Intra-abdominal Inferior Vena Cava Injuries: Operative Strategies and Outcomes

High-grade liver injury: outcomes with a trauma surgery-liver surgery collaborative approach

Background

Operative mortality for high-grade liver injury (HGLI) remains 42% to 66%, with near-universal mortality after retrohepatic caval injury. The objective of this study was to evaluate mortality and complications of operative and nonoperative management (OM and NOM) of HGLI at our institution, characterized by a trauma surgery-liver surgery collaborative approach to trauma care.

Methods

This was an observational cohort study of adult patients (age ≥16) with HGLI (The American Association for Surgery of Trauma (AAST) grades IV and V) admitted to an urban level I trauma center from January 2010 to November 2021. Data were obtained from the electronic medical record and state trauma registry. Patients were categorized by management strategy: immediate OM or planned NOM. The primary outcome was 30-day mortality.

Results

Our institution treated 179 patients with HGLI (78% blunt, 22% penetrating); 122 grade IV (68%) and 57 grade V (32%) injuries. All abdominal gunshot wounds and 49% of blunt injuries underwent initial OM; 51% of blunt injuries were managed initially by NOM. Procedures at the initial operation included hepatorrhaphy±packing (66.4%), nonanatomic resection (5.6%), segmentectomy (9.3%), and hepatic lobectomy (7.5%). Thirty-day mortality in the OM group was substantially lower than prior reports (23.4%). Operative mortality attributable to the liver injury was 15.7%. 19.4% of patients failed NOM with one death (1.4%).

Conclusion

We report an operative mortality of 23.4% for HGLI in a trauma care system characterized by a collaborative approach by trauma surgeons and liver surgeons.

Level of evidence

III.

Treatment of penetrating injuries of the retrohepatic vena cava: systematic review protocol

Injuries to the retrohepatic segment of the inferior vena cava require complex procedures, as exposure without prior vascular control can lead to uncontrollable and fatal bleeding. To achieve such control, the classic techniques of hepatic vascular exclusion and the implantation of an atriocaval shunt have been described, and more recently, endovascular strategies have been reported. However, there is no consensus in the literature regarding which of these strategies is associated with lower mortality. In order to determine which therapeutic strategy presents the lowest mortality and complication rates in the treatment of penetrating injuries to the retrohepatic segment of the inferior vena cava, a systematic review of the literature will be conducted, registered on the PROSPERO platform under the number CRD42023464133. The Cochrane Handbook for Systematic Reviews of Interventions will guide the process. Searches will be carried out in the MEDLINE/PubMed, LILACS, Embase, Scopus, and Web of Science databases. ClinicalTrials.gov and the International Clinical Trials Registry Platform (ICTRP) will be consulted to detect ongoing or unpublished trials. Studies will be selected based on a predefined search strategy, the number of results will be filtered using the Rayyan app, and the studies included will be independently reviewed by two authors to reach a final consensus. The qualitative analysis of the studies will be conducted using the RoB 1.0 tool.

Gunshot wound causing penetrating injury to the inferior vena cava treated with open cell self-expanding stents

Endovascular stents are predominantly utilized for intra-arterial interventions; however, their application in managing venous injuries, especially traumatic ones, lacks comprehensive guidelines and long-term outcome studies. This case report discusses the innovative deployment of an infrarenal inferior vena cava stent for a traumatic inferior vena cava injury after a gunshot wound in a polytrauma patient. This case aims to enhance the existing evidence on the feasibility and potential outcomes of endovascular stenting in traumatic venous injuries.

Bleeding control of an injury to the infrarenal inferior vena cava and right external iliac vein by ipsilateral internal iliac artery and superficial femoral vein ligation after blunt abdominal trauma in Korea: a case report

Inferior vena cava (IVC) injuries, while accounting for fewer than 0.5% of blunt abdominal trauma cases, are among the most difficult to manage. Despite advancements in prehospital care, transportation, operative techniques, and perioperative management, the mortality rate for IVC injuries has remained at 20% to 66% for several decades. Furthermore, 30% to 50% of patients with IVC injuries succumb during the prehospital phase. A 65-year-old male patient, who had been struck in the back by a 500-kg excavator shovel at a construction site, was transported to a regional trauma center. Injuries to the right side of the infrarenal IVC and the right external iliac vein (EIV) were suspected, along with fractures to the right iliac bone and sacrum. The injury to the right side of the infrarenal IVC wall was repaired, and the right internal iliac artery was ligated. However, persistent bleeding around the right EIV was observed, and we were unable to achieve proximal and distal control of the right EIV. Attempts at prolonged manual compression were unsuccessful. To decrease venous return, we ligated the right superficial femoral vein. This reduced the amount of bleeding, enabling us to secure the surgical field. We ultimately controlled the bleeding, and approximately 5 L of blood products were infused intraoperatively. A second-look operation was performed 2 days later, by which time most of the bleeding sites had ceased. Orthopedic surgeons then took over the operation, performing closed reduction and external fixation. Five days later, the patient underwent definitive fixation and was transferred for rehabilitation on postoperative day 22.

Experience of surgical treatments for abdominal inferior vena cava injuries in a regional trauma center in Korea

Purpose

Inferior vena cava (IVC) injuries are a rare type of traumatic abdominal injuries that are challenging to treat and have a very high mortality rate. This study described our experience with the surgical treatment of traumatic IVC injuries, and we investigated the demographics, clinical profiles, and surgical outcomes of cases at a regional trauma center.

Methods

Among the 16 patients who were treated for a traumatic IVC injury between January 2014 and March 2022, 14 underwent surgery. The surgical outcomes included overall mortality and 24-hour mortality, and we investigated the factors associated with these surgical outcomes. The 14 patients were divided into two groups according to the location of the IVC injury (retrohepatic IVC or higher vs. subhepatic IVC), and differences between the two groups were analyzed.

Results

A body mass index (BMI) >23.0 kg/m2 (P=0.046), an elevated serum lactate level (P=0.043), and a shorter operation time (P=0.016) were associated with overall mortality. A higher BMI (P=0.050), higher serum lactate level (P=0.004), shorter operation time (P=0.005), and an injury at the retrohepatic IVC or higher level (P=0.031) were associated with 24-hour mortality. Younger age (P=0.028), higher BMI (P=0.005), more acidic pH, higher lactatemia (P=0.012), a higher hemoglobin level (P=0.012), and shorter door-to-operating room time (P=0.028) were associated with injury at the retrohepatic IVC or higher level. Patients with subhepatic IVC injuries had a high rate of direct repair (75.0%) and a significantly lower 24-hour mortality rate (37.5%, P=0.031).

Conclusions

Subhepatic IVC injuries are easy to access and are usually expected to treat with a direct repair method. Injuries at the retrohepatic IVC or higher level are difficult to treat surgically and require a systematic and multidisciplinary treatment strategy.

[Reconstruction of caval veins]

OBJECTIVE

To study the possibilities and results of reconstruction of caval veins.

MATERIAL AND METHODS

We analyzed the results of reconstruction of caval veins in 31 patients (19 men and 12 women) including superior vena cava (SVC) in 5 cases and inferior vena cava (IVC) in 26 cases. Penetrating wounds with vascular damage were found in 8 patients. Iatrogenic damage to IVC was observed in 19 patients (nephrectomy for kidney cancer - 2, nephrectomy for secondary kidney wrinkling - 1, echinococcectomy from retroperitoneal space - 1, adrenalectomy for adrenal tumors - 5, right-sided lumbar sympathectomy - 1, resection of abdominal aortic aneurysm - 1, resection of a large retroperitoneal tumor - 6). Iatrogenic damage to SVC occurred in 2 patients during resection of mediastinal tumor. In other 4 cases, elective surgery for mediastinal tumor (1), pancreatic head cancer (2) and liver alveococcosis (1) was accompanied by resection and replacement of caval veins.

RESULTS

All interventions for caval vein injury were performed under adequate infusion therapy. Seven (22.6%) patients died. One patient with blunt chest trauma and damage to SVC died during thoracotomy. In another patient, infrarenal IVC was intersected during mobilization of retroperitoneal hydatid cyst that required ligation for vital indications. High venous hypertension below the ligature led to eruption of sutures on the venous stump. The patient died from hypovolemia after additional IVC ligation. Other 5 patients died in early postoperative period without leaving the state of shock. These patients had damage to retrohepatic segment of IVC (1), vascular-organ (1) and iatrogenic (3) injuries. One patient died from pulmonary embolism, two patients - from venous bleeding between the 2nd and the 5th postoperative days. Patients died before reoperations. Two patients with postoperative bleeding underwent redo surgery with favorable outcomes. One patient underwent redo surgery for peritonitis with a favorable result. Thus, 7 (22.6%) patients with caval vein injury died in intraoperative and early postoperative period. Non-specific complications occurred in 4 (12.9%) patients. These events were corrected by conservative measures. Other 24 (77.4%) patients with traumatic and iatrogenic injuries of caval veins were discharged.

CONCLUSION

Caval vein injury is less common event compared to other vascular damages. Nevertheless, this complication is accompanied by severe blood loss, shock and hypovolemia. We can only assume damage to a great vessel in patients with penetrating wounds before surgery and appropriate symptoms of internal bleeding. However, final diagnosis is made during surgery. Hemostasis is a responsible and difficult surgical stage in these patients. There is usually no alternative to reconstructive surgery in these cases. However, ligation is permissible in extremely ill patients and only in infrarenal segment of IVC. Vascular suture is a more acceptable and effective option for reconstruction. However, patch repair is advisable for large defects. In our opinion, this approach is better regarding long-term patency compared to total replacement with synthetic prostheses.