Neoplastic obstruction of the inferior vena cava (IVC) constitutes a rare but formidable challenge in both vascular and oncologic surgery. It may arise from primary tumors originating within the vessel wall, such as leiomyosarcomas, or more frequently as secondary invasion or tumor thrombus from adjacent malignancies, including renal cell carcinoma, hepatocellular carcinoma, or adrenal cortical carcinoma. The anatomic complexity of the IVC, its proximity to vital structures, and the hemodynamic consequences of obstruction demand a thorough understanding of tumor characteristics, precise preoperative imaging, and meticulous surgical planning. This chapter provides a comprehensive review of the classification, diagnostic workup, and detailed surgical techniques used to manage neoplastic IVC obstruction. We explore the roles of segmental resection, reconstruction techniques, and the use of advanced bypass methods, including cardiopulmonary bypass for intracardiac tumor extension. Outcomes, complications, and long-term prognosis are discussed, emphasizing the importance of an aggressive, multidisciplinary approach to optimize patient survival and quality of life.
Cancer can cause inferior vena cava (IVC) obstruction. Usually, an oncologic resection is not possible and palliative treatment is needed. An endovascular procedure can be performed in most cases under local anesthesia plus sedation through a percutaneous approach. Stenting is a safe and the most effective technique and provides excellent technical and clinical success rates with immediate improvement of symptoms. Despite the short life expectancy of these patients, the technique allows them a far better quality of life. On the other hand, treatment of venous sequalae of carcinological treatment can give good long-term results.
Popliteal entrapment (compression) syndrome is a rare disease affecting principally young people, without atherosclerotic involvement. It is due to extrinsic compression of the neurovascular bundle at the popliteal fossa. There is no consensus or guidelines for the diagnosis or management, especially for functional popliteal entrapment. Compression of the popliteal vein manifests itself symptomatically in dynamic situations, such as prolonged standing or physical exercises. These symptoms are not specific, and clinical examination does not identify specific signs either. The ultrasound (US), in supine position, is usually nondiagnostic. Actually, a normal US in patients who complain of symptoms, related to venous insufficiency, should evoke venous compression as a possible diagnostic. Dynamic imaging by US is the key to visualizing the conflict between veins and anatomical structures. If a surgical treatment is considered, magnetic resonance imaging and/or dynamic phlebography are necessary. Nonsurgical procedures for light or mild cases include stretching exercises and botulinic toxin, under US-assisted injection. In more symptomatic patients, and depending on the etiology of compression, several surgical options can be offered: direct decompression through popliteal fossa dissection, aponeurectomy, isolated or combined with lengthening of gastrocnemius and soleus muscles. An often-overlooked syndrome is the chronic venous insufficiency described by Dijkstra and colleagues in patients with morbid obesity: weight loss is able to stabilize or improve venous return without direct vascular interventions and even allows healing of chronic ulcers.
Venous thoracic outlet syndrome (VTOS) is a vascular disorder caused by extrinsic compression of the axillary-subclavian vein, leadingto impaired venous drainage of the upper extremity. Compression most commonly occurs at the costoclavicular junction (CCJ) and, less frequently, at the pectoralis minor space, either independently or as part of a combined "double crush" mechanism. This venous compression may be initially asymptomatic, discovered only incidentally in high-risk populations, but it can evolve into symptomatic disease-manifesting as intermittent swelling and venous congestion, or progressing to acute thrombosis with significant morbidity. VTOS is clinically categorized into 4 subtypes: asymptomatic compression, nonthrombotic VTOS (McCleery syndrome), thrombotic VTOS (Paget-Schroetter syndrome), and postthrombotic VTOS. The diagnostic process requires a high index of suspicion and dynamic imaging under provocative conditions. Advances in duplex ultrasound, magnetic resonance venography, and intravascular ultrasound (IVUS) have improved the detection and characterization of both positional and chronic venous obstruction. Contemporary management emphasizes early thrombus removal, timely surgical decompression, and venous reconstruction in selected cases. Prompt diagnosis and intervention are critical to prevent progression to postthrombotic syndrome and irreversible functional impairment. This review offers a comprehensive overview of VTOS, including its pathophysiology, classifications, diagnostic pathways, and management algorithms, supported by current literature.
May-Thurner syndrome (MTS), also known as iliac vein entrapment syndrome, is caused by extrinsic compression of the left common iliac vein-most often by the right common iliac artery-leading to venostasis and potential development of deep vein thrombosis (DVT). Though historically underdiagnosed, its recognition has increased with the routine use of cross-sectional imaging and intravascular ultrasound (IVUS), which now serves as the gold standard for diagnosis and procedural guidance. MTS primarily affects young women and often presents with unilateral leg swelling, recurrent DVT, or chronic pelvic symptoms. Diagnosis relies on duplex ultrasound, computed tomography or magnetic resonance venography, venography, and IVUS, which can detect subtle intraluminal abnormalities and guide precise stent placement. Endovascular treatment with dedicated venous stents has largely replaced open surgical options due to superior safety, efficacy, and durability. Proper stent selection and IVUS-guided sizing are essential to avoid complications such as restenosis or migration. Postprocedural management includes anticoagulation and patient-specific follow-up. Ongoing research focuses on novel stent technologies, AI-enhanced imaging, and longterm outcome data from registries like the European Venous Registry. Early identification and intervention improve long-term outcomes and quality of life, underscoring the importance of clinical awareness and multidisciplinary care.
