We present a rare case of hepatocellular carcinoma with associated tumor thrombus that extends into the inferior vena cava and right atrium. Our patient presented with lower extremity edema and an elevated D-dimer. CT pulmonary angiography showed no signs of pulmonary embolism however it showed large filling defects involving the inferior vena cava, right atrium, right ventricle and superior vena cava suggestive of an extensive thrombus. On subsequent imaging studies it was identified as a tumor thrombus as opposed to a blood thrombus. A tumor thrombus is a rare complication more commonly associated with renal cell carcinoma and carries a poor prognosis. Surgical thrombectomy is considered the first line of treatment at this time, however, due to the low number of known cases to have IVC and RA involvement, there is little consensus on management. Often patients are referred for microwave ablation. Anti-coagulation is not the treatment of choice for a tumor thrombus however we speculate there may be a role for anti-coagulation.