Venous Chimney Procedure: A Novel Technical Solution to Prevent Iatrogenic Budd– Chiari Syndrome Following Retrohepatic Vena Cava Injury

Abstract

Traumatic inferior vena cava (IVC) lesions account for approximately 25% of abdominal vascular injuries and are among the most challenging and lethal lesions sustained by trauma patients. Whether caused by blunt or penetrating mechanisms of injury, the overall mortality rate is up to 92%; as many as 50% of the patients with those injuries die before reaching medical care, and the mortality rate among patients who arrive to a trauma center, with signs of life and/or receive operative treatment, ranges between 20% and 57% (1).
 Retrohepatic Vena Cava (RHVC) injuries (RHVCI) are extremely rare and as such both the treating trauma surgeon, as well as the vascular surgeon, lacks the necessary experience to deal with such complicated injuries. The mortality rates secondary to these injuries are extremely high, even with damage control management concepts application. Improving the outcome of these injuries remains a significant challenge of modern trauma care (2, 3).
 The treatment of RHVCI confronts the treating surgeon, with major obstacles, which raises from the anatomic location of the RHVC at the posterior aspect of the liver and the abundancy of bridging veins between the RHVC and the liver. These anatomic obstacles creates a major technical challenge of gaining proximal and distal control, in proximity to the injured RHVC. This many times necessitates abdominal as well as thoracic exposure in order to gain proper control.
 The average trauma, as well as the vascular, surgeons are not familiar with handling such complex injuries. This is even truer as referred to the new generation of vascular surgeons, whose experience with open vascular surgery, mainly in such extreme situations, decreases with the increasing usage of endovascular techniques (4). 
 The advancements in endovascular techniques have introduced new alternatives to traditional open repair strategies. In many cases, RHVCI treatment requires exploration of a retro-hepatic hematoma, which might be the single thing that prevents free venous rupture and as such, it should be avoided. Venous balloon occlusion is a novel endovascular strategy that may be particularly advantageous in those circumstances as a bridging maneuver, for proximal and distal control, during hybrid repair. Our case in unique since it highlights the option of total endovascular treatment, using arterial treatment concepts, to treat this extremely challenging injury.