|Year : 2021 | Volume
| Issue : 2 | Page : 169-172
Suprarenal inferior vena cava ligation: All is not lost
Vignesh Kumar1, Vijayan Purushothaman1, Dinesh Bagaria1, Harshit Agarwal2
1 Department of Surgical Disciplines, Division of Trauma Surgery and Critical Care, AIIMS, New Delhi, India
2 Department of Trauma Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
|Date of Submission||28-May-2020|
|Date of Acceptance||06-Jun-2020|
|Date of Web Publication||13-Apr-2021|
Department of Trauma Surgery, King George's Medical University, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Inferior vena cava (IVC) injuries account for about 25%–40% of abdominal vascular injuries. Blunt vena cava injury has a lower survival rate than penetrating injury. They may present with torrential bleed. In extreme cases, ligation of the IVC may have to be done as a damage control procedure. However, it is associated with significant morbidity and mortality, especially when the suprarenal IVC is ligated. It can lead to acute kidney injury and lower limb compartment syndrome. Suprarenal IVC ligation has been done in oncological resections, as it is a chronic disease that allows collateral vessel formation. However, there is a paucity of data on the ligation of the suprarenal IVC in acute trauma. We present a case of penetrating injury to the IVC which was managed initially by suprarenal IVC ligation, followed by synthetic interposition graft placement once the patient stabilized hemodynamically. The case highlights that this approach can be viable as a damage control procedure in exsanguinating patients.
Keywords: Inferior vena cava, ligation, polytetrafluoroethylene
|How to cite this article:|
Kumar V, Purushothaman V, Bagaria D, Agarwal H. Suprarenal inferior vena cava ligation: All is not lost. Indian J Vasc Endovasc Surg 2021;8:169-72
| Introduction|| |
Inferior vena cava (IVC) injuries constitute about 25%–40% of abdominal vascular injuries and remain a challenge to the surgical fraternity. With advances in the management of trauma, repair of venous injury is now recommended to reduce the complication rate and improve survival. Several techniques have been described to deal with IVC injuries, including, primary repair (lateral venorraphy), vein patch repair, synthetic graft repair, and balloon catheter occlusion. However, often patients may be in extremis due to these injuries and the surgeon may have to resort to ligation of the vessel. Ligation is usually the last desperate attempt to achieve hemorrhage control and is an acceptable modality for the infrarenal IVC. However, ligation is not recommended for the suprarenal IVC owing to the high risk of acute kidney injury and congestion of bilateral lower limbs. Further, this modality of treatment has not been widely studied in the suprarenal IVC, as the injury itself is associated with massive blood loss and the mortality rate remains high. Hence, there remains a paucity of studies on outcomes of the ligation of the suprarenal IVC with very few cases reported in the literature. The outcome of IVC injury also depends on the hemodynamic status on presentation, mechanism of trauma, and the extent of associated injuries. We report a case of suprarenal IVC ligation following trauma, the challenges we faced, and a brief review of the literature.
| Case Report|| |
A 60-year-old gentleman sustained a gunshot injury to the back. He was initially taken to a primary health-care facility where the initial evaluation was performed. He was referred to our facility 10 h after injury. On arrival at our hospital, the patient was hemodynamically stable and abdominal examination was grossly normal. An entry wound in the posterior abdominal wall, 6 cm lateral to the midline on the right side at the level of L1 vertebrae, was noted. There was no exit wound. A focused assessment with sonography for trauma examination was positive for fluid in all the abdominal windows. Contrast-enhanced computed tomography (CECT) showed multiple metallic foreign bodies in and around the IVC and paraduodenal areas [Figure 1] with fracture of the L1 lamina and also Grade III liver injury involving segment III with moderate hemoperitoneum. There was no pneumoperitoneum or evidence of any bowel injury. However, it was a high-velocity penetrating injury to the back with hemoperitoneum. Hence, we could not rule out any bowel injury, especially of retroperitoneal organs, convincingly on CECT of the abdomen. Further, there were multiple foreign bodies in and around the IVC which could have led to IVC injury. Hence, a decision for exploratory laparotomy was made.
|Figure 1: Coronal and axial images of contrast-enhanced computed tomography showing hyperdense shadows within and around the inferior vena cava, which during exploration were found to be fragments of bone from the L1 lamina fracture|
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On surgical exploration, about 2 L of hemoperitoneum was noted. A metallic foreign body was removed from the hepatorenal fossa. There was no active bleed from the liver. While exploring the retroperitoneum to rule duodenal and colonic injury, the clot within the IVC got dislodged, resulting in massive hemorrhage. Attempts at proximal and distal control were made; however, complete hemostasis could not be achieved. A through and through tear in the suprarenal part of the IVC was noted 4 cm above the junction of the left renal vein. Multiple bony fragments could be perceived within the IVC and were removed.
Attempts at repair were made but could not be achieved. Due to overwhelming blood loss and unstable hemodynamics of the patient, the suprarenal IVC was ligated above and below the injury. The bowel and portal triad were normal. The abdomen could not be closed primarily, and a temporary abdominal closure with mesh was done. The patient was transferred to the intensive care unit (ICU) for further resuscitation.
Over the next 24 h, he improved hemodynamically and received 80 units of blood products (18 packed red cells, 20 fresh frozen plasma, 18 plasma rich platelets, and 24 cryoprecipitate units). However, his renal function deteriorated and he developed signs of compartment syndrome in both the lower limbs. A decision was made to revascularize the IVC by placing a prosthetic graft so as to allow venous drainage from lower limbs and kidneys. On re-exploration, the ligated part of the IVC was skeletonized and a part of the wall of the IVC was found to be contused [Figure 2]. Proximal and distal control of the IVC was achieved. A massive thrombus in the IVC, extending to both the renal veins, iliac veins, and lower limb veins was removed [[Figure 3] and Video 1]. Good backflow was noted from the IVC and left renal vein. Subsequently, an end-to-end polytetrafluoroethylene (PTFE) graft of the injured IVC segment [Figure 4] and two-incision four-compartment fasciotomy of both the legs were done. Post surgery, he was shifted back to the ICU for resuscitation and supportive management.
|Figure 2: Inferior vena cava exposed (postligature status) – The suprarenal part of the inferior vena cava and left renal vein junction are seen, along with contused wall of the inferior vena cava at the junction. The contused part has been excised, and one can visualize the clot within the inferior vena cava|
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|Figure 4: Postpolytetrafluoroethylene graft between the proximal and distal part of the inferior vena cava|
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He recovered well in the ICU, his renal function improved with serum creatinine levels falling from presurgery levels of 4 mg/dl to 1.4 mg/dl over the next 48 h, and edema of the limbs reduced. A venous Doppler done 3 days and 7 days postoperatively did not reveal any thrombus in the renal or lower limb veins. However, in the ICU, he developed ventilator-associated pneumonia leading to acute respiratory distress syndrome. We re-explored the abdomen on day 10th for any source of sepsis as he was hemodynamically unstable. However, no pus or any collection or any bowel compromise was noted. His stay was further complicated by septic shock and subsequently multi-organ dysfunction syndrome. He eventually died on the 14th postoperative day.
| Discussion|| |
The management of IVC injuries remains challenging. The three most important factors predicting outcome in IVC injury are (a) hemodynamic status of a patient, (b) mechanism of IVC injury, and (c) location of injury. Hemodynamic instability and requirement of massive blood transfusion are the most important factors with mortality varying between 27% and 93% in patients who received less than or more than 20 units of blood, respectively.,,
If the patient is hemodynamically stable, IVC injuries usually present as a hematoma behind the ascending colon and around the C-loop of the duodenum. This is a unique situation in trauma when one deliberately changes a controlled environment into an uncontrollable disaster, something we were the firsthand experience in our patients. The bleed is tamponaded by the retroperitoneum and unroofing the same results in uncontrollable bleeding. However, such injuries require surgical intervention and exposure remains the key in such cases. A right-sided medial visceral rotation (Cattell–Braasch maneuver) is performed to expose the IVC and aorta. It is important to let the anesthesiologist know what you are dealing with at hand and to expect significant blood loss and rapid alteration in blood pressure due to compression of the IVC which reduces the preload significantly. Aortic compression may be used as a hemodynamic adjunct to maintain supply to the heart and brain. A primary repair after achieving proximal and distal control should be done. If there is a segmental loss, a synthetic graft may be placed.
Ligation of the IVC should only be done under extreme circumstances, and one must be doubly certain that ligating the suprarenal IVC is the only option left to save the patient. Ligation of the suprarenal IVC has been done in oncological resections as the chronicity of disease allows collateralization of vessels, while in acute trauma state, the surgeon is not in such a beneficial situation. There is enough evidence to suggest that ligation of the IVC is associated with a higher mortality rate as compared to repair. Sullivan et al. quoted that ligation of the infrarenal IVC is associated with 59% mortality as compared to 21% in patients who underwent repair. They also reported a mortality of 67% in suprarenal IVC ligation. On the contrary, repair of IVC is easier said then done with IVC ligation being reported as the preferred method (40-63%) to tackle such injuries. Ligation of the suprarenal IVC has been deemed an inherently fatal event. However, there have been few case reports suggesting that suprarenal IVC ligation is not routinely fatal. In our case, we ligated the suprarenal IVC as a damage control measure, and the patient was planned for re-exploration and synthetic PTFE graft between proximal and distal ends of the IVC, a day later, once his physiology was at a more tolerable state. This serves as a viable option to reverse the adverse effects that may occur following suprarenal IVC ligation, namely renal insufficiency, venous stasis associated with lower extremity edema, and compartment syndrome. Such delayed reconstructions have been tried in other veins such as superior mesenteric vein where it has been done to reduce bowel edema. However, from the literature we reviewed, we believe that this is the first case of IVC recanalization following ligation reported till date. Although concerns regarding the possibility of pulmonary embolus during recanalization of the IVC exist, this is purely theoretical. From our experience, the pressure that is built within the venous system, post ligation, is extremely high, and the formed thrombus can be removed in toto, as evident in the image above.
From the reviewed literature, we found nine patients who underwent suprarenal IVC ligation.,,,,, Of the nine patients, five patients survived to discharge, two of them had early mortality, and one patient recovered from renal insufficiency but developed several complications and eventually died of sepsis and multi-organ failure. In a case series by Navsaria et al., there was no information regarding the survival of the patient who underwent suprarenal IVC ligation. In our case, the patient developed acute renal failure in early stages which recovered after PTFE graft but later occurred again when he landed in sepsis. Although the above facts represent suprarenal IVC ligation as a viable option with enhanced survivability, one has to keep in mind that there are patients who died after ligation of the suprarenal IVC and who are not reported in the literature. Theoretically, patients who survive after suprarenal IVC ligation with or without renal failure do so because of adequate-sized collaterals between the perirenal IVC, the ascending lumbar veins, and the azygos–hemiazygos system.
To conclude, ligation of the suprarenal IVC may be done as a last treatment option, if necessary, although few survivors exist. With regard to lower limb edema and compartment syndrome, the patients can be managed expectantly with serial measurements of compartment pressure and low threshold for early four-compartment fasciotomy release. Relook surgery and establishing continuity of the IVC, post ligation, is a viable and novel option and can be considered in such patients to mitigate the complications associated with suprarenal IVC ligation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]