Inferior Vena Cava Injuries: Outcomes and ligation of infrarenal injuries

Inferior vena cava injuries incur a high mortality rate, with ranges quoted from 20-66%. These patients frequently arrived to a trauma center in profound shock due to massive blood loss. The cycle of hypotension, hypothermia, acidosis, shock, coagulopathy and cardiac arrhythmias all lead to the patient's ultimate demise. Death from IVC injuries are typically related to hemorrhage with subsequent hypovolemic shock from exsanguination. Despite advances in modern medicine, little improvement in these mortality rates have been shown.  Certain prognostic factors in the trauma patient have been described which ultimately are indicators and sequelae of profound hypovolemic shock.

Hansen et al. in 2000 examined outcomes of abdominal vena caval injuries and identified certain factors for increased mortality in the trauma patient. In their study, they had 47 patients with a diagnosis of IVC injury. These were predominately young males sustained penetrating trauma. Most were hypotensive and acidotic on arrival to their trauma unit. Their overall mortality rate was 55% (26 patient deaths). Not surprisingly, when they compared survivors to nonsurvivors, the most prominent factors different between the two were related to hemorrhagic shock. These include systolic blood pressure, hemoglobin (10.9 vs 8.1 g/dL), bicarbonate levels (20.1 vs 14 mEq/L), temperature (34.6 vs 31.7 C), coagulation profile (prothrombin time 18.9 vs. 35.3 sec), and volume of blood products transfused (2.2 vs 4.9L). Initial SBP in the field (124 mmHg vs 81) was the most predictive variable as patient who had an unattainable prehospital SBP died. Furthermore, mortality was 100% for patients with initial SBP in the field but subsequently losing it en route. Location and type of IVC injury were also examined. Avulsions and lacerations which were larger than 5cm carried the highest mortality rate (67%). Location of injuries also played a factor with mortality for suprarenal (75%), retrohepatic (66%) were the highest as compared to infrarenal (23%). The authors concluded that focus on management include aggressive fluid resuscitation and avoidance of hypothermia with subsequent coagulopathy.

During exploratory laparotomy, caval injuries should be suspected upon visualization of a hematoma behind the ascending colon and around the duodenal loop. In these cases, the injury is typically tamponaded by the retroperitoneum. Exploration and release of hematoma may result in uncontrollable bleeding. A right sided medial visceral rotation before entering the hematoma may be once approach to consider. Temporary control with compression of the vena cava against the spine above and below the injury should be performed to attain proximal and distal control. Should there continue to be excessive bleeding, an aortic compressor may also be used to decrease blood flow. If an ED thoracotomy has already been performed, aortic cross clamping will also assist in acheiving control of excessive, uncontrolled bleeding. Options for repair include primary venorrhaphy, wide-caliber vein graft from saphenous vein, prosthetic patch venorrhaphy, tube graft placement, and ligation of the IVC. There have been case reports of endovascular stenting of IVC injuries as well though situations in which this may be an option are limited due to the majority of trauma patients being unstable.

With regards to ligation of the IVC, typically this manuever is with the mindset of a damage control laparotomy. In 2010, Sullivan et al. examined outcomes of ligation of the IVC with a focus on long term data. Their overall conclusion is that ligation of the IVC is an acceptable damage control technique, however with associated high mortality rates. In their study, they had 54 of 100 (54%) infrarenal IVC injuries. Of those 54, 3 had died prior to any intervention. Of the remaining 51 patients, 22 (43%) underwent ligation. Early mortality rate was found to be 41% (9/22) and an overall mortality was 59% (13/22). In addition, they also found a significantly longer hospital stay and length of time in the ICU. Long term data was only available for 7 of the 9 remaining infrarenal ligation patients with an average follow up of 42 months. No long-term sequelae including change in function or leg edema was seen. Thus, in this subset of patients, ligation of the infrarenal IVC appears to be well tolerated in patient surviving injury to the IVC.

In summary, IVC injuries are associated with a high mortality rate and options for management and improving outcomes remain a struggle. Though still with a considerable mortality rate, ligation of the IVC in damage control situations provides a viable option with little long term outcomes, though more studies and data are needed.

References:

1. Hansen CJ1, Bernadas C, West MA, Ney AL, Muehlstedt S, Cohen M, Rodriguez JL. Abdominal vena caval injuries: outcomes remain dismal. Surgery. 2000 Oct;128(4):572-8.

2. Navsaria PH1, de Bruyn P, Nicol AJ.Penetrating abdominal vena cava injuries. Eur J Vasc Endovasc Surg. 2005 Nov;30(5):499-503.

3. Asensio JA1, Chahwan S, Hanpeter D, Demetriades D, Forno W, Gambaro E, Murray J, Velmahos G, Marengo J, Shoemaker WC, Berne TV. Operative management and outcome of 302 abdominal vascular injuries. Am J Surg. 2000 Dec;180(6):528-33; discussion 533-4.

4. Sullivan PS1, Dente CJ, Patel S, Carmichael M, Srinivasan JK, Wyrzykowski AD, Nicholas JM, Salomone JP, Ingram WL, Vercruysse GA, Rozycki GS, Feliciano DV. Outcome of ligation of the inferior vena cava in the modern era. Am J Surg. 2010 Apr;199(4):500-6.

5. Castelli P1, Caronno R, Piffaretti G, Tozzi M. Emergency endovascular repair for traumatic injury of the inferior vena cava. Eur J Cardiothorac Surg. 2005 Dec;28(6):906-8.

from Dr. Michael Tran