A 67-year-old woman with hepatitis C was found to have a liver tumor located in segment 8 during follow-up computed tomography (CT) for pyogenic spondylitis. She also had a past medical history of cirrhosis due to hepatitis C infection and diabetes mellitus. Laboratory examination showed normal levels of carcinoembryonic antigen, carbohydrate antigen 19–9, and α-fetoprotein but elevated protein induced by vitamin K antagonist-II at a level of 106 mAU/mL. Other laboratory studies showed the following: total bilirubin 0.6 mg/dL, albumin 3.2 g/dL, prothrombin time 13.7 s, aspartate aminotransferase 28 IU/L, alanine aminotransferase 22 IU/L, blood urea nitrogen 16 mg/dL, and creatinine 0.54 mg/dL. The Child-Pugh score was grade A (6 points), and the indocyanine green retention rate at 15 min was 16.6%. A diagnosis of hepatocellular carcinoma (HCC) located in segment 8 was indicated by CT (Fig. ), magnetic resonance imaging (Fig. ), and ultrasonography. The tumor was attached to the MHV. CT scans also showed multiple varices (Fig. ). MHV resection was necessary to obtain sufficient surgical margins. Central bisectionectomy (S4, S5, and S8 resection) was suggested but could not be tolerated because of her poor liver function and low future liver remnant volume, which preoperatively was only 56% by CT volumetry. Therefore, we decided to perform partial hepatectomy with MHV resection. Preoperative CT scans revealed the existence of duplicated IVC (Fig. ), so we chose to use the left IVC as the graft for reconstructing the MHV.\nThe surgery started with an inverted L-shaped incision. Intraoperative ultrasonography confirmed a 3.5-cm tumor that was touching the MHV. After mobilization of the right lobe, the liver parenchyma was transected, preserving the right hepatic vein and right anterior glissonian pedicle. A 3-cm portion of the MHV was resected around the tumor to obtain sufficient surgical margins. Immediately before resecting the MHV, we harvested the left IVC for use as the graft. After incising the retroperitoneum beside the Treitz ligament, the LRV, which had ramified from the IVC, was detected. The left IVC, which had ramified 3 cm peripherally from the origin of the LRV, was then isolated and harvested for 5 cm from the confluence of the LRV. The cut ends of the left IVC were closed with 4–0 polypropylene running sutures. The venous graft was anastomosed first to the proximal end of the MHV and then to the distal end using 6–0 polypropylene (Fig. ). A good Doppler flow through the graft was confirmed after the reconstruction. The operation required 394 min, and the estimated blood loss was 1,894 mL.\nMacroscopic evaluation showed a 35-mm bile-stained tumor (Fig. ). Histologic examination revealed moderately differentiated HCC without direct invasion of the MHV and a tumor-free surgical margin (Fig. ). The tumor was classified as stage II (T2N0M0) according to the TNM staging system for HCC. The patient recovered uneventfully and was discharged on postoperative day 12.\nThe patency of the reconstructed MHV was confirmed postoperatively by ultrasonography and dynamic CT (Fig. ). Laboratory examination 2 years after surgery showed normal levels of total bilirubin (0.6 mg/dL), albumin (4.0 g/dL), aspartate aminotransferase (24 IU/L), alanine aminotransferase (24 IU/L), prothrombin time of 13.5 s, blood urea nitrogen (15 mg/dL), and creatinine (0.46 mg/dL).\nNew lesions were found in the left lobe of the liver 4 months after surgery and in the right lobe 26 months after surgery. Both lesions were treated using transabdominal catheter embolization.
Our patient was an 18-year-old girl with recent onset right leg pain and swelling with extension to her inguinal area. She also had dyspnea with respiratory distress. At the time of presentation, she was ill and febrile. She also had pitting edema of right leg and significant size difference between circumferences of her two legs. On the day of admission, she suddenly presented with dyspnea and severe thoracic pain on the right side. All other physical examination was normal.\nShe had no predisposing factor for venous thrombosis. Besides, she had no known a history of DVT, clotting disorders, recurrent abortion, peripheral vascular disease, non-healing ulcerations on the extremities, cerebrovascular accidents or taking oral contraceptive pills.\nHer laboratory data showed only mild normochromic, normocytic anemia, elevated erythrocyte sedimentation rate (ESR) to 75 (normal range less than 25) and CRP = 16 (normal less than 8). Other laboratory test including renal, electrolytes, liver, and urine analysis and culture were normal.\nColor duplex ultrasound study demonstrated deep venous thrombi in the right popliteal, superficial and common femoral veins, with external iliac vein.\nIn addition, hypercoagulable workup was revealed no abnormal finding and also negative for antiphospholipid syndrome and lupus anticoagulant antibodies.\nA multi-detector computed tomography (CT) pulmonary angiography of the chest defined pulmonary emboli in the territory of right main and segmental branch pulmonary artery and suggesting extensive infarction of the right middle pulmonary lobe. She was subsequently started on a low molecular weight heparin (Clexane®: 60 mg, every 12 h SC). Subsequently, CT of the abdomen and CT angiography with IV contrast injection carried out after the procedure confirmed duplication of the IVC []. Both two IVC originate in the pelvis, run parallel to each other, bordering the aorta and left-sided IVC drained into the left renal vein. There was no other pathologic finding in thoracic and abdominopelvic CT studying.\nAfter fully anticoagulated with low molecular weight heparin for 5 days and starting warfarin international normalized ratio (INR) range was between 2 and 3, she was discharged from hospital and was not symptomatic in her follow-up until next 3 months. According to the previous studies, for this patient we planned to continue anticoagulant therapy for 6 months.[]