A 19-YR-OLD man with previously resected testicular cancer presented with suspected metastatic teratoma within the inferior vena cava (IVC). Magnetic resonance showed the tumor arising from the IVC wall, inferior to the hepatic vein's confluence and above the renal veins. Initial intraoperative transesophageal echocardiography assessment was performed to ensure no interim tumor expansion above hepatic veins and absence of intracardiac shunts, predisposing to paradoxical embolization. During IVC cross-clamp and total liver vascular exclusion, echocardiography imaging helped in the placement of the vascular clamp above the tumor and was essential for assessment of the ventricular preload, fluid management, and titration of vasopressors.

Figure. No caption available.

Figure. No caption available.

Transesophageal echocardiography revealed near-complete IVC occlusion by the tumor (A, thick arrow ) inferior to a hepatic vein (thin arrow ). Color Doppler demonstrated laminar flow in the hepatic vein (B, thin arrow ) but turbulent flow (thick arrow ) in the IVC. The short-axis view revealed trace turbulent color flow (C ). Supplemental Digital Content 1, http://links.lww.com/ALN/A763, and Supplemental Digital Content 2, http://links.lww.com/ALN/A764, depict peritumoral turbulent flow in the short and long axes.

Surgery was completed successfully. Postoperative pathology revealed inflammatory myofibroblastic tumor. This report illustrates the utility of intraoperative echocardiography in guiding surgical resection of endoluminal tumors occluding the IVC1,2and hemodynamic management during complete IVC cross-clamping.

References

1.
Sharma V, Cusimano RJ, McNama P, Wasowicz M, Ko R, Meineri M: Intraoperative migration of an inferior vena cava tumour detected by transesophageal echocardiography. Can J Anesth 2011; 58:468–70
2.
Cywinski JB, O'Hara JF Jr: Transesophageal echocardiography to redirect the intraoperative surgical approach for vena cava tumor resection. Anesth Analg 2009; 109:1413–5