C Özbek, U Yetkin, T Gökto?an, H Ya?a, G ?lhan, S Bayrak, N Karahan, A Gürbüz
abdominal multisystem organ injuries, infrarenal ivc injuries, lateral venorrhaphy, oral anticoagulant
C Özbek, U Yetkin, T Gökto?an, H Ya?a, G ?lhan, S Bayrak, N Karahan, A Gürbüz. Experience Wıth Infrarenal Vena Cava Injuries. The Internet Journal of Thoracic and Cardiovascular Surgery. 2006 Volume 11 Number 1.
Aim: Regardless of whether the etiological factor is blunt or penetrating trauma in infrarenal inferior vena cava (IVC) injuries, the diagnosis is generally made during surgical exploration. Abdominal multisystem organ injuries almost always accompany the trauma.
Material And Method: We determined infrarenal IVC injury in 16 patients who were admitted to our hospital's emergency service in shock and underwent emergent explorative laparotomy due to acute abdomen between January 2000 and December 2005. We joined the operation team as the group of surgeons that made the first operative intervention requested peroperational consultation for retroperitoneal hematoma. Nine patients had stab (56.25%), 5 had blunt (31.25%) and 2 had gunshot (12.5%) injuries. In all patients, lateral venorrhaphy method was used for primary repair. Intraabdominal organ injuries were treated by the general surgery team.
Results: In our series, only one patient died in the early postoperative period. Intravenous heparin was administered until peroral feeding and heparin plus oral anticoagulants were administered for the next three days after peroral feeding was started. Following the administration of heparin and oral anticoagulants for three days, the patient received solely anticoagulants for 3 months. Color Doppler ultrasonographic examination was performed before and 3 months after the discharge and it was observed that IVCs were patent and no stenotic complications were present.
Conclusion: We believe that; organized evaluation, examination, exposition and if possible, primary repair with lateral venorrhaphy are the most important surgical steps for a successful outcome in the treatment of infrarenal IVC injuries diagnosed during surgical exploration with retroperitoneal hematoma symptoms.
Injuries of the inferior vena cava (IVC) result from blunt or penetrating mechanisms (1). Generally, they are diagnosed during surgical exploration and almost always accompanied with abdominal multisystem organ injuries (2). We aimed to present our approach to these vascular injuries, which are among the most significant injuries that demonstrate operational symptoms such as retroperitoneal hematoma.
Material And Method
We prospectively collected the data on all the IVC injury patients who were admitted to Izmir Atatürk Training and Research Hospital, between January 2000 and December 2005. There were 16 patients with IVC injuries. Of these 16 patients, 9 (56.25%) had stab wounds, 5 (31.25%) blunt injuries and 2 (12.5%) had gunshot wounds. All of the patients were men. Average age was 22.4±5.3 years (ranging between 10 and 36 years). All the patients arrived in shock to our emergency service and general surgery team performed emergent laparotomy due to acute abdomen. All patients had both intraabdominal organ injuries and infrarenal IVC injuries (Table I).
Emergent laparotomy was performed with blood and fluid replacement and cardiovascular consultation was needed due to perioperative retroperitoneal active bleeding and our team found infrarenal IVC injury in all patients. After examining the hemorrhage, the location of the injury was determined precisely. Subsequently, the injury region was examined with a side-biting Satinsky clamp permitting light venous return and primarily repaired with lateral venorrhaphy using 5-0 polypropylene sutures. Retroperiton was closed. General surgeons performed the necessary repairs for intraabdominal organ injuries. Averagely 6.1 units of blood were transfused during operation (between 3 and 11 units).
In our series, only one patient died in the early postoperative period. Our mortality rate was 6.25%. We performed colostomy to 5 patients and tube gastroduodenostomy to 3 patients. We had to perform splenectomy in 3 (60%) of the 5 patients with blunt trauma. Right femoral embolectomy was performed in another blunt trauma patient and after he was diagnosed with arteriospasm, he was followed with medical treatment. Combined parenteral ceftriaxone and metronidazol therapy protocol was used for prophylaxis. IV heparin was administered until oral feeding IV heparin and for the next 3 months oral anticoagulant was used. Elastic bandaging and leg elevation were used at least for a week to avoid volume load in early postoperative period and venous pooling at the lower limbs. Patients were evaluated with noninvasive Color Doppler ultrasonography before and 3 months after the discharge. The patency of the IVCs was confirmed and no stenotic complications were observed (Figure 1).
Peripheral vascular trauma treatment techniques were improved dramatically due to the violence in social life. IVC injuries, when accompanied by intraabdominal organ injuries, may sometimes be overlooked and a gradual and careful priority method must be used (3, 4). The examinations performed to determine the damage in life-threatening aim to exclude the hemorrhage in the first place (5). Organized evaluation, examination, exposition and repair increase the successful outcome chance (1,6).
In vena cava hemorrhages, firstly bleeding is taken under control and then injury area is determined and finally, the vena cava injury is repaired. Control of the hemorrhage and precise determination of the injury area are vital in the repair procedure (3,7,8).
The majority of traumatic IVC injuries can be managed by direct compression or local clamping and primary venorrhaphy. Direct repairs are associated with a low thrombosis and embolic complication rate (7,9). As for the anterior injuries, a side-biting Satinsky clamp can control the injury site and permit continued venous return as well. Suture lines should be kept as short as possible in order to avoid late thrombosis. Most vena cava injuries can be repaired by lateral venorrhaphy, provided that the diameter of vena cava is not narrowed to less than 50% (10).
The use of synthetic grafts in infrarenal IVC injuries still constitutes a problem because their long-term patency rates are unsatisfactory (11). Additionally, infrarenal IVC replacements have high thrombosis rates due to low blood flow and external positive pressure. Ringed prosthetic graft usage and distal arteriovenous fistula are recommended to eliminate these two factors (2,12). Without using these extended and highly complicated methods, we performed primary repair with lateral venorrhaphy.
We concluded that color Doppler ultrasonography could provide reliable noninvasive evaluation of the repaired IVC. We recommend that all patients with a repaired IVC injury should be evaluated for patency before the discharge and 3 months after the discharge.
Doppler wave-forms and pressure index measures are convenient screening methods (13). Any suspicious or recorded anomaly must be evaluated with venorrhaphy (13,14). To revise the stenotic part of the primary repair area in the early period before occlusion can dramatically elongate the flow and maintain the continuity. None of our patients developed postoperative complications of IVC stenosis requiring venorrhaphy and all were followed with Color Doppler ultrasonography routinely.
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