Intravascular tumor extension in the inferior vena cava (IVC) is known to occur with abdominal tumors, such as renal cell, hepatocellular, adrenal cell carcinoma, and Wilm's tumor. We encountered a 53‐year‐old male patient presenting with pulmonary embolism and a right atrial mass with imaging evidence of an adrenal tumor extending into the IVC, up to the right atrium. The patient underwent surgery for the resection of the tumor using cardiopulmonary bypass by a team of cardiothoracic surgeons and urologists. Histology identified the tumor as hepatocellular carcinoma, which developed as ectopic hepatic tissue in the right adrenal gland.

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Objectives To assess the feasibility of Multi-Detector Computed Tomography Angiography (MDCTA) volumetry for the quanti cation and grading of acute non-cerebral, non-gastrointestinal bleeding.Methods This retrospective, single-center, study investigated consecutive patients with MDCTA positive for active non-cerebral, non-gastrointestinal bleeding, between January 2020 and June 2020. Outcome measures were the quanti cation of active extravasation at the arterial and parenchymal phase using volumetry measurements, the calculation of active bleeding rate and bleeding grading, 30-day mortality rate, identi cation of independent predictors of mortality and correlation between volumetric analysis, various clinical features and the decision to proceed with an intervention.Results In total 30 patients (17 females; 56.6%; mean age 70.0±16.0 years) were analyzed. Volumetric analysis was feasible in all cases resulting in excellent inter-observer variability (interclass correlation coe cient 0.999 for arterial and 0.919 for venous volume measurements). Mean volume of contrast extravasation was 1.06±1.09ml and 3.07±2.48 ml at the arterial and parenchymal phases, respectively.Mean bleeding rate was 6.95±7.82 ml/min. High bleeding volume at arterial phase (grade 4 bleeding) was the only independent predictor of 30-day mortality (HR 1383.58; p=0.042). There was a positive correlation between bleeding volume at arterial phase (r s = 0.340; p=0.033) and arterial bleeding rate (r s = 0.381; p=0.019) with the decision to proceed with an intervention. Bleeding volume of 0.6ml was the cutoff value for the prediction of intervention (sensitivity 96.3%; speci city 66.7%).Conclusions MDCTA volumetric analysis for the quanti cation and grading of acute hemorrhage was feasible with excellent inter-observer agreement. The proposed bleeding grading system could optimize decision making and predict clinical outcomes. Key PointsThis article reports a newly proposed quanti cation and grading system of acute non-cerebral, nongastrointestinal hemorrhage using MDCTA volumetric analysis.Volumetric analysis was feasible with excellent inter-observer variability.For the rst time, volumetric values and bleeding grading were associated with clinical outcomes and the decision to proceed to intervention.High bleeding volume at arterial phase (grade 4 bleeding) was the only independent predictor of 30day mortality and bleeding volume of 0.6ml was the cutoff value for the prediction of intervention.

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