Journal of Vascular Surgery: Venous and Lymphatic Disorders
Volume 5, Number 1 1.2 mg/L and no severe symptoms should be evaluated and managed conservatively.
Efﬁcacy of Primary Inferior Vena Cava Closure in the Setting of Advanced Renal Cell Carcinoma Venous Tumor Thrombus Hallie E. Baer, MD, Scott Swain, BS, Taylor Hicks, MD, Matthew Sideman, MD, Lori Pounds, MD, Dharam Khausik, MD, Ronald Rodriguez, MD, Mark Davies, MD, PhD, MBA, Georges Haidar, MD, Anne Laux, MD. University of Texas Health Science Center at San Antonio.
DVTdwere retrospectively studied. Electronic DD results, CP data, and VDU analysis data were merged. Enzyme-linked immunosorbent assay was used to provide DD values. DD accuracy and threshold levels were created on the basis of receiver operating characteristic curve analysis. Positive DVT was further differentiated into proximal (above popliteal vein) or distal (below popliteal vein). Results: The consecutive medical records of 1909 ED patients who presented during the months of June to July during a 4-year period (2012-2015) were reviewed. After exclusion of 239 patients (12.5%) screened for follow-up, surveillance, or history of DVT or pulmonary embolism, 1670 patients were left for analysis. The average age was 62.1 6 16.3 years, with more women (931 [55.7%]), and the majority reported limb pain and edema. There were 202 DD tests performed with a median value of 1.7 mg/L (25th and 75th percentiles were 0.864.3 mg/L). Our current laboratory cutoff of 0.6 mg/L identiﬁed all positive DVT cases (100% sensitivity and negative predictive value). Area under the curve for DD was 0.71 (P ¼ .001; Fig 1), and DD values were divided into low, mid, and high categories. For low DD (0.1-0.59 mg/L), there were no DVTs as expected; however, there were 3 (5.9%) DVTsdall distaldfor mid DD (0.6-1.2 mg/L) and 25 (20%) for high DD ($1.3 mg/L; P ¼ .004). Interestingly, for age $50 years, DVT was found in mid (7.7%) and high (20%) range (Fig 2). Patients in the ED with DD $0.6 mg/L were all sent for stat VDU; 745 patients were coded as having low CP and DD values, mid CP and DD values, or low CP with no DD, and all were deemed unnecessary to be sent directly to VDU. Potential charge savings were calculated as VDU for all (745 $1557 ¼ $1,159,965), DD for all (745 $182 ¼ $135,595), which equals a charge savings of $1,024,370, avoiding unnecessary VDU costs to patients and hospital. Conclusions: We suggest that the DD test be used during the initial workup for all patients who present to the ED for suspected DVT. Patients with low and moderate Wells CP should be sent for DD analysis before ultrasound testing is performed. Patients with DD values from 0 to
Background: Advanced renal cell carcinoma is associated with venous tumor thrombus, which invades along the renal vein to the inferior vena cava (IVC) and ultimately ascends to the atrium. Its presence is a signiﬁcant independent adverse prognostic factor; however, surgical management with caval thrombectomy has been associated with prolonged cancer-free survival. Multiple surgical techniques have been described to close the IVC after caval thrombectomy. The aim of this study was to examine the efﬁcacy of primary closure of the IVC at a high-volume urban medical center. Methods: We reviewed a prospectively maintained database of patients with venous tumor thrombus who underwent radical nephrectomy with vena cava reconstruction. Level 0 lesions were excluded. A standardized treatment protocol was established including preoperative admission for medical optimization and repeated imaging to assess for progression of thrombus, using renal protocol computed tomography or magnetic resonance imaging, as well as evidence of metastases. The surgical team consisted of members of the urology, cardiothoracic, and vascular surgery departments. Thrombus was evaluated intraoperatively by Doppler ultrasound and transesophageal echocardiography to aid in dissection by identiﬁcation of lumbar and hepatic vein insertion points, to conﬁrm thrombus level, and to ensure complete resection. Long-term caval patency was assessed on repeated imaging during oncologic follow-up. Results: A total of 44 patients underwent radical nephrectomy with caval thrombectomy during a 2-year period. Patients were predominantly Hispanic men with a history of tobacco use and symptomatic presentation (hematuria, ﬂank pain, weight loss). Thrombus level for L1, L2, L3, and L4 disease was 14%, 41%, 32%, and 14%, respectively. Bypass was required in 45% of cases (venovenous, 32%; cardiopulmonary, 14%); 42 patients (95.5%) underwent primary closure of the IVC. IVC reconstruction was indicated in only two patients (4.5%) for one L2 and one L3 disease. There were no perioperative IVC thrombotic events. Median length of stay was 12 days with a 30-day readmission rate of 16%. Mortality at 30 and 90 days for all patients was 6.8% and 11.3%, respectively. Conclusions: Primary venacaval closure is associated with effective caval preservation without any associated morbidity and obviates the need for patch closure or replacement.
Successful Surgical Treatment of the Superior Vena Cava Syndrome with Pulmonary Embolism Caused by Congenital Anomalous Muscle Bundle in the Right Atrium Jeko Madjarov, Michael Katz, David Miller, Frank Arko. Background: The most common cause of superior vena cava syndrome (SVCS) is malignant obstruction; however, nonmalignant causes, such as indwelling central venous catheterization and mediastinal ﬁbrosis, contribute to the rise in SVCS incidence. Endovascular repair techniques including percutaneous transluminal angioplasty and stenting are the “gold standard” treatments for benign causes of SVCS. The indications for open surgical repair are rare and usually reserved for patients whose symptoms are refractory to anticoagulation and endovascular treatments. This case report describes an unusual presentation of SVCS due to congenital anomalous muscle bundle in the right atrium and its surgical removal. Methods: A 53-year-old woman with a history of pulmonary embolism and unsuccessful endovascular angioplasty presented to the vascular service with facial swelling and persistent cough. She was unable to lie down and had mild to moderate shortness of breath. The patient reported that she was previously well, and her symptoms had gotten gradually worse during a 3-month period and worsened signiﬁcantly in the preceding month. Results of complete blood count, genetic studies, and immunohistochemical investigations were normal. Further workup