Real-time transesophageal echocardiography-guided surgical resection of hepatocellular carcinoma with inferior vena cava tumor thrombus: a case report

Introduction

Hepatocellular carcinoma (HCC) with inferior vena cava (IVC) tumor thrombus is associated with a poor prognosis (1). In selected patients, surgical resection remains the only potentially curative treatment option (2). Although thrombectomy can relieve venous obstruction and prevent life-threatening complications such as pulmonary embolism, it is associated with substantial risks, including tumor embolization and hemodynamic instability. The reported mortality rate ranges from 6% to 9% (3). In such high-stakes surgical procedures, transesophageal echocardiography (TEE) has emerged as a valuable intraoperative monitoring tool that provides real-time guidance and may enhance procedural precision and safety (4). We report a case of advanced HCC with an IVC tumor thrombus extending into the right atrium, in which anesthesiologist-led intraoperative TEE guided surgical decision-making, optimized vascular control, and enabled prompt detection of acute secondary bland thrombus. We present this case in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0022/rc).

Case presentation

A 49-year-old female patient was admitted to Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University with a one-month history of persistent right upper abdominal distension. Her medical history was notable for chronic hepatitis B infection without prior antiviral therapy and previous thyroidectomy. Physical examination at admission was unremarkable. Laboratory evaluation showed normal bilirubin, international normalized ratio (INR), platelet count, and thromboelastography results, while alpha-fetoprotein (AFP) exceeded 2,000 ng/mL. Her Child-Pugh score was 6 (Class A), and Eastern Cooperative Oncology Group (ECOG) performance status was 2. Contrast-enhanced abdominal computed tomography (CT) revealed a left hepatic lobe mass radiologically suggestive of HCC, with tumor thrombus extending from the left portal vein branches, including the segment IV portal branch, through the left hepatic vein into the IVC and up to the right atrial inlet. These findings were further confirmed on contrast-enhanced magnetic resonance imaging (MRI) (Figure 1A,1B). Imaging also demonstrated cirrhosis and splenomegaly. Following multidisciplinary evaluation, a left hemihepatectomy combined with IVC tumor thrombectomy was planned due to the high risk of tumor embolization and intracardiac extension.

Figure 1 Preoperative contrast-enhanced liver MRI and baseline intraoperative transesophageal echocardiography findings. (A,B) Contrast-enhanced liver MRI revealed a malignant lesion in the left hepatic lobe, accompanied by tumor thrombus (white arrows) extending from the left portal vein branches, including the segment IV branch, through the left hepatic vein into the IVC and up to the right atrial inlet. (C) Baseline intraoperative TEE demonstrated a moderately echogenic mass (white arrow) extending from the left hepatic venous outflow into the IVC. (D) The mass (white arrow) showed synchronous motion with the cardiac cycle and protruded into the right atrium at the cavoatrial junction. IVC, inferior vena cava; MRI, magnetic resonance imaging; RA, right atrium; TEE, transesophageal echocardiography.

Peripheral venous access was secured in the preoperative holding area. Under local anesthesia, invasive monitoring was established with left radial arterial cannulation and right internal jugular central venous catheterization. In the operating room, standard monitoring included continuous invasive arterial pressure, electrocardiography, pulse oximetry, bispectral index, and cardiac output monitoring. Active temperature management was implemented using a warming blanket, elevated ambient temperature, and fluid-warming devices. Following uneventful induction of general anesthesia and endotracheal intubation, a comprehensive baseline intraoperative TEE examination was performed using a multiplane probe. Initial mid-esophageal views, including the mid-esophageal bicaval view at approximately 90°, were used to assess cardiac anatomy and function, with particular attention to excluding intracardiac tumor extension. The probe was then advanced to obtain deep transgastric views of the hepatic venous confluence and retrohepatic IVC at approximately 60° for assessment of tumor thrombus location and mobility. Visualization of the cavoatrial junction and retrohepatic IVC was optimized by probe advancement, withdrawal, and rotation. Color flow and pulsed-wave Doppler were used to evaluate flow patterns, luminal flow, and vascular patency. TEE demonstrated a moderately echogenic mass extending into the IVC from the left hepatic venous outflow, consistent with the tumor thrombus identified preoperatively (Figure 1C). The mass exhibited synchronous pulsatile motion with the cardiac cycle, intermittently prolapsing into the right atrium at the cavoatrial junction (Figure 1D), while changing the patient’s position from supine to reverse Trendelenburg resulted in partial retraction of the thrombus into the IVC. These findings suggested that the thrombus was mobile and amenable to cautious repositioning under continuous TEE guidance. Based on these real-time findings, the surgical team proceeded with tumor thrombectomy using careful manual reduction of the thrombus into the IVC, followed by a dual-incision approach for complete resection.

The patient was placed in the supine position with the head elevated. A standard surgical approach was used to dissect the hepatic hilum, and occlusion bands were placed around the hepatic pedicle and infrahepatic IVC. After incision of the proximal left portal vein branch, the thrombus was completely extracted under controlled blood release. The venotomy was then irrigated locally with heparinized saline and closed with continuous sutures. The Spiegel lobe was subsequently resected, and dissection was continued toward the second hepatic hilum. The diaphragm was then incised longitudinally to expose the supradiaphragmatic and infradiaphragmatic segments of the IVC. After the cardiac surgeon joined the procedure, the supradiaphragmatic IVC was further mobilized. Under continuous real-time TEE guidance, an occlusion band was placed around the proximal IVC approximately 2 cm above the superior margin of the tumor thrombus (Figure 2A). The band was gently pre-tightened to stabilize the segment without compressing the thrombus. After inflow occlusion of the hepatic pedicle and infrahepatic IVC had been achieved, the cardiac surgeon manually compressed the right atrium. Under continuous TEE guidance, the site, direction, and angle of compression were adjusted in real time, and direct surgical visualization confirmed complete retraction of the tumor thrombus into the IVC lumen (Figure 2B). The proximal IVC occlusion band was then immediately tightened to prevent retrograde migration into the right atrium. Subsequently, an approximately 3-cm longitudinal venotomy was made at the common trunk of the left and middle hepatic veins and extended into the infradiaphragmatic IVC. Controlled blood release allowed complete expulsion of the thrombus. The IVC lumen was thoroughly irrigated with heparinized saline and repaired with continuous sutures.

Figure 2 Intraoperative surgical field and transesophageal echocardiography findings. (A) Intraoperative view showing placement of an occlusion band (green arrow) around the proximal IVC, approximately 2 cm above the superior margin of the tumor thrombus. (B) TEE showed complete repositioning of the thrombus (white arrow) into the IVC lumen following directed right atrial compression, with immediate subsequent tightening of the occlusion band (green arrow). IVC, inferior vena cava; RA, right atrium; TEE, transesophageal echocardiography.

Immediately following vascular suturing, repeat TEE detected an echogenic mass within the IVC lumen (Figure 3A), suggesting an acute secondary bland thrombus. Secondary thrombectomy with complete excision of the bland thrombus and IVC reconstruction was performed promptly. Postprocedural TEE confirmed restoration of IVC patency with physiological flow (Figure 3B). Final assessment demonstrated no residual bland thrombus, and only mild mitral and tricuspid regurgitation was noted. Thus, left hemihepatectomy combined with IVC tumor thrombectomy was successfully completed under continuous TEE-guided vascular control.

Figure 3 Intraoperative transesophageal echocardiography findings after vascular repair and secondary thrombectomy for acute bland thrombus. (A) Immediately after vascular suturing, repeat TEE detected an echogenic mass (white arrow) within the IVC lumen, indicating formation of an acute secondary bland thrombus. (B) After secondary thrombectomy for the acute bland thrombus and IVC reconstruction, TEE confirmed the absence of any residual abnormal mass. IVC, inferior vena cava; TEE, transesophageal echocardiography.

During the procedure, the Pringle maneuver was applied intermittently for six cycles of 10, 9, 5, 13, 9, and 13 minutes, respectively, with 5-minute reperfusion intervals. The IVC was clamped three times for 11, 40, and 34 minutes, including one episode of simultaneous suprahepatic and infrahepatic occlusion lasting 34 minutes. No major hemodynamic collapse occurred during right atrial compression or IVC clamping, although vasoactive support was adjusted as needed. The total operative time was 410 minutes. Estimated blood loss was 1,000 mL, urine output was 2,000 mL, and transfusion requirements included 800 mL of plasma, 6 units of packed red blood cells, and 17 units of platelets, without transfusion-related reactions.

No systemic anticoagulation was administered intraoperatively, and only local irrigation with heparinized saline was used after thrombectomy. Intraoperative thromboelastography showed impaired clot formation and reduced clot strength, without evidence of hyperfibrinolysis. Postoperatively, the patient was admitted to the intensive care unit, received thromboprophylaxis with enoxaparin, and was started on tenofovir for hepatitis B virus infection. She was extubated on postoperative day 2, transferred to the ward on day 3, and discharged without major complications.

Histopathological examination revealed a tumor measuring 13 cm × 12 cm × 5.5 cm, consistent with moderately to poorly differentiated HCC. Vascular and biliary invasion were present. Surgical margins were negative (R0 resection). According to the American Joint Committee on Cancer (AJCC) 8th edition, the tumor was staged as pT4N0M0. Tumor cells were identified within the thrombus specimen, confirming the diagnosis of tumor thrombus.

At 1 month postoperatively, contrast-enhanced CT revealed multiple intrahepatic metastases. The patient subsequently underwent two sessions of transcatheter arterial chemoembolization (TACE) and received targeted therapy with donafenib (200 mg twice daily for 8 cycles). At the 12-month follow-up, contrast-enhanced MRI demonstrated no recurrence of IVC tumor thrombus. Timeline of the clinical course is summarized in Table 1.

All procedures performed in this study were in accordance with the ethical standards of the Ethics Committee of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University (approval No. 2025-0331) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

For patients with advanced HCC complicated by IVC tumor thrombus, combined hepatic resection and thrombectomy is a validated management strategy that provides a modest survival benefit (5). However, these procedures are technically demanding due to major blood loss, prolonged operative duration, hemodynamic instability, and the need for IVC occlusion, all of which place substantial demands on perioperative management. While thrombus location is critical for surgical planning, its dynamic mobility—driven by hemodynamics, respiration, and patient positioning—limits the value of conventional static imaging (6).

Intraoperative TEE provides continuous visualization of thrombus movement and cardiovascular status, supporting staged vascular control, confirming thrombus withdrawal and complete removal, and enabling early detection of secondary thrombus or embolic events (7). Importantly, the novelty of the present case lies not merely in the use of TEE itself, but in its anesthesiologist-led integration into surgical decision-making as a real-time intraoperative navigation tool. In this case, TEE facilitated repositioning of the mobile thrombus from the right atrium into the IVC and enabled immediate detection of an acute secondary bland thrombus after vascular repair. This was achieved through two synergistic strategies: reverse Trendelenburg positioning to facilitate caudal displacement of the thrombus and staged IVC clamping to prevent thrombus transection during manipulation. Continuous TEE guidance confirmed complete withdrawal of the thrombus from the right atrium into the IVC before definitive clamping and thrombectomy.

By converting the thrombus location from the right atrium to the supradiaphragmatic IVC, this strategy allowed management analogous to Cheng type IIIa tumor thrombus (8), thereby avoiding median sternotomy and cardiopulmonary bypass, reducing operative risk, and shortening operative time (9). In addition, immediate detection of acute secondary bland thrombus enabled prompt re-intervention and may have prevented catastrophic complications.

Despite the patient’s systemic hypocoagulable profile—due to cirrhosis, impaired clot formation and reduced clot strength on intraoperative thromboelastography, perioperative hypothermia (nasopharyngeal temperature as low as 35 ℃), and substantial blood loss—acute secondary bland thrombus still occurred. According to Virchow’s triad, thrombosis arises from endothelial injury, blood stasis, and hypercoagulability (10). In this patient, endothelial injury from surgical manipulation, local blood flow stasis due to IVC and hepatic pedicle clamping, and procedural factors such as prolonged occlusion likely contributed to thrombus formation. This observation highlights the critical importance of intraoperative thrombus prevention and real-time monitoring, which may easily be overlooked. Although irrigation with heparinized saline helps reduce thrombus risk and maintain IVC patency (11), it may be insufficient to prevent acute thrombosis in high-risk settings.

Although limited by its single-case design and lack of long-term oncologic outcome data, this report provides practical insights into integrating TEE into complex hepatobiliary surgery and supports its broader application in similar high-risk cases.

Conclusions

Anesthesiologist-led intraoperative TEE plays a pivotal role in improving the safety and precision of surgical resection for HCC with IVC tumor thrombus. Its ability to provide real-time guidance and facilitate immediate detection of complications makes it an indispensable tool in complex oncovascular surgery.

Acknowledgments

We sincerely thank the patient for consenting to the publication of this case report. We also acknowledge the contributions of the anesthesiology, hepatobiliary surgery, cardiac surgery, intensive care, and pathology teams for their collaborative efforts in the diagnosis, surgical management, and perioperative care of this patient.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0022/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0022/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0022/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the Ethics Committee of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University (approval No. 2025-0331) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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