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INTRODUCTION: Cardiac involvement in hepatocellular carcinoma is rare. This includes intra-atrial metastases, and tumor thrombus with extension of tumor into the inferior vena cava and the right atrium. We describe a patient presenting with inferior vena cava syndrome complicating hepatocellular carcinoma with extension of tumor into the inferior vena cava and the right atrium. CASE DESCRIPTION/METHODS: An 83 year old female with a history of hepatocellular carcinoma and underlying cirrhosis presented with bilateral leg edema to her thighs, and abdominal distension. She had a history of hepatitis C successfully treated with direct acting anti-viral therapy. Her hepatocellular carcinoma was treated with radiofrequency ablation. Several months later, she received transarterial chemo-embolization for recurrent hepatocellular carcinoma. She remained well for one year and was lost to follow-up, until she presented with bilateral leg edema, abdominal distension and shortness of breath. Physical exam showed no jugular venous distension. She had moderate abdominal distension with shifting dullness, hepatomegaly, and edema to both lower extremities extending to her thighs. Computed tomography of her abdomen with and without contrast revealed hepatomegaly with a large tumor mass in the left lobe of the liver extending into the inferior vena cava and right atrium. The thrombus in the inferior vena cava and right atrium showed contrast enhancement. Ascites was present. 2D echo showed tumor thrombus in her right atrium. The patient was diagnosed with inferior vena cava syndrome due to extension of hepatocellular carcinoma into her inferior vena cava and right atrium. She had some improvement with diuretics, and was discharged home to hospice care. DISCUSSION: Hepatocellular carcinoma with tumor extension into the inferior vena cava and atrium is rare. This can present with inferior vena cava syndrome, superior vena cava syndrome, or both. Aggressive treatments have been performed in this situation, including surgical resection of the atrial tumor thrombus while under cardio-pulmonary bypass, with or without resection or ablation of the hepatocellular carcinoma. Given the understandably poor prognosis and age of the patient, hospice care was chosen. Tumor extension into the inferior vena cava and right atrium should be considered in patients with advanced hepatocellular carcinoma presenting with inferior vena cava syndrome.

Catheter-directed computed tomography angiography (CDCTA) is an imaging technique where CT images are acquired after selective catheterization of a vessel. Images obtained in this fashion provide several advantages over conventional imaging techniques such as fluoroscopic angiography, digital subtraction angiography, cone-beam CT, and conventional CT angiography. At this point, there is still limited literature on the subject, with prior studies examining a small number of potential uses. The goal of this pictorial essay is to illustrate our single tertiary care center experience using CDCTA.