Surgery for tumor thrombi in the right atrium and inferior vena cava of patients with recurrent hepatocellular carcinoma.

This is a report on a 42-year-old woman with a tumor thrombus in the inferior vena cava and the right atrium caused by recurrent hepatocellular carcinoma. The tumor thrombus, which extended from the retrohepatic inferior vena cava into the right atrium close to the tricuspid valve was successfully resected using a cardiopulmonary bypass and total hepatic vascular exclusion. The cardiopulmonary bypass was established by cannulating the ascending aorta, the superior vena cava and the infrarenal vena cava, and was performed under moderate hypothermia and ventricular fibrillation. To reduce the duration of ventricular fibrillation, after the tumor thrombus had been removed from the right atrium into the suprahepatic inferior vena cava through the atriotomy, the atriotomy was closed. The intrapericardial or suprahepatic vena cava was then clamped. The caval tumor thrombus was removed using the total hepatic vascular exclusion technique through a vena cava incision. To reduce total hepatic vascular exclusion time the suprahepatic vena caval clamp was released after the caval tumor had been removed from the suprahepatic vena caval. The infrahepatic vena cava just below the hepatocaval junction was then clamped and the entire tumor thrombus was removed. The vena caval incision was closed without a prosthesis. The total hepatic vascular exclusion and vena caval exclusion times were 10 and 30 minutes, respectively. The ventricular fibrillation and total cardiopulmonary bypass times were 15 and 52 minutes, respectively. The operating time was 9 hours and 30 minutes and the total blood loss was 4,000 ml.