**3. Anesthetic management**

154 Front Lines of Thoracic Surgery

Fig. 3. Same Patient of figure 2. Operative view of the removal, through a cavotomy (A) and atriotomy (B), of intravascular leiomyomatosis. Operative specimen removed is shown in C: 1 and 2 are the right atrial extensions, 3 the right ventricular extension, 4 the caval iliac

Leiomysarcomas of the inferior vena cava (IVC) are rare malignant tumours originating from the smooth muscle cells of the media layer that typically show three growth patterns: extra-luminal, intra-luminal and both (Mingoli et al., 1996). They may be classified anatomically according to Chiappini et al., 2002, as for renal tumours, into four types: Type I infra-hepatic, type II retro-hepatic, type III supra-hepatic IVC and type IV the thrombus

Patient with type IV was treated and reported by Hassan et al., 2010, using normothermic CPB and Pringle's manoeuvre to remove the atrial thrombus reporting mild hyperbilirubinemia and normal renal function. They discussed the possible advantages of the technique used, compared to HCCA which they thought to be associated with an extended CPB time, increased postoperative bleeding and coagulopathy, and increased neurological risk. On the other hand HCCA provides a bloodless surgical field with reduced risk of spreading/embolization, and fatal haemorrhage. Furthermore the advantages include reduced liver and kidney warm ischemia, reduced risk of incomplete excision, optimal visualization of the IVC/right atrial lumen minimizing the need for a too extensive

Scattered case reports of ovarian haemangioma (Tamburino et al., 1992), testicular tumour (Kanda et al., 1991), embrional carcinoma of the testis (Paule et al., 1991), testicular teratoma (Moon et al., 1992) and even pancreatic cancer (Ozben et al., 2007) have been reported so far.

extensions and 5 right ovarian vein involvement.

retro-peritoneal dissection (Chiappini et al., 2002).

**2.4 Vena cava** 

**2.5 Others** 

extends in the right atrium.

In the following sections, an overview of the main technical features for the management of anaesthesia, extracorporeal circulation and hypothermic circulatory arrest for cavo-atrial thrombectomy are summarized.
