Imaging Pearls ❯ Vascular ❯ IVC
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- “Primary leiomyosarcoma of the inferior vena cava (IVC) is a very rare mesenchymal tumor associated with extremely poor prognosis. It accounts for less than 1 in 100,000 of all adult malignancies and approximately 0.5% of adult soft tissue sarcomas. Notably, approximately less than 450 cases are described in the literature. However, these tumors are the most common primary tumors of the IVC. IVC leiomyosarcoma predominantly occurs in females with female/male ratio of approximately 3:1. These tumors tend to be more common in the ffth or sixth decades of life, although any age group may be afected. These slowgrowing tumors can arise in any vein, but usually develop in the IVC and accounts for 50% of all venous leiomyosarcomas.”
Current update on IVC leiomyosarcoma
Mindy X. Wang et al.
Abdominal Radiology (in press) - “IVC leiomyosarcomas are classified according to the IVC segment involved: lower segment, middle segment, and upper segment, with the middle segment being the most commonly afected segment . IVC leiomyosarcomas are associated with three tumor growth patterns: extraluminal (62%), intraluminal (5%), and combined extraluminal and intraluminal (33%).”
Current update on IVC leiomyosarcoma
Mindy X. Wang et al.
Abdominal Radiology (in press) - “The clinical presentation depends on the location, growth pattern, and segment involvement of the IVC leiomyosarcoma. IVC leiomyosarcoma in the upper segment, also known as infrarenal involvement (from the iliac veins up to the renal veins), may manifest as Budd-Chiari syndrome due to the hepatic vein outfow obstruction. IVC leiomyosarcoma in the middle segment (from the renal veins to the hepatic veins) may present as nephrotic syndrome and right upper quadrant pain, due to obstruction of the renal vein drainage. IVC leiomyosarcoma in the lower segment (from the hepatic veins to the right atrium) can manifest as lower extremity edema, due to inflow obstruction.”
Current update on IVC leiomyosarcoma
Mindy X. Wang et al.
Abdominal Radiology (in press) - “Common CT features include an irregularly distended IVC flled with a complex, lobulated, heterogeneously enhancing soft tissue mass. Tumor heterogeneity occurs due to internal hemorrhage and necrosis, and areas of recent hemorrhage may demonstrate increased attenuation on CT. The tumor’s primary growth pattern can be defned, as intraluminal involvement is suggested by an irregularly enhancing intraluminal mass obstructing and extending along the IVC course. A potential diagnostic conundrum may occur with diferentiating IVC leiomyosarcomas with extraluminal growth pattern versus other venous retroperitoneal leiomyosarcomas.”
Current update on IVC leiomyosarcoma
Mindy X. Wang et al.
Abdominal Radiology (in press) - “An especially helpful imaging feature is an imperceptible IVC at the point of maximal contact with the mass, which elucidates its site of origin as the IVC rather the retroperitoneum; this has a sensitivity and specificity of 75% and 100%, respectively. Conversely, a mass compressing the IVC suggests that the mass’ origin is outside of the IVC. Additionally, extraluminal involvement typically follows tissue planes of least resistance and displaces adjacent organs. Combined extra- and intraluminal involvement demonstrates patterns of both extra- and intraluminal growth, and its appearance depends on the relative size of each component.”
Current update on IVC leiomyosarcoma
Mindy X. Wang et al.
Abdominal Radiology (in press) - “Primary retroperitoneal neoplasms are important differential considerations for IVC leiomyosarcoma, including retroperitoneal leiomyosarcomas, leiomyomas, adipocytic tumors, fibroblastic tumors, neurogenic tumors, rhabdomyosarcoma, and cystic tumors, as prognosis and management can differ. Retroperitoneal leiomyosarcomas are large, heterogeneous masses with similar pattern of spread compared to IVC leiomyosarcomas; differentiating them by imaging features such as imperceptible IVC help delineate their site of origin.”
Current update on IVC leiomyosarcoma
Mindy X. Wang et al.
Abdominal Radiology (in press) - “IVC leiomyosarcoma is a rare, aggressive retroperitoneal malignancy. Clinical symptoms are often nonspecifc and may contribute to delay in the diagnosis. Imaging, especially CT and MRI, play a critical role in the diagnosis, staging and follow-up of this tumor. Awareness of the multimodality imaging features of IVC leiomyosarcoma and its differential diagnoses can help guide optimal patient management. However, histopathology may be required for definitive diagnosis. Aggressive surgical resection is essential for curative treatment, while chemotherapy and/or radiation may further aid management of this rare sarcoma.”
Current update on IVC leiomyosarcoma
Mindy X. Wang et al.
Abdominal Radiology (in press)
- Interruption of the inferior vena cava: facts
- Interruption of the inferior vena cava (IVC) with azygos continuation is a rare congenital anomaly, in which the IVC is interrupted below the hepatic vein and venous return beyond this point is restored by the dilated azygos and hemiazygos veins draining into the superior vena cava.
- this congenital anomaly could be isolated, but often it is part of more complex syndrome including for example cardiac malformations, asplenia, and polysplenia syndrome. Interruption of the IVC with azygos continuation is the second most common abnormality associated with polysplenia syndrome - “The polysplenic syndrome is defined by the presence of multiple spleens, usually numbering between two and six. In contrast to accessory spleens, the spleens are of uniform size. Accessory spleens usually measure between 1 and 2 cm and are not considered as a form of the polysplenic syndrome. Splenosis, an acquired rather than congenital condition that arises in the context of traumatic splenic rupture, can be ruled out by patient history.”
Polysplenia syndrome
B. De La Villeon et al.
Journal of Visceral Surgery,Volume 148, Issue 5,2011, Pages e395-e396, - ”Splenosis typically consists of multiple small implants of splenic tissue; it can mimic peritoneal carcinomatosis or endometriosis depending on the clinical context.”
Polysplenia syndrome
B. De La Villeon et al.
Journal of Visceral Surgery,Volume 148, Issue 5,2011, Pages e395-e396, - "The syndrome of polysplenia is often accompanied by a variable spectrum of visceral and vascular developmental anomalies. It is rarely diagnosed in adults. While it is estimated that 2.5/100,000 infants are born with this anomally, fewer than 5% are still alive at five years of age due to the associated severe cardiac anomalies.The syndrome is associated with multiple congenital malformations that may involve the solid organs and digestive tube of the abdominal cavity, the heart, or the great vessels. The diagnosis is often made during surgical exploration for an associated cardiac or digestive anomaly. Among the most common vascular anomalies are agenesis of the suprarenal inferior vena cava with persistent continuity of the azygos vein, and pre-duodenal position of the portal vein. Biliary atresia is found in nearly 50% of cases, common mesentery in more than 75% of cases, and an abbreviated or annular pancreas in 85–90% of cases.”
Polysplenia syndrome
B. De La Villeon et al.
Journal of Visceral Surgery,Volume 148, Issue 5,2011, Pages e395-e396 - "Anomalies include asplenia, the congenital absence of the spleen. This can be isolated or part of a clinical sequela of a broader syndrome such as Ivermark syndrome, a heterotaxy syndrome occurring in 1 in 10,000 to 40,000 cases. CT will show lack of spleen and Tc-99 red blood cell scan will show lack of uptake.”
MDCT Findings of Splenic Pathology
Sangster GP et al.
Current Problems in Diagnostic Radiology 2021 (in press) - "Accessory spleen is a frequent congenital variation (20% of autopsy) due to failure in coalescence of mesodermal buds in the dorsal mesogastrium.The accessory spleen is supplied by the splenic artery and most are located near the splenic hilum. On pre- and post-contrast imaging, this enhances similarly to splenic parenchyma. This entity is important to recognize because it could be responsible for the recurrence of hematologic disorders after splenectomy.”
MDCT Findings of Splenic Pathology
Sangster GP et al.
Current Problems in Diagnostic Radiology 2021 (in press) - "Splenosis in an acquired condition that occurs after splenectomy or splenic rupture is represented by seeding or implantation of splenic cells in any location, frequently simulating tumors. On pre- and post-contrast, imaging, splenosis appears similar to the normal spleen. When ectopic splenic tissue or splenosis is in the differential for a mass around the splenic hilum or splenectomy bed, a technetium tagged heat-damaged red blood cell scan is a nuclear medicine examination that can delineate ectopic splenic tissue. Splenosis is usually managed conservatively and history is key to help differentiate it from other lesions.”
MDCT Findings of Splenic Pathology
Sangster GP et al.
Current Problems in Diagnostic Radiology 2021 (in press)
- “Venous invasion is a distinctive feature of hepatocellular carcinoma and renal cell carcinoma with known prognostic and treatment implications; however, this finding remains an underrecognized characteristic of multiple other malignancies including cholangiocarcinoma, adrenocortical carcinoma, pancreatic neuroendocrine tumor, and primary venous leiomyosarcoma and can be a feature of benign tumors such as renal angiomyolipoma and uterine leiomyomatosis.”
Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion
LeGout JD et a.
RadioGraphics 2020; 40:2098–2116 - "Recognition of tumor venous invasion at imaging has clinical significance and management implications for a range of abdominal and pelvic tumors. For example, portal vein invasion is a strong negative prognostic indicator in patients with hepatocellular carcinoma. In patients with rectal cancer, diagnosis of extramural venous invasion helps predict local and distant recurrence and is associated with worse survival. The authors present venous invasion by vascular dis- tribution and organ of primary tumor origin with review of typical imaging features. Common pitfalls and mimics of neoplastic thrombus, including artifacts and anatomic variants, are described to help differentiate these findings from tumor in vein.”
Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion
LeGout JD et a.
RadioGraphics 2020; 40:2098–2116 - • At imaging, tumor thrombus is more expansive than bland thrombus, demonstrates enhancement, and may have imaging features similar to those of the primary malignancy. Another helpful indicator of tumor thrombus is contiguity with the primary mass.
• Tumor types most commonly associated with invasion of the IVC are RCC, HCC, adrenocortical carcinoma, and primary leiomyosarcoma of the IVC.
Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion
LeGout JD et a.
RadioGraphics 2020; 40:2098–2116 - “With CT, the shared imaging features of tumor thrombus—including direct extension from the primary tumor into a vein, overly expansive thrombus, and thrombus enhancement—can be accurately assessed. Detection of neovascularity in a portal vein thrombus at CT has been reported to be 100% specific for malignancy. The enhancement pattern of the tumor thrombus may match that of the primary malignancy, such as arterial hyperenhancement and later-phase washout in cases of HCC.”
Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion
LeGout JD et a.
RadioGraphics 2020; 40:2098–2116 
Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion
LeGout JD et a.
RadioGraphics 2020; 40:2098–2116
Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion
LeGout JD et a.
RadioGraphics 2020; 40:2098–2116- “Primary leiomyosarcoma of the IVC is found in women in more than three-fourths of cases and occurs at a mean age of 54 years. Primary leiomyosarcoma originating from the renal vein is extremely rare, occurring much less frequently than leiomyosarcoma of the IVC. When reported, primary leiomyosarcoma of the renal vein is more commonly found on the left, likely owing to the longer length of the left renal vein.”
Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion
LeGout JD et a.
RadioGraphics 2020; 40:2098–2116 - "Three main growth patterns for primary leiomyosarcoma of the IVC have been described in relation to the IVC lumen, with extraluminal growth most common in 62% of cases, combined extraluminal and intraluminal growth in 33%, and entirely intraluminal growth in 6%. Other authors have described the growth pattern as predominantly extraluminal (76%) or predominantly intraluminal (20%). The site of origin from the IVC is most commonly the middle segment (from the renal veins to the hepatic veins) in 43% of cases, the lower (infra- renal) segment in 37%, and the upper segment (above the hepatic veins) in 19%.”
Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion
LeGout JD et a.
RadioGraphics 2020; 40:2098–2116 - “At imaging, primary leiomyosarcoma of the IVC is typically a large heterogeneous mass that frequently contains areas of necrosis. In contrast to adrenocortical carcinoma, calcification is uncommon. In cases of a predominantly extraluminal growth pattern, differentiation from other retroperitoneal sarcomas or the other tumors described earlier may be difficult.”
Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion
LeGout JD et a.
RadioGraphics 2020; 40:2098–2116
- “The most common variants in IVC anatomy are a duplicated IVC and a left IVC. A duplicated IVC results when both the right and left supracardinal veins persist. This variant is seen in 0.2–3% of the population. Generally, when a duplicated IVC is present, the left moiety drains into left renal vein, which in turn usually joins with the right IVC, leading to the normal suprarenal anatomy. Iliac venous inflows into the duplicated system may be isolated to each respective side or may join at the inferior origin of the duplicated IVC.”
The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
David S. Shin et al.
Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3 - “Renal cell carcinoma (RCC) is the most common malig- nancy to involve the IVC, with caval extension seen in 4–10%. Any venous tumor thrombus is consid- ered Robson Stage IIIa, while in the Internal Union Against Cancer tumor-node-metastasis (TNM) classification, renal vein only, infradiaphragmatic IVC, and supradiaphragmatic IVC involvements correspond to T3b, T3c, and T4b, respec- tively. CT has been shown to have negative and positive predictive values for venous extension of 97% and 92%, respectively, with the corticomedullary phase of enhancement being most useful.”
The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
David S. Shin et al.
Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3 - “Adrenocortical carcinoma (ACC) is a rare malignancy of the adrenal gland and may be endocrinologically functional. Age distribution is bimodal, with one peak before 5 years of age and the second in the 4th to 5th decades of life. At diagnosis, ACC tumors tend to be larger than 5 cm, enhance heterogeneously, and have irregular shape with blurred margins. In 9–19% of patients, there is invasion of the tumor into the IVC , which is considered Stage III disease. MRI can be helpful for identifying IVC extension, as well as in differentiating ACC from adenoma or pheochromocytoma.”
The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
David S. Shin et al.
Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3 - “Involvement of the IVC and right atrium by hepatocellular carcinoma (HCC) is not uncommon in advanced disease, either due to intracaval extension of hepatic venous tumor thrombus or direct invasion of the IVC wall. Caval involvement is associated with a poor prognosis in most patients due to increased risk of distant metastases. While direct IVC invasion can be seen with cholangiocarcinoma and metastatic disease, hepatic venous tumor thrombus is uncommon in other primary or secondary hepatic malignancies, and thus is a differentiating feature of HCC.”
The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
David S. Shin et al.
Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3 - “Leiomyosarcoma, the primary malignancy arising from the IVC, originates from the smooth muscle cells of the caval wall media and is much less common than secondary tumors. Given the rarity of the tumor, the true incidence of primary IVC leiomyosarcoma is unclear. The malignancy most commonly affects women in their fifth or sixth decade. The pattern of tumor growth is extraluminal in 59–76%, intraluminal and extraluminal in 16%, and exclusively intraluminal in 20–25%. Central necrosis is common."
The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
David S. Shin et al.
Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3 - “Etiologies of IVC thrombosis include congenital IVC anomalies and acquired conditions. Although congenital anomalies of the IVC are relatively uncommon and usu- ally accompanied by well-developed collaterals, thrombosis can ensue and become symptomatic if venous hypertension or stasis develops in these collaterals. Acquired IVC thrombosis can occur for a number of reasons. Examples include external compression of the IVC (e.g., adjacent tumor), malignancies involving the IVC wall and lumen, extension of deep vein thrombosis (DVT) from the iliac veins, and damage to the endothelium (e.g., penetrating or iatrogenic injury; presence of a catheter or IVC filter)”
The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
David S. Shin et al.
Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3 - “Fistula formation between the aorta and IVC can be an acute complication of abdominal aortic aneurysm rupture or repair, or rarely due to trauma. Spontaneous aortocaval fistula may present with abdominal or back pain, pulsating abdominal mass, continuous abdominal bruit, pelvic and lower extremity venous hypertension, shock, or congestive heart failure. This diagnosis is suggested on contrast- enhanced CT when there is early enhancement of the IVC similar to the aorta. Fistulous communication between the aorta and IVC may be directly visualized. Treatment can be surgical or endovascular.”
The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
David S. Shin et al.
Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3 - “IVC injury is a rare event for both blunt and penetrating traumas and has a high mortality rate. While some patients with IVC trauma are too unstable for imaging, CT signs of IVC injury include retroperitoneal hematoma with or without IVC contour abnormality and active contrast extravasation. Hepatic laceration may coexist, and injuries of the retrohepatic IVC carry a poor prognosis. Given the low intraluminal pressure, self-tamponade can occur in the absence of significant concomitant disruption of the surrounding soft tissues.”
The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
David S. Shin et al.
Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3 - ”Flattened IVC constitutes one of the CT signs of clinically significant hypoperfusion in adult blunt trauma patients (i.e., hypoperfusion complex) along with flattened renal veins, active contrast extravasation, free peritoneal fluid, and small bowel enhancement and dilation. Collapsed IVC may also be a helpful predictor of clinical outcome in pediatric and elderly trauma patients, in whom heart rate and blood pressure may be less reliable indicators of hypovolemia.”
The inferior vena cava: a pictorial review of embryology, anatomy, pathology, and interventions
David S. Shin et al.
Abdominal Radiology https://doi.org/10.1007/s00261-019-01988-3
- “Primary tumors of the IVC are exceedingly rare. Leiomyosarcoma of the IVC is a tumor of mesenchymal origin arising from the smooth-muscle cells found in the vessel wall and is associated with a poor prognosis, with a reported 10-year survival of 14%. Most leiomyosarcomas are large at presentation and manifest with nonspecific complaints of abdominal pain, a palpable right upper quadrant mass, or progressive lower extremity edema.”
Imaging of the Inferior Vena Cava with MDCT
Sheth S, Fishman EK
AJR 2007; 189:1243–1251 - “Leiomyosarcomas of the IVC are classified according to their location [11–13]. Data gathered from a compiled review of 218 cases from the world literature reveal that approxi- mately 37% of tumors occur in segment I, be- low the level of the renal veins and above the iliac vein bifurcation; 43% involve segment II, between the renal veins and the level of the hepatic veins; and 20% form in segment III at or above the hepatic veins level and may extend into the right atrium .”
Imaging of the Inferior Vena Cava with MDCT
Sheth S, Fishman EK
AJR 2007; 189:1243–1251 - “At imaging, exophytic leiomyosarcomas appear as large retroperitoneal masses with heterogeneous contrast enhancement. Cystic necrotic areas are not rare. Because the origin of these large tumors may be difficult to as- certain on imaging, percutaneous biopsy is valuable to achieve a definitive diagnosis.”
Imaging of the Inferior Vena Cava with MDCT
Sheth S, Fishman EK
AJR 2007; 189:1243–1251 - “The IVC is formed by the confluence of the right and left common iliac veins draining blood from the lower extremities and pelvis. As it ascends in the retroperitoneum to the right of the abdominal aorta, the IVC receives major tributaries including the lumbar veins, the left and right renal veins, the right gonadal vein, and the hepatic veins. The azygos venous system connects to the IVC either directly or through the renal veins. The IVC and its branches are best seen in the coronal plane .”
Imaging of the Inferior Vena Cava with MDCT
Sheth S, Fishman EK
AJR 2007; 189:1243–1251 - “Four of 18 (22%) retroperitoneal masses were IVC leiomyosarcomas. The IVC was imperceptible at the interface with the mass in three of the four (75%) IVC leiomyosarcomas (κ = 0.88) and in no alternate diagnosis (p < 0.02). No IVC leiomyosarcoma showed a positive embedded organ sign versus one of 14 masses of alternate origin (p = 1.0, κ = 0.56). The negative embedded organ sign was seen in most primary retroperitoneal masses (11/14 or 79%, κ = 0.85) but in no case of IVC leiomyosarcoma (p = 0.01). Intraluminal tumor was seen in one of four (25%) IVC leiomyosarcomas and in two of 14 other retroperitoneal masses (p = 1.0, κ = 1.0).”.
Can CT features differentiate between inferior vena cava leiomyosarcomas and primary retroperitoneal masses?
Webb EM et al.
AJR Am J Roentgenol. 2013 Jan;200(1):205-9 - “An imperceptible IVC at the point of maximal contact with a retroperitoneal mass was the most useful CT feature for predicting the origin of IVC leiomyosarcoma. A negative embedded organ sign was useful for excluding IVC origin. Knowledge of these CT features may assist with preoperative planning.”
Can CT features differentiate between inferior vena cava leiomyosarcomas and primary retroperitoneal masses?
Webb EM et al.
AJR Am J Roentgenol. 2013 Jan;200(1):205-9 - Arteriovenous (AV) Grafts and Fistulas for Hemodialysis Access—The Role of MDCT with CT Angiography and 3-D Reconstructions in Delineating Anatomy and Identifying Complications
Sameer Ahmed MD, Siva P. Raman MD, Elliot K. Fishman MD - Introduction
871,000+ people are being treated for end-stage renal disease, and account for 6% of the Medicare budget ($29 billion).
- Complications of hemodialysis access account for a sizable proportion of these costs
AV fistulas and grafts are placed for long-term hemodialysis access.
- General guidelines: 1) Autogenous hemodialysis access is favored over prosthetics, 2) Distal extremity access sites should be utilized first in order to preserve more proximal options, 3) Upper extremity access is preferred over lower extremity.
- “Intravenous leiomyomatosis (IVL) is a rare gynecologic disease characterized by overgrowth of histologically benign smooth muscle within the lumen of pelvic and systemic veins. IVL was originally described in 1896 in an autopsy case by Birch-Hirschfeld . Subsequently, in 1907, Durk reported the first case of IVL with intracardiac extension. Yet it was not until 1959 that the earliest case by Marshall and Morris was described in the English literature.”
Intravenous Leiomyomatosis with Intracaval and Intracardiac Involvement
Low G et al
Radiology. 2012 Dec;265(3):971-5. - “IVL generally occurs in premenopausal parous white women (median age, 44 years; age range, 28–80 years) (8). It has a recognized association with a history of prior hysterectomy for uterine leiomyomas. In a review, Lam et al (6) found a history of hysterectomy in 38 (55.9%) of 68 patients with IVL with intracardiac extension.”
Intravenous Leiomyomatosis with Intracaval and Intracardiac Involvement
Low G et al
Radiology. 2012 Dec;265(3):971-5. - “Aside from IVL, the differential diagnosis for a contiguous intracaval and intracardiac soft-tissue mass includes bland thrombus, primary caval leiomyosarcoma, and tumor thrombus (from renal cell carcinoma, adrenal cortical carcinoma, or hepatocellular carcinoma in adults and from Wilm tumor in children).”
Intravenous Leiomyomatosis with Intracaval and Intracardiac Involvement
Low G et al
Radiology. 2012 Dec;265(3):971-5. - “Aside from IVL, the differential diagnosis for a contiguous intracaval and intracardiac soft-tissue mass includes bland thrombus, primary caval leiomyosarcoma, and tumor thrombus (from renal cell carcinoma, adrenal cortical carcinoma, or hepatocellular carcinoma in adults and from Wilm tumor in children).”
Intravenous Leiomyomatosis with Intracaval and Intracardiac Involvement
Low G et al
Radiology. 2012 Dec;265(3):971-5. - “Surgery is the treatment of choice for IVL. This involves total hysterectomy, bilateral salpingo-oophorectomy (as the tumor is estrogen dependent), and removal of the intravenous tumor. IVL typically adheres to but does not invade the vessel wall. Thus, if IVL extends into the IVC only, it can usually be removed by downward traction from the ovarian vein, iliac vein, or IVC at venotomy. However, a multidisciplinary surgical approach is required if there is intracardiac extension.”
Intravenous Leiomyomatosis with Intracaval and Intracardiac Involvement
Low G et al
Radiology. 2012 Dec;265(3):971-5.
"Patients with renal cell carcinoma in whom multidetector computerized tomography fails to detect tumor thrombus are unlikely to have a tumor thrombus found at surgery that would change the surgical approach."
The Accuracy of Multidetector Computerized Tomography for Evaluating Tumor Thrombus in Patients With Renal Cell Carcinoma
Guzzo TJ, Pierorazio PM, Schaeffer EM, Fishman EK, Allaf ME
J Urology Vol 181,486-491 February 2009" Multidetector computerized tomography with 3-dimensional mapping is an effective imaging modality for accurately characterizing the level of venous thrombus in patients with renal cell carcinoma."
The Accuracy of Multidetector Computerized Tomography for Evaluating Tumor Thrombus in Patients With Renal Cell Carcinoma
Guzzo TJ, Pierorazio PM, Schaeffer EM, Fishman EK, Allaf ME
J Urology Vol 181,486-491 February 2009- Tumor Thrombus vs Bland Thrombus?
- Tumor thrombus typically
- Have gross invasion of tumor parenchyma into adjacent vein
- Abnormal arterial vascularity (within the thrombus) of the thrombus
- Irregular venous lumen expansion - Which tumors have the highest risk for venous thrombosis?
- Uterus
- Brain
- leukemia Acute vs Chronic Venous Thrombosis
Acute thrombosis
- Thrombi are homogeneous
- expand the lumen
- Located centrally in the vessel
- Peripheral residual flow common
Chronic thrombosis - Thrombi are heterogeneous
- Decreased vein diameter
- Are peripherally attached to the vessel wall
- Venous Thrombosis in Cancer Patients
- Hypercoagulability states due to indirect pathway activation by production of procoagulents
- Venous stasis due to reduced mobility (cachexia, surgery) or to compression by tumors
- Vessel wall damage by direct invasion of vessels on by indwelling catheters "The purpose of this article is to review the imaging of venous thrombosis in patients with cancer."
Imaging Presentation of Venous Thrombosis in Patients With Cancer
Khosa F et al.
AJR 2919; 194:1099-1108- "High speed MDCT has the potential to replace traditional imaging techniques in the evaluation of pathologic processes involving the IVC. The ability to acquire near isotrophic data allows high-quality reconstructions in the sagittal and coronal planes and thus overcomes one of the major limitations of CT in evaluating the IVC."
Imaging of the Inferior Vena Cava with MDCT
Sheth S, Fishman EK
AJR 2007;189:1243-1251
- Splanchnic Artery Aneuyrsms: Sites of Origin
- Splenic artery 60%
- Hepatic artery 20%
- SMA 5.5%
- Celiac artery 4%
- Pancreatic aa. 2%
- GDA 1.5%
- "The performance characteristics of CTV and deep venous sonography were similar when compared with a clinical standard. The results support the use of indirect CTV after CT pulmonary angiography as an alternative to sonography in the ICU patient."
Prospective Comparison of Indirect CT Venography Versus Venous Sonography in ICU Patients
Taffomi MJ et al. AJR 2005; 185:457-462
- "Retrograde opacification of the inferior vena cava or hepatic veins on CT is a specific but insensitive sign of right sided heart disease at low contrast injection rates, but the usefullness of this classic sign decreases with high injection rates."
Clinical Relevance of Retrograde Inferior Vena Cava or Hepatic Vein Opacification During Contrast Enhanced CT Yeh BM et al. AJR 2004; 183:1227-1232
- Retrograde IVC or Hepatic Vein Opacification: Causes
- High injection rates
- Tricuspid atresia
- Pulmonary hypertension
- Right ventricular systolic dysfunction
- Factoid: The left ovarian vein arises off the left renal vein while the right ovarian vein arises directly off the IVC.