A large malignant adrenocortical carcinoma extending to the inferior vena cava and right atrium presented in the form of hemoptysis. Magnetic resonance imaging allowed precise evaluation without any other invasive procedure. Cardiopulmonary bypass is usually employed in these circumstances to remove the cavo-atrial thrombus. This approach may be advantageously replaced by the use of total vascular exclusion of the liver. The only unusual feature of the procedure is that the upper caval clamp is applied across the right atrium. Major collateral circulation due to caval thrombosis allows complete resection of the inferior vena cava up to the hepatico-caval confluence without the need for prosthetic replacement. After an uneventful postoperative course, malignant spread despite chemotherapy with op'-DDD led to death 4 months after surgery.