Abstract

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) (Genetech, 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 × 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.