Management of malignant tumor with intracaval extension by selective clamping of IVC

Malignant tumors with retrohepatic intracaval extensions are difficult to treat. We report five cases of intracaval tumor emboli (3 hepatocellular carcinoma, 2 renal cell carcinoma).

The tumor embolus is removed by the following methods according to site: in the right atrium, by open heart surgery after clamping of the inferior vena cava between the superior vena cava and the intrahepatic inferior vena cava and of the portal vein, in combination with a cardiopulmonary bypass using a pump oxygenator; above the confluence of the hepatic vein with the inferior vena cava, by inferior vena cava clamping between its suprahepatic and intrahepatic portions, shunting from the inferior vena cava and the portal vein to the axillary vein; below the inferior vena cava-hepatic vein confluence, by inferior vena cava clamping below the confluence and in the infrahepatic portion; and around the confluence, by side clamping of the inferior vena cava, maintaining both hepatic and systemic circulations.

Pulmonary emboli were diagnosed in one patient. However, the patient's condition improved with anti-coagulant therapy. No major complication was observed in any other patient. All patients were discharged after a mean postoperative period of 32.8 days. One patient with HCC died of lung metastasis at 5 months and the other two, of recurrence in the residual portion of the liver at 4 and 16 months, and the two with RCC are still alive without recurrence of the carcinoma 9 and 14 months later.

Preoperative recognition by ultrasonography, computed tomographic scanning, cavography and especially trans-esophageal endoscopic ultrasonography is important. Vascular exclusion may also be performed by various techniques depending on the site of the tumor embolus.