Endovascular Balloon Occlusion of the Inferior Vena Cava in Trauma: A Single-Center Case Series

Abstract

Injury to the inferior vena cava (IVC) can produce bleeding that is difficult to control. Endovascular balloon occlusion provides rapid vascular control without extensive dissection and may be useful in large venous injuries, especially in the juxtarenal IVC. We describe the procedural steps, technical considerations, and clinical scenarios for using the Bridge occlusion balloon (Philips) in IVC trauma. We present a single-center case series of 5 patients in which endovascular balloon occlusion of the IVC was used for hemorrhage control. All 5 patients were men (median age 35, range 22 to 42 years). They all sustained penetrating injuries—4 gunshot wounds and 1 stab wound. Median presenting Shock Index was 0.7 (range 0.5 to 1.5). Median initial lactate was 5.4 mmol/L (range 4.6 to 6.9 mmol/L). There were 2 suprarenal IVC injuries, 2 juxtarenal injuries, and 3 infrarenal injuries. Four patients underwent primary repair of their injury, and one underwent IVC ligation. Four patients had intraoperative Resuscitative Endovascular Balloon Occlusion of the Aorta for inflow control and afterload support. The median number of total blood products transfused during the initial operation was 37 units (range 16 to 77 units). Four patients underwent damage control operations, and one patient had a single definitive operation. Four of the 5 patients (80%) survived to discharge with the lone mortality being due to other injuries. Endovascular balloon occlusion serves as a valuable adjunct in the management of IVC injury and demonstrates the potential of hybrid open–endovascular operative techniques in abdominal vascular trauma.

Damage control surgery: old concepts and new indications

“…Originally designed for superior vena cava injuries sustained during pacemaker lead extractions, the Bridge balloon is advanced over a wire with confirmation of the balloon position by direct palpation within the laparotomy exposure. Of the 5 patients in the small series by Howell et al , all survived the index operation with a median total blood product transfusion of 37 units (range 16 to 77 units), consistent with the severe hemorrhage associated with vena cava injuries [75 ▪ ]. All except 1 survived to discharge.…”

A porcine study of ultrasound-guided versus fluoroscopy-guided placement of endovascular balloons in the inferior vena cava (REBOVC) and the aorta (REBOA)

“…Case reports where REBOVC has been used as a bridge to surgery in hemorrhagic shock and patients in extremis have been published 3 4 27. A recent report from Baltimore, presenting the use of REBOVC in five trauma patients, provides support for successful clinical use of REBOVC in the management of vena cava injuries 5. The use of REBOVC as an adjunct to REBOA in vena cava injuries is a new tool, recommended under very special circumstances.…”

“… 3 4 27 A recent report from Baltimore, presenting the use of REBOVC in five trauma patients, provides support for successful clinical use of REBOVC in the management of vena cava injuries. 5 The use of REBOVC as an adjunct to REBOA in vena cava injuries is a new tool, recommended under very special circumstances. REBOVC may be considered a tool for the hybrid management of vena cava injuries, where vascular control is achieved by combining endovascular techniques with definitive open surgical repair.…”

“…Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been shown to be a valid alternative to emergency thoracotomy and open aortic cross-clamping in patients in extremis due to severe hemorrhagic shock 2. Endovascular balloons can stabilize patients in hemorrhagic shock and increase the probability of reaching an operating suite, where definitive surgical management of the injury can be achieved 3–5…”

IVC Injury at Its Origin

“…Resuscitative balloon occlusion of the aorta has been used in patients with caval gunshot wounds to reverse hypotension and there are emerging case reports suggesting that balloon occlusion of the inferior vena cava can be used in concert with Reboa to facilitate caval repair [10]. Massive transfusion protocols (MTP) are necessary in most of these cases as blood loss can be rapid.…”