Management of penetrating juxtahepatic inferior vena cava injuries under total vascular occlusion.
Academic Article
Overview
abstract
BACKGROUND: Juxtahepatic inferior vena cava injuries are often lethal. Various operative strategies have been used to improve outcome, but the mortality rate reported in the literature is 80 percent or more. The atriocaval shunt has been advocated for isolation of bleeding retrohepatic vena cava, but recent reports suggest that mortality might be even higher in patients selected for shunting, perhaps owing to ongoing hemorrhage because of indecision and delay prior to insertion, or to technical difficulty with insertion. A series of patients with juxtahepatic inferior vena cava injuries treated successfully with total vascular isolation and occlusion were studied. STUDY DESIGN: Consecutive series of 10 patients with penetrating injuries to the juxtahepatic inferior vena cava were treated at an urban, university-affiliated Level I trauma center. A rapid and direct approach was used along with isolation techniques similar to those used in liver transplantation and elective resection for neoplasm. As resuscitation continued, repair of the inferior vena cava was accomplished in a bloodless field, created by manual compression of the liver, wide exposure, portal inflow occlusion, and proximal and distal control of the inferior vena cava. Aggressive fluid resuscitation and transient aortic cross-clamping controlled resulting systemic hypotension. RESULTS: Mean injury severity score was 26 and mean penetrating abdominal trauma index score was 28. After exposure, three patients had tangential injuries controlled by undersewing a partially occluding clamp. Subdiaphragmatic aortic cross-clamping was performed if total occlusion of the inferior vena cava reduced systolic blood pressure to 60 mm Hg, which was necessary in the remaining seven patients. Nine patients survived surgery, and seven of nine survived to hospital discharge. One postoperative death was a result of multiple organ dysfunction syndrome, and the other of necrotizing bacterial pneumonia. CONCLUSIONS: Total vascular occlusion with selective use of aortic cross-clamping yielded 70 percent survival in an injury that historically has been associated with survival of 20 percent or less. Minimization of visceral ischemia is accomplished by occluding the aorta only after complete isolation of the inferior vena cava.
