Complex penetrating liver injury

(A) Complex penetrating liver injury; (B) combined open and endovascular liver isolation with REBOA, REBOVC, and Pringle maneuver. The open and endovascular liver isolation is achieved performing the REBOA in zone 1 and REBOVC at the level of the retrohepatic vena cava with the goal of achieving proximal and distal vascular control of a possible retro/suprahepatic vessel injury. The Pringle maneuver is obtained via the hepatoduodenal ligament clamping.