Reconstruction of a total avulsion of the hepatic veins and the suprahepatic inferior vena cava secondary to blunt thoracoabdominal trauma

Kaemmerer, Daniel; Daffner, Wolfgang; Niwa, Martin; Kuntze, Thomas; Hommann, Merten

doi:10.1007/s00423-010-0652-z

Cited by 10 publications

(10 citation statements)

References 15 publications

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“…Vessel wall damage is a known complication to all arterial and venous endovascular management, and a risk associated with the method. Venous vessels are thinner, more fragile and may more easily be hurt, which must be considered when dealing with venous endovascular catheters 8 32. That incident happened despite guidance by fluoroscopy.…”

Section: Discussionmentioning

confidence: 99%

“…Retrohepatic venous injuries are rare, but carry high mortality rates (30%–80%) 6–10. In the surgical management of life-threatening retrohepatic venous bleeding, total hepatic vascular isolation has traditionally been used, that is, ‘the Heaney Maneuver’ with cross-clamping of the aorta, the infrahepatic and suprahepatic vena cava and ‘the portal triad’ in ligamentum hepatoduodenale 11.…”

Section: Introductionmentioning

confidence: 99%

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

Wikström

Åström

Hurtsén

et al. 2023

Trauma Surg Acute Care Open

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ObjectivesIn fluoroscopy-free settings, alternative safe and quick methods for placing resuscitative endovascular balloon occlusion of the aorta (REBOA) and resuscitative endovascular balloon occlusion of the inferior vena cava (REBOVC) are needed. Ultrasound is being increasingly used to guide the placement of REBOA in the absence of fluoroscopy. Our hypothesis was that ultrasound could be used to adequately visualize the suprahepatic vena cava and guide REBOVC positioning, without significant time-delay, when compared with fluoroscopic guidance, and compared with the corresponding REBOA placement.MethodsNine anesthetized pigs were used to compare ultrasound-guided placement of supraceliac REBOA and suprahepatic REBOVC with corresponding fluoroscopic guidance, in terms of correct placement and speed. Accuracy was controlled by fluoroscopy. Four intervention groups: (1) fluoroscopy REBOA, (2) fluoroscopy REBOVC, (3) ultrasound REBOA and (4) ultrasound REBOVC. The aim was to carry out the four interventions in all animals. Randomization was performed to either fluoroscopic or ultrasound guidance being used first. The time required to position the balloons in the supraceliac aorta or in the suprahepatic inferior vena cava was recorded and compared between the four intervention groups.ResultsUltrasound-guided REBOA and REBOVC placement was completed in eight animals, respectively. All eight had correctly positioned REBOA and REBOVC on fluoroscopic verification. Fluoroscopy-guided REBOA placement was slightly faster (median 14 s, IQR 13–17 s) than ultrasound-guided REBOA (median 22 s, IQR 21–25 s, p=0.024). The corresponding comparisons of the REBOVC groups were not statistically significant, with fluoroscopy-guided REBOVC taking 19 s, median (IQR 11–22 s) and ultrasound-guided REBOVC taking 28 s, median (IQR 20–34 s, p=0.19).ConclusionUltrasound adequately and quickly guide the placement of supraceliac REBOA and suprahepatic REBOVC in a porcine laboratory model, however, safety issues must be considered before use in trauma patients.Level of evidenceProspective, experimental, animal study. Basic science study.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

Wikström

Åström

Hurtsén

et al. 2023

Trauma Surg Acute Care Open

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“…Complete mobilization of the liver by division of the suspensory ligaments will provide some mobility to access the retrohepatic portion of the cava but removes the possibility of tamponade by the organ. Access to the suprahepatic IVC will always require division of the diaphragm for adequate exposure and a sternotomy may be due for proximal control of such injuries ( 53 ). Percutaneous approaches that involve use of compliant endovascular balloons for inflow and outflow occlusion may be sought to address injuries to this portion of the IVC.…”

Section: Truncal Venous Injuriesmentioning

confidence: 99%

“…Open liver total isolation requires sternotomy or a right thoracoabdominal incision plus a Pringle maneuver and is rarely tolerated by the patient while the ultimate step involves supraceliac aortic clamping ( 58 , 59 ). The use of circulatory arrest ( 52 , 53 , 61 ), veno-venous bypass, hypothermia, and liver autotransplantation ( 62 ) require demanding equipment, surgical team experience, and are time consuming, thus only marginally improving outcomes.…”

Section: Truncal Venous Injuriesmentioning

confidence: 99%

Management of Peripheral and Truncal Venous Injuries

Giannakopoulos

Avgerinos

2017

Front. Surg.

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Civilian injuries are increasing according to the World Health Organization, and this is attributed mainly to road traffic accidents and urban interpersonal violence. Vascular injuries are common in these scenarios and are associated with high morbidity and mortality rates. Associated peripheral venous trauma is less likely to lead to death and controversy remains whether ligation or repair should be the primary approach. Conversely, non-compressible truncal venous insult can be lethal due to exsanguination, thus a high index of suspicion is crucial. Operative management is demanding with fair results but recent endovascular adjuncts demonstrate promising results and seem to be the way forward for these serious conditions.

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“…[1][2][3][4] However, once appearing, the mortality rates are high (30-80%). [5][6][7][8][9][10][11] Three major hepatic veins drain into the IVC in the retrohepatic area, where the IVC is partly adherent to the liver and the area is hostile for exploration. Once the liver is mobilized, the contained venous injuries often start bleeding profusely, which may cause life-threatening hemorrhagic shock.…”

mentioning

confidence: 99%

A randomized porcine study of the hemodynamic and metabolic effects of combined endovascular occlusion of the vena cava and the aorta in normovolemia and in hemorrhagic shock

Wikström

Smårs

Karlsson

et al. 2021

J Trauma Acute Care Surg

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BACKGROUND Mortality from traumatic retrohepatic venous injuries is high and methods for temporary circulatory stabilization are needed. We investigated survival and hemodynamic and metabolic effects of resuscitative endovascular balloon occlusion of the aorta (REBOA) and vena cava inferior (REBOVC) in anesthetized pigs. METHODS Twenty-five anesthetized pigs in normovolemia or severe hemorrhagic shock (controlled arterial bleeding in blood bags targeting systolic arterial pressure of 50 mm Hg, corresponding to 40–50% of the blood volume) were randomized to REBOA zone 1 or REBOA+REBOVC zone 1 (n = 6–7/group) for 45 minutes occlusion, followed by 3-hour resuscitation and reperfusion. Hemodynamic and metabolic variables and markers of end-organ damage were measured regularly. RESULTS During occlusion, both the REBOA groups had higher systemic mean arterial pressure (MAP) and cardiac output ( p < 0.05) compared with the two REBOA+REBOVC groups. After 60 minutes reperfusion, there were no statistically significant differences between the two REBOA groups and the two REBOA+REBOVC groups in MAP and cardiac output. The two REBOA+REBOVC groups had higher arterial lactate and potassium concentrations during reperfusion, compared with the two REBOA groups ( p < 0.05). There was no major difference in end-organ damage markers between REBOA and REBOA+REBOVC. Survival after 1-hour reperfusion was 86% and 100%, respectively, in the normovolemic REBOA and REBOA+REBOVC groups, and 67% and 83%, respectively, in the corresponding hemorrhagic shock REBOA and REBOA+REBOVC groups. CONCLUSION Acceptable hemodynamic stability during occlusion and short-term survival can be achieved by REBOA+REBOVC with adequate resuscitation; however, the more severe hemodynamic and metabolic impacts of REBOA+REBOVC compared with REBOA must be considered. LEVEL OF EVIDENCE Prospective, randomized, experimental animal study. Basic science study, therapeutic.

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Reconstruction of a total avulsion of the hepatic veins and the suprahepatic inferior vena cava secondary to blunt thoracoabdominal trauma

Abstract: We treated the patient under internal bypassing of the retrohepatic vena cava by using the heart-lung machine and reconstructed the hepatic veins and suprahepatic vena cava with a conduit made of pericard.

Cited by 10 publications

References 15 publications

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

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

Management of Peripheral and Truncal Venous Injuries

A randomized porcine study of the hemodynamic and metabolic effects of combined endovascular occlusion of the vena cava and the aorta in normovolemia and in hemorrhagic shock

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