Ann Thorac Surg 1995;59:997-998
© 1995 The Society of Thoracic Surgeons
Case Reports
Use of Active Shunt for Surgical Repair of Intrapericardial Inferior Vena Caval Injury
Eric Picard, MD,
Charles Henri Marty-Ané, MD,
Jean Pierre Meunier, MD,
Jean Marc Frapier, MD,
Jacques R. Séguin, MD,
Henri Mary, MD,
Paul André Chaptal, MD
Thoracic and Cardiovascular Unit and Thoracic and Vascular Unit, Centre Hospitalier Universitaire, Hôpital Arnaud de Villeneuve, Montpellier, France
Accepted for publication July 28, 1994.
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Abstract
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We report a case of intrapericardial inferior vena caval disruption due to goring by a bull, and we describe the surgical repair of this uncommon penetrating cardiac injury. Review of the literature indicates that, as with other penetrating cardiac injuries, this rare lesion requires aggressive treatment involving an emergency thoracotomy. The use of an atrial caval active shunt was necessary for successful surgical management, and therefore we conclude that surgical treatment of this lesion is comparable with surgical repair of hepatic veins and retrohepatic vena caval injuries incurred during blunt vascular trauma or penetrating abdominal injuries.
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Introduction
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A 30-year-old man sustained penetrating chest trauma as the result of being gored by a bull. The initial clinical status was shock, gasping respiration, and a right parasternal bleeding entrance wound. Volume replacement, endotracheal intubation, and chest tube placement were carried out, and the patient was transported to the operating room in our unit for exploration and repair. The incision used for the emergency thoracotomy was a right lateral thoracotomy in the fifth intercostal space. At operation, a 2- to 3-cm-long laceration was noted in the pericardium, and the inferior vena cava was found to be disrupted. This was associated with massive extravasation of blood into the chest cavity but without tamponade. The right internal mammary artery and a section of the right phrenic nerve also were injured. An attempt to clamp the inferior vena cava caused the patient's clinical status to worsen, so active shunting for the purpose of venovenous bypass was performed with extracorporeal circulation but without oxygenation (Fig 1
). One end of the shunt was placed in the inferior vena cava and the other end was inserted into the right atrium. The cannula placed in the inferior vena cava was inserted beyond the wound. Two lateral clamps were placed around this cannula and the wound was closed with 5-0 polypropylene. The right internal mammary artery injury was treated by ligation. Other than the chest tubes, a pericardium drain was also used. The chest wall and skin were closed primarily after copious irrigation with an antibiotic solution. A chest roentgenogram showed right phrenic nerve paralysis. Echocardiography showed no pressure gradient between the abdominal inferior vena cava, hepatic veins, and right atrium. The patient was discharged on the twentieth postoperative day without sequelae.
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Fig 1. . Atrial caval active shunt with inferior cannula inserted beyond the inferior vena caval wound.
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Comment
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Inferior vena caval disruption due to penetrating abdominal injuries is usual, but intrathoracic inferior vena caval injury uncommon, as the result of penetrating cardiac injuries or blunt vascular trauma [1–4]. Few of these injuries have been described in the literature, and they are typically associated with a very high mortality rate. Omert and co-workers [5] reported 6 cases of inferior vena caval injury induced by blunt thoracic trauma; only 1 of their patients survived. The intrathoracic portion of the vena cava is an intrapericardial great vessel. The intrathoracic inferior vena cava is just a few centimeters long, and this probably explains the rarity of this injury in association with penetrating cardiac injuries. The anatomic location of the various chambers of the heart account for the common sites of cardiac penetration. The right ventricle, with its maximal anterior exposure, is the most vulnerable to injury. In a collective review of 1,802 patients, Karrel and co-workers [6] found that only 3.3% had intrapericardial great vessel injuries. On initial evaluation of the literature, it would appear that the most frequent clinical status is a composite of the relative roles of the two prime consequences of this injury: pericardial tamponade and severe hemorrhage [4, 7]. In our case, the lengthy laceration of the pericardium probably explains the clinical findings consisting of hemothorax but without tamponade.
Tavares and associates [8] firmly believe that, based on their experience, aggressive treatment is justified, including emergency room thoracotomy for lifeless cardiac injury victims whose condition is deteriorating. Our experience, too, has demonstrated that aggressive resuscitation followed by emergency thoracotomy is indicated in this setting. It is uncommon to use cardiopulmonary bypass for the surgical repair of penetrating cardiac injuries [3, 4], but the literature indicates that successful repairs of hepatic veins and retrohepatic inferior vena caval injuries can be accomplished with the use of an atrial caval shunt [9, 10]. Diebel and colleagues [10] found that the active shunting of blood using a venovenous bypass with a pump appears to be much superior hemodynamically to passive shunting, which relies only on hydrostatic pressure. In our patient, it was necessary to use an atrial caval shunt because only total clamping of the inferior vena cava controlled the hemorrhage, but with deteriorating clinical status. In a case report, Hartman and co-workers [11] describe the use of profound hypothermic circulatory arrest to facilitate the repair of a penetrating injury to the retrohepatic vena cava and hepatic veins.
In summary, disruption of the inferior vena cava is uncommon as the result of penetrating thoracic or cardiac injuries. Aggressive treatment with emergency thoracotomy is necessary, and the use of an atrial caval active shunt is indicated, as often as it is in the surgical repair of hepatic veins and retrohepatic vena caval injuries.
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Footnotes
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Address reprint requests to Dr Picard, Thoracic and Cardiovascular Surgery, CHU Hôpital Arnaud de Villeneuve, 34295 Montpellier Cedex 5, France.
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References
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- Symbas PN. Cardiothoracic trauma. Curr Probl Surg 1991;28:741–800.[Medline]
- Cooper C, Rodriguez A, Omert L. Blunt vascular trauma. Curr Probl Surg 1992;29:281–360.[Medline]
- Attar S, Suter CM, Hankins JR, Sequeira A, McLaughlin JS. Penetrating cardiac injuries. Ann Thorac Surg 1991;51:711–6.[Abstract]
- Ivatury RR, Rohman M. Thoracic trauma. Surg Clin North Am 1989;69:93–110.[Medline]
- Omert L, Rodriguez A, Simon B, O'Callaghan T, Dunham CM. Vascular injuries of the thorax and abdomen induced by blunt trauma. Panam J Trauma 1991;2:102–11.
- Karrel R, Shaeffer MA, Franaszek JB. Emergency diagnosis, resuscitation, and treatment of acute penetrating cardiac trauma. Ann Emerg Med 1982;11:504–17.[Medline]
- Demetriades D. Cardiac penetrating injuries: personal experience of 45 cases. Br J Surg 1984;71:95–7.[Medline]
- Tavares S, Hankins JR, Moulton AL, et al. Management of penetrating cardiac injuries: the role of emergency room thoracotomy. Ann Thorac Surg 1984;38:183–7.[Abstract]
- Moulton SL, Lynch FP, Canty TG, Collins DL, Hoyt DB. Hepatic vein and retrohepatic vena caval injuries in children. Sternotomy first? Arch Surg 1991;126:1262–6.[Abstract/Free Full Text]
- Diebel LN, Wilson RF, Bender J, Paules B. A comparison of passive and active shunting for bypass of the retrohepatic IVC. J Trauma 1991;31:987–90.[Medline]
- Hartman AR, Yunis J, Frei LW, Pinard BE. Profound hypothermic circulatory arrest for the management of a penetrating retrohepatic venous injury: case report. J Trauma 1991;31:1310–1.[Medline]
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Abstract
Introduction
