill patients. Diuretics are commonly prescribed to remove excess fluid and can be used alone or in combination with other drugs. Common indications for diuretic use in critically ill patients include conditions where fluid accumulation negatively impacts organ function, situations where continued fluid administration is necessary despite the risk of fluid accumulation, and adjunctive management of hypertension. The goal of diuretic therapy is to increase urine output and decrease fluid pressure in the body. Monitoring diuretic therapy involves assessing the balance between effectiveness and safety, with indicators of effectiveness including improved respiratory status, decreased levels of natriuretic peptides, improved organ function, and resolution of congestion on imaging. Diuretic efficacy may decrease in the setting of hypovolemia, refractory venous congestion, inadequate concentrations at sites of action, and insufficient renal function. Adverse effects of diuretics can include electrolyte imbalances and metabolic disturbances. Continuous infusion of diuretics may be more effective than intermittent dosing, and combining diuretics with albumin may improve effectiveness. The furosemide stress test is a diagnostic tool to evaluate tubular function and can be used to assess diuretic response in patients with acute kidney injury. Diuretic resistance may occur due to various factors, and management involves addressing contributing factors and considering combination therapy or extracorporeal methods if necessary. [Extracted from the article]