Atriocaval Shunt Research Articles

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and the International Clinical Trials Registry Platform (ICTRP) will be consulted to detect ongoing or unpublished trials.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.

Successful Treatment of Dual Juxtahepatic Inferior Vena Cava Injuries Using Formal Atriocaval Shunt: A Case Report and Review of the Literature

Repair of penetrating retrohepatic inferior vena cava (IVC) injuries continues to challenge trauma surgeons due to difficulty in accessing the injury, hemorrhage prior to the repair, and associated high mortality rates. Complication by suprahepatic vena cava injuries portends an increased risk of an unfavorable outcome. Over time, overall survival has been relatively unchanged, and the morbidity and mortality associated with these injuries continue to be very high. First proposed by Shrock et al. in 1968, atriocaval shunt placement remains the gold standard approach for the temporary bypass of these lesions by controlling bleeding from the retrohepatic IVC to allow time for repair prior to exsanguination and death. Despite familiarity with this management strategy for decades, these injuries remain infrequent but continue to have poor survival due to their complexity. There are only rare examples of the use of this approach resulting in successful discharge from the hospital. We present a case report of survival after the successful deployment of an atriocaval shunt in a patient who sustained multiple gunshot wounds to his right thoraco-abdomen, left chest, and upper and lower extremities. He ultimately survived to discharge from the hospital. We provide a brief review of the current literature and propose future approaches to repairs of juxtahepatic IVC injuries.

Modeling variability in the inferior vena cava into fenestrated endografts for retrohepatic caval injuries

ObjectiveInjury of the retrohepatic inferior vena cava (IVC) is rare, but extremely fatal. Open repair of these injuries is challenging. Various maneuvers, including atriocaval shunting and total vascular isolation, have been described, but are poorly tolerated in the severely injured patient. Endovascular repair is an attractive alternative strategy, but effective hemostasis of complex injuries requires an endograft that excludes the injury while permitting flow from the hepatic veins. Unfortunately, IVC and hepatic vein anatomy is highly variable and has not been clearly described in injured patients. Our purpose was to characterize critical human IVC morphology in trauma patients, and develop the design parameters of an off-the-shelf fenestrated endograft intended for caval deployment. MethodsOne hundred consecutive adult trauma patients with an admission computed tomography scan including a portal venous phase of the abdomen were reviewed. Specific anatomic measurements including segmental IVC lengths and diameters were obtained. Multiple theoretical endografts were modeled to optimize caval coverage in the retrohepatic segment, assuming 10% to 40% oversizing for seal. ResultsThis sample population had a mean age of 50 years, height of 173 cm, and weight 84 kg. Seventy-one percent were male and 89% had a blunt mechanism of injury. The median caval length from the renal veins to right atrium was 111 mm (interquartile range [IQR], 102-120 mm), diameter was 22 mm (IQR, 19-26 mm), and hepatic venous orifice area was 336 mm2 (IQR, 267-432 mm2). All patients had a landing zone of at least 12 mm in the suprahepatic and 10 mm in the suprarenal segments. Three models of graft length were developed to accommodate patients with segmental and overall dimensions in the smallest half, third quartile, and fourth quartile. These could provide 95% of patients with coverage of the retrohepatic segment without risk of hepatic or renal vein occlusion. Four graft diameters were developed for cross-sectional fit. Graft diameters of 20, 24, 30, and 38 mm could provide adequate coverage in, respectively, 11%, 35%, 49%, and 16% of patients. These combinations of graft length and diameter would accommodate 93% of patients. ConclusionsWe defined human IVC morphology essential for endovascular therapy and developed parameters for fenestrated IVC endografts to address retrohepatic caval injuries in trauma patients. Although additional study and testing are required, this proof-of-concept study supports the hypothesis that exclusion of the most devastating retrohepatic IVC injuries can be achieved with a reasonable number of off-the-shelf fenestrated endografts. These findings form the basis for additional research toward the development of novel devices for endovascular therapy of these often lethal injuries.

Retrohepatic vena cava lesion: which we cannot forget?

Vascular lesions are the leading cause of death after abdominal trauma. Among them, the inferior vena cava (IVC) lesion, especially its retrohepatic portion, is one of the most severe, rare, and complicated treatment. The difficult access and delicate anatomical relationships do not favor hemostasis. The etiology of the lesion is variable, resulting from penetrating trauma (transection and/or laceration), blunt or, more rarely, iatrogenic causes. After the initial approach of the polytraumatized patient, the identification of vascular damage must be early, so that surgical treatment of those patients presenting severe hypovolemic shock can be successful. Therapeutic options include tamponade of the lesion through adequate hepatic packaging, digital compression, or repair of the lesions after exposure of the retrohepatic area. In injuries that have not been controlled with tamponade, the total hepatic vascular exclusion is the treatment of choice. In extreme cases, the atriocaval shunt can be performed; however, compared with the vascular isolation technique, the latter showed a better survival rate. Besides, conservative treatment in selected cases of traumatic lesions of retrograde hepatic IVC is feasible and a priority because of the high mortality intrinsic to the surgical procedure. In this sense, the present review reinforces the need for continuous clinical and surgical improvement to obtain outcomes with a better prognosis, especially in retrohepatic vena cava lesions.

Comparison of atriocaval shunting with perihepatic packing versus perihepatic packing alone for retrohepatic vena cava injuries in a swine model

BackgroundRetrohepatic vena cava (RVC) injuries are technically challenging and often lethal. Atriocaval shunting has been promoted as a modality to control haemorrhage from these injuries, but evidence from controlled studies supporting its benefit is lacking. We hypothesised that addition of an atriocaval shunt to perihepatic packing would improve outcomes in our penetrating RVC injury swine model. MethodsAfter a survivable atriocaval shunting model was refined in 4 swine without an injury, 13 additional female Yorkshire swine were randomised into either perihepatic packing and atriocaval shunt (PPAS, n=7) or perihepatic packing alone (PP, n=6) treatment arms prior to creating a standardised, 1.5cm stab wound to the RVC. Haemodynamic parameters, intravenous fluid, and blood loss were recorded until mortality or euthanisation after 4h. Statistical tests used to test differences include the Wilcoxon rank sums test, Fisher exact test and analysis of covariance. A p-value ≤0.05 was considered statistically significant. ResultsImmediately before and after RVC injury, no difference in temperature, cardiac output, heart rate, mean arterial pressure or mean pulmonary artery pressure was detected (all p>0.05) between the two groups. While the RVC injury did affect measures parameters in PPAS swine over time, haemodynamic compromise and blood loss were not significantly greater in PPAS than PP swine. Survival time was significantly different with all PPAS swine dying within 2h (mean survival duration 39 (SD 58)min) while all 6 PP swine survived the entire 4h study period. ConclusionsWhile perihepatic packing alone slowed haemorrhage to survivable rates during the 4h study period, atriocaval shunt placement led to rapid physiologic decline and death in our standardised, penetrating RVC model.

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Introduction: Retrohepatic vena cava (RVC) injuries are among the most lethal of injuries, often leading to exsanguination while vena cava repair is attempted. One well known yet seldom studied method of controlling RVC hemorrhage is the atriocaval shunt. Methods: Four female Yorkshire swine (30-40kg) were anesthetized, intubated, and underwent placement of femoral and pulmonary arterial catheters for continuous hemodynamic monitoring. After laparotomy and sternotomy, swine were shunted with 28Fr thoracostomy tubes. Shunts were secured in place with a right atrial appendage purse string suture and umbilical tape around the infracardiac and infrahepatic IVC. Swine were actively resuscitated with IV fluids while hemodynamic parameters, resuscitation volumes, and blood loss were measured for up to 4 hours before animals were euthanized. Results: Prior to shunting, the mean heart rate (HR), mean arterial pressure (MAP), and cardiac output (CO) were 102 ± 9 bpm, 65 ± 7 mmHg, and 4 ± 1 L/min, respectively. Immediately following shunt placement (n=4; mean EBL, 889 ± 208cc), shock became physiologically evident in measured parameters: HR 122 ± 34 bpm, MAP 36 ± 10 mmHg, and CO 3 ± 1 L/min. Two swine died after 11 and 14 minutes (IVF, 1800 ± 707cc; EBL, 912 ± 52cc) and two survived 2 hours after shunting (IVF, 3400 ± 1697cc; EBL, 865 ± 354cc). When compared to pre-shunt values, animals surviving 2 hours after shunting had decreased mean arterial pressures (65.3 ± 6.5 vs. 36.5 ± 7.8 mmHg; p=0.008) and decreased cardiac output (4.0 ± 1.1 vs. 1.6 ± 1 L/min; p=0.04). One of 4 (25%) swine survived the entire 4 hour study period following shunt placement (IVF, 4600cc; EBL, 1115cc) and was euthanized Conclusions: Despite normal pre-shunt hemodynamic parameters and the absence of a RVC injury, only one swine survived 4 hours after atriocaval shunting. While further study is warranted, our results highlight the profound physiologic compromise caused by the atriocaval shunting procedure itself

Management of liver trauma in adults.

The liver is one of the most commonly injured organs in abdominal trauma. Recent advancements in imaging studies and enhanced critical care monitoring strategies have shifted the paradigm for the management of liver injuries. Nonoperative management of both low- and high-grade injuries can be successful in hemodynamically stable patients. Direct suture ligation of bleeding parenchymal vessels, total vascular isolation with repair of venous injuries, and the advent of damage control surgery have all improved outcomes in the hemodynamically unstable patient population. Anatomical resection of the liver and use of atriocaval shunt are rarely indicated.

Management of Liver Trauma

Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems. A literature review was undertaken to determine the current consensus on investigation and management strategies. The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing. Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.

Uso de balão intra-hepático para controle temporário da hemorragia em lesão da veia cava retro-hepática

Juxtahepatic veins, retrohepatic vena cava or major hepatic veins injuries carry a very high mortality rate regardless the technique used for its repair. Isolated survivor reports have for the most part been managed by vascular isolation techniques, usually with atriocaval shunt. We report one case with a unique management technique in a patient who sustained gunshot wound to the retrohepatic vena cava. Hemorrhage control had been obtained by intrahepatic balloon tamponade after others maneuvers have failed. The balloon was left in situ for two days as damaged control laparotomy principles and planned reoperation has been chosen.

TS03 RETROHEPATIC VENA CAVA INJURY REMAINS A CHALLENGE TO TRAUMA SURGEONS

Although uncommon, and despite the modern in diagnostic tools and therapeutic alternatives, retrohepatic and main hepatic veins injury remains associated with high mortality rate. Preoperative diagnosis is uncommon, and bullet trajectory may be a helpful sign in penetrating trauma patients.Patients and Methods Hospital records of patients sustaining retroheptic vena cava (RHVC) injury were retrospectively reviewed as to diagnosis, associated injuries, injury characteristics, surgical management, and outcome, last ten years.Results Eight male, 17 to 45 (mean 27.5) years‐old patients sustaining RHVC injury were reviewed. Mean trauma indexes for the 8 cases were: ISS 36.6, RTS 7.55 and TRISS 89.0; and for the group who died: ISS 41.6, RTS 7.18, and TRISS 80.5. Two patients had sustained blunt trauma (one died), and six had penetrating injuries (two died). The injury diagnosis was achieved during surgery in all cases. A transfixing RHV injury occurred in 4 (50% of the) patients, and was found in all the 3 patients who died. An atriocaval shunt was employed in four patients, 3 of them had with transfixing injury with two deaths. The number of associated injuries was higher in the patients who died. Overall mortality rate was 37.5%.Comments Despite advances in image diagnosis, injuries to RHVC are frequently diagnosed during surgery. Tangential injuries were managed with direct approach and sutures, and to control blending in transfixing injuries, were managed with atriocaval shunts, before suture.Conclusion Despite improvements in its diagnosis and management, RHVC injuries remain with a high mortality rate, mainly when transfixing, and associated with numerous associated injuries.

Exclusão vascular do fígado em lesões venosas hepáticas complexas

Injuries to the main hepatic veins carry a very high mortality rate, regardless of the technique used for repair. Isolated reports of survivors have, for the most part, been managed by hepatic vascular exclusion (EVE) techniques, usually with an atriocaval shunt. Herein we report a case of a severe intrahepatic major hepatic vein injury successfully managed with EVE.

Use of a Refined Operative Strategy in Combination with the Multidisciplinary Approach to Manage Blunt Juxtahepatic Venous Injuries

Despite continuous advances in traumatology, juxtahepatic venous injuries are still the most difficult and deadly form of liver trauma. Most deaths result from exsanguination, and reported mortality ranges from 50% to 80%. This is an evaluation on our experience with the management of this high mortality injury following a refined operative strategy. This is a retrospective study of consecutive patients sustaining blunt juxtahepatic venous injuries. The management for these patients was mainly a refined operative strategy combined with a multidisciplinary approach. Preoperative conditions and the patient demographics were gathered. In addition, the number and type of interventional procedures, overall complications, and operative procedures were collected and analyzed. From January, 1996 to March, 2004, 19 patients (M:F = 13:6) with juxtahepatic venous injuries were included and all were managed operatively. The operative procedures included hepatectomy by finger fracture technique for direct repair (8), perihepatic packing (1), packing and hepatic artery embolization (1), packing and hepatic artery ligation (1), hepatorrhaphy and packing (5), packing followed by hepatectomy (2) and atriocaval shunt for direct repair (1). The survival rate for the packing group was higher than that of the direct repair group (75% versus 45%), but was not statistically significant (p = 0.352). Injury to the retrohepatic vena cava influenced the patient's survival significantly (p = 0.041). The overall survival was 58% (11/19). A well-defined operative strategy helps surgeons deal with the problem of blunt juxtahepatic venous injury, and its combination with multidisciplinary management will improve patient outcomes.

Shunt atricova A propósito de dos casos: Report of two cases

The mortality of grade V and VI liver trauma fluctuates between 30% and 70%. The atriocaval shunt, described by Shrock et al, in 1968, is a therapeutic option that, after being installed, allows to repair the suprahepatic veins and retrohepatic cava in a bloodless surgical field. Its use requires an experienced and skilled surgeon to obtain survival rates similar to those obtained with other methods. We report two male patients of 17 and 18 years old treated successfully with this technique after suffering a blunt and a penetrating liver trauma by a shotgun, respectively.

Retrohepatic Vena Cava and Juxtahepatic Venous Injuries

The daunting mortality encountered with retrohepatic vena cava and juxtahepatic venous trauma is testimony to the difficulties inherent in their management. For a successful outcome, the operating surgeon must be able to rapidly identify the nature of the injury and tailor the choice of procedure accordingly. Atriocaval shunting, balloon shunting, sequential vascular clamping, and perihepatic packing are all methods of treatment with which the surgeon must be familiar. In this review, we present a case of this injury caused by a gunshot wound. This serves as a useful starting point for a discussion of the techniques available for addressing this injury.

Repair of lacerated inferior vena cava with the intravascular tube graft in redo cardiac surgery

Laceration of the proximal inferior vena cava (IVC) is a rare but fatal complication of redo cardiac surgery if it is situated at the posterior supradiaphragmatic, juxtadiaphragmatic, or retrohepatic region of the IVC. Redo valve and congenital cardiac operations, which are performed by the transatrial approach, may carry the risk of IVC laceration. Laceration of the IVC, mostly at its posterior wall, may occur during application of a snare or Cooley clamp or from stretching of the incompletely liberated adherent IVC during traction on the atrium for valve exposure. The laceration may extend for a variable distance down the IVC. Not infrequently, this complication may also be encountered in other cardiovascular interventions (ie, IVC filter implantation, thrombectomy), some upper abdominal operations (ie, IVC fistula repair, thoracoabdominal aneurysm surgery, hepatic surgery), and in blunt or penetrating chest traumas. Different methods have been proposed to repair this complication, such as atriocaval shunt, lateral phleborrhaphy, patch plasty, total vascular occlusion, tube graft or duplicated saphenous interposition, and diaphragmatic or pericardial flap repair. However, the inaccessible location of some lacerations and the high mortality are still a problem. 1-5 We are presenting a case of an IVC laceration at an inaccessible location treated by means of a novel approach. Clinical summary. A 53-year-old woman who had a closed mitral commissurotomy operation 22 years earlier because of rheumatic valve disease was admitted to our hospital for mitral restenosis and insufficiency and 3+ tricuspid regurgitation. The operation was conducted as usual with aorta-bicaval cannulation, intermittent cold cardioplegia, and moderate hypothermia (28°C). Abundant bleeding appeared around the IVC after the cannulas were drawn back into the right atrium. External interventions to stop the bleeding proved futile and total circulatory arrest had to be established. Tactile exploration from the right atrium revealed a long laceration extending down the IVC for an indeterminate distance in the

Factors determining operative mortality of grade V blunt hepatic trauma.

Despite recent advances in the management of severe hepatic injuries, the operative mortality rate of grade V hepatic injuries still ranges from 67% to 80%. Grade V hepatic injuries involving the retrohepatic cava or main hepatic veins are almost always lethal, especially those from blunt trauma. The purpose of this study is to understand the risk factors determining operative mortality in grade V blunt hepatic trauma, and to try to improve the surgical management of these injuries. A retrospective study was conducted at a medical center that offers services including primary, secondary, and tertiary care. Forty-four patients with grade V blunt hepatic injuries were treated during a 6-year period from January 1, 1991, to December 31, 1996. The operative mortality was compared by a multivariate analysis. Forty-four patients with grade V blunt hepatic injuries were identified. Seven patients had only parenchymal injuries, and the others had vascular and associated parenchymal injuries. Venorrhaphy was used in 37 patients; 29 were treated using a nonshunting approach, and 8 with an atriocaval shunt. The overall mortality rate was 68% (30 of 44), and liver-related mortality was 50% (22 of 44). Univariate analysis revealed that the significant variables affecting operative mortality were initial systolic blood pressure, initial base deficit, the Glasgow Coma Scale, injury type, number of resected segments, and total intraoperative blood loss. Based on forward stepping logistic regression analysis, patients with an initial base deficit of -6 mmol/L or less (relative risk = 17.3), and a total intraoperative blood loss of 5,000 mL or more (relative risk = 23.5) would, significantly, encounter a worsening prognosis. Initial base deficit and total intraoperative blood loss were the significant factors that determined operative mortality after grade V blunt hepatic trauma. We suggest that prompt resuscitation and expeditious and appropriate surgical management, to control operative blood loss, is the only way to reduce operative mortality in patients with grade V blunt hepatic trauma.

Deep Venous Thrombosis in the Pediatric Trauma Population: An Unusual Event: Report of Three Cases

The incidence of deep venous thrombosis (DVT) in the pediatric population has been reported to be lower than in adults. Pediatric trauma patients have predisposing risk factors for DVT similar to those in the general trauma population. We reviewed the records of 2746 children under 16 years of age admitted to our Level I pediatric trauma service from 1989 to 1997. Only three cases of DVT were documented, all adolescents. DVT was located in the upper (n = 1) and lower (n = 1) extremity venous system. One patient presented with pulmonary embolism alone without identifiable DVT. Risk factors found were venous system manipulations, including atriocaval shunt, subclavian central line, and hyperinflated medical antishock trousers garment. Therapy consisted of heparin followed by warfarin anticoagulation. A vena cava filter was inserted in one patient for whom systemic anticoagulation was contraindicated. No DVT was seen in 1123 closed head injury patients or 29 spinal cord injury patients without associated risk factors. The thrombotic risk in pediatric trauma patients is low. Routine screening or prophylaxis is not indicated except for patients who are likely to remain immobile for an extended period of time and require prolonged rehabilitation, have venous manipulations, or present with clinical symptoms. Hematologic evaluation in patients with diagnosed DVT is necessary to identify individual risk factors.

Venovenous Bypass for Major Hepatic and Caval Trauma

Severe trauma to the liver and juxtahepatic cava require vascular isolation of the lesion. In addition to the techniques of vascular clamping and atriocaval shunting, venovenous bypass is a viable alternative to repair such injuries. We herein report its use in five consecutive patients. The technique obviates the hemodynamic sequelae of uncompensated caval occlusion and the technical dangers of atriocaval shunting.

Surgical management of juxtahepatic venous injuries in blunt hepatic trauma.

The purpose of this analysis was to understand better the problems faced in the management of blunt juxtahepatic venous injuries and to try and simplify the controversies regarding the optimal surgical approach to these injuries. Charts of 92 blunt liver trauma patients treated between July 1, 1991 to June 30, 1993 were reviewed. Nineteen patients with blunt juxtahepatic venous injuries were identified. The isolated left hepatic vein injury group (five patients) were all treated using a nonshunting approach with no mortalities. Half of the isolated right hepatic vein injury group (ten patients) received an atriocaval shunt, and the other half did not. These two different approaches each produced one survivor, with a combined mortality rate of 80% (eight of ten patients). One of the combined injuries group (four patients) received a total hepatectomy followed by liver transplantation. Another received a shunt. The other two were treated without shunting, but all of them expired. The overall mortality rate was 63.2% (12 of 19 patients), with nine patients dying intraoperatively or immediately postoperatively from exsanguination. The other three died 10, 25, and 30 days postoperatively because of sepsis. Juxtahepatic venous injury should be suspected after failure of the Pringle maneuver to stop bleeding and the different venous injuries differentiated by palpation of the adjacent hepatic parenchymal injuries. If an isolated left hepatic vein injury is found and the liver parenchymal injury is limited to segments II, III, or IV, then a nonshunting approach will achieve the optimal outcome.

Deep Hypothermic Circulatory Arrest for Blunt Retrohepatic Venous Injury

A case of major blunt hepatic injury requiring liver resection is described. An associated retrohepatic vena cava injury could not be repaired despite the use of an atriocaval shunt. Deep hypothermic circulatory arrest was used as a last resort.