A 35-year-old man with the diagnosis of mitral atresia, a double outlet right ventricle, pulmonary atresia with interrupted inferior caval vein, and azygous continuation to the right superior caval vein underwent a Blalock-Taussig shunt in early childhood and a Kawashima operation at the age of 17 at another institution. He presented to our clinic with progressive cyanosis and fatigue 18 years after his last surgical procedure. His oxygen saturation was 65%.\nCardiac catheterization revealed left pulmonary artery stenosis and a decompressing vein from the right superior caval vein to the left superior caval vein which directly drains to the left atrium. Left pulmonary artery stenting was done via right internal jugular approach (Figures , , and ).\nHe underwent a second catheterization for occlusion of the left superior caval vein via left internal jugular approach. The anomalous vein measured 22 and 20 mm in AP and lateral projections, respectively. Balloon test occlusion resulted in immediate increase in oxygen saturation from 65% to 82% without drop of blood pressure. The mean pressure in the azygous vein remained at 9 mmHg; pressure in the left internal jugular vein increased to 11 mmHg and dropped within a few minutes to 10 mmHg. Angiography showed good venous collateral drainage.\nThe largest available vascular plug, 24 mm in diameter, failed to completely occlude the vessel, which was successfully occluded using a 24 mm ASD occluder (Cera Lifetech, China) via a 12 Fr sheath. Upon completion of the procedure the patient had oxygen saturation of 80%, left internal jugular pressure of 10 mmHg, and right superior caval vein and pulmonary artery pressure of 9 mmHg.\nAfter occlusion, the patient had significant improvement of his exercise intolerance and fatigue. Follow-up hemodynamic study 12 months later showed no increase in venous pressure, no development of venous collaterals, and no decrease in his oxygen saturation.
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.