My Doc Told Me I Had Six Months to Live; That Was Nine Years Ago

Purpose: Small bowel origin carcinoid tumor is indolent but may metastasize relentlessly to various sites, including the liver. For example, over the past 9 years, a 69-year old woman has undergone five percutaneous liver ablations, five hepatic intraarterial chemoembolizations, an ovarian cryoablation, and a transventral hernia mesenteric cryoablation, all related to carcinoid malignancy that was initially incompletely resected. After the patient presented with swelling of the abdomen and both lower extremities, computed tomography angiography revealed a circumferential hepatic metastasis encasing the intrahepatic inferior vena cava (IVC) and extensive third spacing of fluids specific to the IVC distribution.

Materials and Methods: A venogram of the intrahepatic IVC revealed extrinsic compression causing 95% narrowing of the vessel. A balloon was advanced to the level of the lesion and expanded, increasing vessel caliber. Subsequently, two 28- ´ 33-mm covered aortic stent graft cuffs (Gore, Flagstaff, AZ) were deployed in overlapping fashion within the lumen of the IVC, traversing the area of narrowing. Next, a 36- ´ 80 mm open-cell aortic dissection stent (Cook Medical, Bloomington, IN) was placed across both overlapping aortic stents from the renal veins to the hepatic veins.

Results: Posttreatment venogram revealed patent stent grafts within the intrahepatic IVC and restoration of wide vessel patency. No immediate postoperative complications were noted. The patient’s abdominal and lower extremity swelling resolved completely 24 hours postprocedure.

Conclusions: This palliative procedure allowed the patient to maintain good performance status and alleviated her symptoms of IVC syndrome, potentially enabling her to maintain independence and spend her 70th birthday with her family. The radial force generated by the multiple aortic stents will ostensibly maintain the patency of the intrahepatic IVC, although the encasing carcinoid metastasis will continue to grow and exert mass effect. There are plans to perform cryoablation on the encasing tumor at follow-up, now that the immediately life-threating symptoms have been alleviated.