IVC injuries in trauma patients

Inferior vena cava (IVC) injuries in trauma occur mainly as a result of penetrating trauma, 10% of which are secondary to gun shot wounds (GSW) and 3% as a result of stab wounds (SW).(3,4) The abdominal IVC lies along the vertebral column, mostly within the retroperitoneum protected by a number of visceral organs, and to the right of the aorta, which poses a challenge to even the most experienced of trauma surgeons. 

The IVC is anatomically divided into five sections: the infrarenal IVC (IRIVC), pararenal IVC (PRIVC), suprarenal IVC (SRIVC), retrohepatic IVC (RHIVC), and suprahepatic IVC (SHIVC). (1) Insult to the IVC carries a high mortality rate (40-70% of patients who are alive upon arrival to a level I trauma center) and increases according to location: the best survival rate in patients with IRIVC injuries and the worst occurring in patients with SHIVC injuries. (1-4) 

Management and repair of IVC injuries, poses a challenge in the operating room. Advanced Trauma Life Support (ATLS) guidelines are the mainstay of initial management of all trauma patients and the primary survey is of utmost importance.  Some studies have shown that mortality of the patient with such injuries is not only associated with the location of insult (injuries with close proximity to the heart appear to have higher mortality rates as do RHIVC injuries), but that a low systolic blood pressure (<90) upon arrival to the ED without appropriate response to resuscitative measures and presence of additional injuries also proved to be a factor in poor prognosis. (1,3-4)

Intraoperative management of IVC lacerations is approached by use of Damage Control and begins with attempts to control of the bleeding by use of manual pressure and abdominal packing.  Some literature supports that if the hematoma is contained and is nonpusatile or nonexpanding and there appears to be not other injuries involving surrounding structures, that exploration is not warranted at the time of initial surgery, especially in the region of a RHIVC injury (3). Often times, however, this is not the case.

Identification of an IRIVC injury is best exposed with mobilization of the right colon, kocherization of the duodenum and medial rotation of the pancreas, which allows for visualization of the IVC from infrarenally down to the bifurcation.  Collateral circulation from lumbar veins can make control of the bleeding difficult with use of clamps and may require use of a Foley or Fogarty catheter placed intraluminally to gain control of the hemorrhage. Manual compression with tightly rolled sponges, although cumbersome, is widely recommended for proximal and distal control of the injury while sequentially exposing and clamping the defect in need of repair with Babcock clamps(1,3). For large destructive infrarenal defects, ligation of the IVC is an option and usually well tolerated. (1) Ideally the defect would be primarily repaired and would be performed transversely to decrease the narrowing of the IVC. Lumbar tributaries may need to be ligated to mobilize and repair the IVC defect. Posterior defects may require expansion of the injury anteriorly to gain better exposure and allowing for repair intraluminally. In addition, vein patch and graft reconstruction are also feasible options, however more time consuming and should be opted in patients who are hemodynamically stable. (2) If the hemorrhage cannot be controlled, ligation of the IRIVC is usually well tolerated in the initial perioperative phase and may allow time for further resuscitation.

PRIVC, SRIVC, and RHIVC injuries pose the greatest challenge primarily due to the limited access of the IVC and mobilization of the liver. The RHIVC receives the hepatic veins, which are short and fragile again making mobilization of the liver difficult, therefore control of the hemorrhage with tight abdominal packing is the best approach. (2) Additionally, the Pringle maneuver may be of benefit to control bleeding from the IVC allowing time to isolate the injury and repair it.  Ligation of the IVC may be necessary, however should be reserved for extremis circumstance. SRIVC ligation results in a significant fall in cardiac output and venous return to the heart in addition to renal hypertension.(4) In the case of a RHIVC injury, ligation is not compatible with life.  An atriocaval shunt may be beneficial to slowing the hemorrhage of a RHIVC injury, however, some reports suggest that mortality might even be higher in patients selected for shunting, perhaps secondary to ongoing hemorrhage because of indecision and delay of insertion, or to technical difficulty of the insertion, therefore a definitive plan should be made prior to incision.(2,4-5) 

SHIVC hemorrhage is of the highest mortality and is controlled through access of the chest cavity, whether that be via median sternotomy or right thoracotomy. (2,4) unfortunately there is a high mortality rate for this type of injury

Primary repair of the insult is recommended even if the luminal diameter of the vessel is compromised.  However, results of operation are not without complications; lower extremity thrombus and edema, pulmonary embolism, as well as pulmonary and intrabdominal septic causes to name a few. (4)

Penetrating trauma to the IVC continues to be a challenge even for the most experienced surgeons and is associated with a poor prognosis. Predictors of mortality are a SBP <90 without an appropriate response to resuscitation (persistent shock) and the presence of additional intrabdominal or vascular injuries. (1, 3-4) Regardless of injury type, the primary concern of operative procedures involving venous injury is hemostasis and secondarily repair.(2)

from Dr. Andrea Boedecker