Endovascular Biopsy of Intracaval Mass Using Clamshell Forceps: Anatomy, Indications, and Approach

Learning Objectives:

1. Review endovascular biopsy techniques for intracaval masses.


2. Discuss inferior vena cava anatomy and associated intravascular lesions.


3. Demonstrate endovascular clamshell forceps biopsy technique with a pictorial review of cases.

Background: Endovascular biopsy of suspected intravascular or infiltrating perivascular tumors involving the inferior vena cava (IVC) is a recognized technique, but one that is often underutilized compared to open or percutaneous biopsy {1}. Although endovascular methods such as transcatheter brush biopsy {2}, scoop biopsy {3}, needle biopsy {4}, and aspiration biopsy {5}, have been described to biopsy intracaval tumors, no standard approach exists. This is largely due to variability in mass location, extent of the lesion, risk of injury to adjacent structures (including the vessel wall), possible tumor dissemination, and available local expertise. The interventional radiologist must account for these factors when determining the safest approach for biopsy. An effective endovascular option is the use of flexible clamshell forceps, which can obtain high-quality samples for histopathological analysis, diagnosis, and treatment planning through a safe, minimally invasive venous access.

Clinical Findings/Procedure Details: This exhibit will (1) discuss two cases of intracaval tumor thrombus requiring biopsy for treatment planning, (2) review the pre-biopsy work-up to include anatomy, imaging, and important considerations used to determine the safest approach and biopsy technique, (3) present a pictorial summary to highlight the technical details of using clamshell forceps to safely obtain tissue via a transfemoral approach, and (4) review alternative endovascular techniques to biopsy suspected intraluminal venous tumors.

Conclusion and/or Teaching Points:

1. Biopsy of intracaval masses is challenging because of the intravascular location of the mass and the central location of the IVC.


2. Surgical biopsy and biopsy methods that traverse the IVC wall are high risk for the patient.


3. Several endovascular biopsy techniques exist to safely obtain tissue from intravascular lesions.


4. Endovascular biopsy using clamshell forceps from a femoral approach is low risk and can successfully obtain adequate tissue samples for pathologic diagnosis.