Traumatic and iatrogenic injury to the inferior vena cava

INTRODUCTION — Inferior vena cava (IVC) injury is extremely morbid and particularly challenging to manage as it is not usually identified until the time of exploration. Despite its protected location, the IVC is a commonly injured vascular structure. Traumatic and iatrogenic injury to the inferior vena cava is reviewed. Other intra-abdominal vascular injuries are reviewed separately. (See "Abdominal vascular injury".)

IVC injuries are commonly associated with injuries to the liver, duodenum, and the portal triad. These are reviewed in detail separately. (See "Management of hepatic trauma in adults" and "Management of duodenal trauma in adults" and "Traumatic injury to the portal triad" and "Surgical techniques for managing hepatic injury".)

MECHANISM OF INJURY — A variety of traumatic and iatrogenic mechanisms can result in injury to the IVC.

Traumatic injury — Traumatic injury to the IVC can be due to penetrating or blunt mechanisms. While penetrating injury is overall more common, blunt injury is the more common mechanism for suprarenal injuries. In a review of the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry, among 140 patients identified with traumatic IVC injury, 62 percent had penetrating mechanism [1].

●Penetrating trauma – Penetrating injuries to the inferior vena cava are reported to occur in between 0.5 and 5 percent of cases of penetrating abdominal injury [2]. Penetrating injuries range from low-velocity stab wounds for which the injury will be confined to the tract itself to highly destructive wounds from high-velocity projectiles.

The clinical presentation of penetrating injury runs the gamut from an isolated stab wound contained as a retroperitoneal hematoma to a gaping, actively bleeding venous wound from a higher velocity round.

Injuries can occur at any level of the IVC from the bifurcation to the suprahepatic region. Injuries may be tangential, single anterior or posterior wall injuries, or a combination anterior/posterior injury.

●Blunt trauma – Blunt injuries to the IVC can occur due to sudden deceleration events (eg, motor vehicle crash, fall from a height) that may avulse the liver from the IVC. These can be immediately catastrophic leading to rapid death, or if contained in the bare area of the liver, might be identified on computed tomographic (CT) scan. Examples of such injuries include:

•Avulsion of the liver or hepatic veins from the suprahepatic cava (eg, right lobe, left lobe)

•Vascular avulsion from the IVC from traction on the kidney (similar mechanism to blunt thrombosis or avulsion of the renal artery)

•Injuries from osteophytes involving the infrarenal IVC

•Avulsion of the intrapericardial IVC from the right atrium

Iatrogenic injury

Laparoscopic access — IVC injury because of laparoscopic access is fortunately an uncommon injury, as laparoscopy has become standard of care for a myriad of intra-abdominal procedures, and the level of expertise has increased substantially as a result. Injuries experienced during the early 1990s included punctures to the IVC and iliac veins from the Veress needle, and these could range from punctures to lacerations to both the anterior and posterior walls as well as any intervening structures between the abdominal wall and the retroperitoneum. (See "Abdominal access techniques used in laparoscopic surgery" and "Complications of laparoscopic surgery", section on 'Vascular injuries'.)

Abdominal surgery — Any open, laparoscopic, or robotic abdominal operation that requires dissection in the region of the IVC has the potential to cause injury. Iatrogenic IVC injury may be most common during resection of retroperitoneal tumors or lymph nodes that are adherent or encasing the IVC, but it can also happen during aortic surgery or anterior spinal exposure procedures.

●Retroperitoneal tumor excision – (See "Surgical resection of retroperitoneal sarcoma", section on 'Tumor resection'.)

●Anterior spine exposure procedures – Inferior vena cava injury can occur as a complication of anterior spine exposure procedures. Two approaches are used to provide exposure to the anterior spine.

•The anterior lumbar spine may be approached from the anterior retroperitoneal approach through a paramedian skin incision for exposure of the L4, L5, and S1 vertebral bodies. The incision is carried down into the retroperitoneum through an incision of the anterior and posterior rectus sheaths to enter the retroperitoneal space. The dissection is essentially blunt as the peritoneal envelope is mobilized medially and then as the left common iliac artery and vein come into view. Care must be taken during the dissection of the lateral portion of the lumbar bodies to avoid injury to the ascending iliolumbar veins off the common iliac veins.

•Alternatively, if exposure of the higher levels of the lumbar spine are required, then a flank incision with retroperitoneal dissection can be used usually from the left side.

●Open aortic surgery – The estimated incidence of IVC injury during aortic surgery is about 2 percent. IVC injury can occur during operative exposures of the abdominal aorta, particularly with redo operations when the normal anatomic tissue planes are obscured.

Endovenous intervention — IVC injury from filter devices is usually related to tilt or migration which can lead to perforation by the legs of the device (figure 1). Filter-related IVC perforation is defined as penetration of the IVC filter >3 mm into the wall of the vena cava, which accounts for about 20 percent of IVC filter complications as reported by the MAUDE database [3]. Most are found incidentally on imaging studies (eg, CT). Removal of the IVC filter may be appropriate in selected cases with significant symptoms.

Transmural injury of the IVC or free rupture may be a complication of endovenous intervention to manage perforation or filter thrombosis (See "Placement of vena cava filters and their complications" and "Endovenous intervention for iliocaval venous obstruction".)

TRAUMA EVALUATION — We perform the initial resuscitation, diagnostic evaluation, and management of the trauma patient with blunt or penetrating trauma based upon protocols from the Advanced Trauma Life Support (ATLS) program, established by the American College of Surgeons Committee on Trauma. The initial resuscitation and evaluation of the patient with blunt or penetrating abdominal or thoracic trauma is discussed in detail elsewhere.

●(See "Initial evaluation and management of blunt abdominal trauma in adults".)

●(See "Initial evaluation and management of abdominal gunshot wounds in adults".)

●(See "Initial evaluation and management of abdominal stab wounds in adults".)

●(See "Initial evaluation and management of blunt thoracic trauma in adults".)

●(See "Initial evaluation and management of penetrating thoracic trauma in adults".)

Hemodynamically unstable trauma patients should be transferred immediately to the operating room for evaluation and management. If the clinical setting allows, a Focused Assessment with Sonography for Trauma (FAST) examination, diagnostic peritoneal aspirate, or CT scan may be performed. The choice of test and their value in the diagnostic evaluation of the trauma patient are discussed in detail elsewhere.

●(See "Initial evaluation and management of blunt abdominal trauma in adults", section on 'Ultrasound' and "Initial evaluation and management of abdominal gunshot wounds in adults", section on 'Ultrasound' and "Initial evaluation and management of abdominal stab wounds in adults", section on 'Ultrasound'.)

●(See "Initial evaluation and management of blunt abdominal trauma in adults", section on 'Diagnostic peritoneal lavage' and "Initial evaluation and management of abdominal stab wounds in adults", section on 'Diagnostic peritoneal tap and diagnostic peritoneal lavage' and "Initial evaluation and management of abdominal gunshot wounds in adults", section on 'Diagnostic peritoneal lavage'.)

Specific elements of the trauma history, physical examination, and imaging evaluation that pertain to liver injury are discussed below.

History and physical examination — A history of trauma to the right flank or to the right of the midline from the level of the diaphragm to the pelvis increases suspicion for IVC injury. Specific attention should be paid to any wounds that penetrate the right chest, abdomen, flank, or back. Patients with IVC injury may present with symptoms and signs of retroperitoneal hematoma or with intra-abdominal bleeding with variable degrees of tachycardia and/or hypotension. The patient may complain of pain in the abdomen or pelvis, or right shoulder due to diaphragmatic irritation from blood.

●Retroperitoneal hematoma – The low pressure within the IVC allows for tamponade in the retroperitoneum (eg, some blunt injuries, iatrogenic injury). Significant decreases in intravascular volume may result in even lower central venous pressures, thus decreasing venous bleeding. Such patients do not die in the field (unlike aortic injuries). The patient may be normotensive or slightly hypotensive with tachycardia and they may respond transiently to resuscitation.

●Intra-abdominal bleeding – For penetrating IVC injury, there is usually a tract through the abdominal cavity with bleeding that is uncontained. These patients are usually hemodynamically unstable and will have a FAST examination consistent with intraperitoneal fluid prompting urgent operation.

Associated injuries — Given the posterior location deep in the retroperitoneum, it is very common to have associated intra-abdominal and retroperitoneal injuries. The liver, duodenum, colon, portal triad, and other vascular structures at risk with blunt or penetrating IVC injury.

●(See "Management of hepatic trauma in adults".)

●(See "Traumatic injury to the portal triad".)

●(See "Management of duodenal trauma in adults".)

●(See "Management of pancreatic trauma in adults".)

●(See "Abdominal vascular injury".)

Laboratory studies — Routine laboratory studies are obtained in trauma patients including complete blood count, electrolytes, blood urea nitrogen, creatinine, coagulation parameters, and liver function tests. None of these are specific for vena cava injury. A finding of anemia may be consistent with blood loss, the degree of which is related to the volume of blood lost, which can be from sites other than or in addition to the IVC, and the nature and volume of fluid resuscitation. In patients with acute blood loss, hemoglobin and hematocrit in the peripheral blood sample may remain normal because the patient is losing whole blood.

DIAGNOSIS — IVC injury may be suspected based on the mechanism of injury and clinical signs of associated injuries, but the diagnosis requires demonstration of the injury either on direct inspection in the operating room or on vascular imaging, typically abdominal CT.

●Intra-abdominal bleeding – The presence of perihepatic blood may be seen on cross sectional imaging, although this is not a specific finding. During abdominal exploration, dark blood pooling up around the liver/right upper quadrant is the most common finding.

●Retroperitoneal hematoma – A zone I (figure 2) retroperitoneal hematoma may be appreciated on abdominal exploration or on imaging studies. Radiologic findings on abdominal CT scan include vena cava contour abnormalities, active extravasation, pseudoaneurysm, and pericaval hematoma [4]. Zone I injuries of the retroperitoneum are generally explored to confirm and manage the injury. (See 'Damage control surgery' below and "Overview of the diagnosis and initial management of traumatic retroperitoneal injury", section on 'Zone 1'.)

Vena cava injury grading — Vena cava injury represents the highest level of injury on the American Association for the Surgery of Trauma (AAST) abdominal vascular injury scale (table 1). This grade of injury reflects mortality with IVC injury representing one the most lethal injuries with which trauma surgeons still struggle. (See 'Mortality and complications' below.)

DAMAGE CONTROL SURGERY — For hemodynamically unstable patients, abdominal exploration is performed in the context of damage control surgery, and the goals are to first contain hemorrhage, limit contamination, and maintain blood flow. Whenever there is a suspicion of IVC injury (or any other vascular injury), it is imperative to prepare the potential operative field from chin to knees. This will allow access to the abdomen and chest as intended via midline laparotomy or extension to median sternotomy (if needed), while still providing groin access for potential cannulation for endovenous maneuvers and saphenous vein for vascular reconstructions. The rule of proximal and distal control is important before surgical management of a stable zone I retroperitoneal hematoma. (See "Overview of damage control surgery and resuscitation in patients sustaining severe injury" and "Abdominal vascular injury", section on 'Approach to management'.)

Upon exploration, the surgeon may encounter free intraperitoneal bleeding, which can be difficult to locate and control, or retroperitoneal hematoma. Hematoma in retroperitoneal zone I, which contains the aorta, inferior vena cava, celiac axis, and the origin of the mesenteric arteries, should be explored (figure 2). (see "Overview of the diagnosis and initial management of traumatic retroperitoneal injury", section on 'Retroperitoneal zones' and "Overview of the diagnosis and initial management of traumatic retroperitoneal injury", section on 'Surgical approach by zone'):

Direct broad compression of hematoma may be required until the surgeon can optimize lighting, surgical assistance, vascular access, vascular instrumentation, and further resuscitation with blood products before exposing and then repairing the injury. Another option for vascular control is balloon occlusion of the IVC (picture 1) from a femoral venous access [5].

Once the patient's physiologic condition has improved, sequential release of vascular control will allow identification of normal anatomy and begin to define the requisite proximal and distal sites to control the bleeding vessel. More directed compression with sponge sticks on the superior and inferior portion of the IVC leading into the hematoma might provide additional time to complete a further dissection of the vessel wall for safe clamping of the IVC. Likewise, it is important to obtain sufficient exposure of the IVC to control, see, and definitively repair an injury to the IVC. (See 'IVC exposure by level' below and 'Approach to vena cava injury' below.)

For patients in extremis, ligation of the infrarenal IVC should be considered and is generally well tolerated. (See 'Vena cava ligation' below.)

Often, we will leave the abdomen open as part of the overall damage-control approach. If the IVC repair resulted in significant narrowing, the patient can be returned to the operating room as soon as they are physiologically stable to patch the IVC narrowing. (See 'Primary repair' below and 'Patch repair or interposition grafting' below.)

IVC EXPOSURE BY ANATOMIC LEVEL

Anatomic levels — The IVC is located in the retroperitoneum and is the major vein in the abdomen and provides venous drainage for the abdominal organs, retroperitoneal organs, abdominal wall, and lower extremities. The IVC is divided into six confluent anatomic levels that influence techniques for anatomic exposure. These include the infrarenal, pararenal, suprarenal, retrohepatic, suprahepatic, and intrapericardial components. (See 'IVC exposure by level' below.)

●Infrarenal – The infrarenal IVC forms from the confluence of the common iliac veins at the level of L5 and travels proximally to the level of the renal veins, which typically enter the IVC at the L2 level. The right gonadal vein enters the anterior surface of the IVC approximately 5 cm distal to the renal veins. (See 'Infrarenal/pararenal' below.)

●Pararenal – The renal veins drain into the IVC the level of the second lumbar vertebrae. In most patients, the left renal vein travels anterior to the aorta deep to the superior mesenteric artery. In 2 to 3 percent of patients, the left renal vein may pass deep to the aorta or form a circumaortic venous collar. The right renal vein often enters the IVC about 1 cm lower than the left renal vein. (See 'Infrarenal/pararenal' below.)

●Suprarenal – The short segment of the suprarenal IVC receives the short and somewhat large right adrenal vein that enters directly into the IVC in the right posterolateral approach, as the adrenal gland is deep and posterior in the retroperitoneum. The IVC continues beneath the second part of the duodenum and the portal vein. The anterior portion of the pararenal/suprarenal vena cava forms the posterior element of the foramen of Winslow. (See 'Suprarenal/subhepatic' below.)

Over the course of the infrarenal, pararenal, and suprarenal vena cava, numerous lumbar veins enter at the caudal surface of the IVC. These tend to correspond to the segmental lumbar arteries, which are identified in the retroperitoneum at the midportion of the lumbar body.

●Retrohepatic – The IVC travels deep to the caudate lobe of the liver to form the retrohepatic vena cava at the level of L1. There are several short caudate veins that drain directly into the anterior surface of the IVC. Mobilization of the caudate lobe anteriorly allows for additional exposure of the suprarenal/retrohepatic cava and requires direct ligation of these veins. On occasion, there is a prominent low-lying right hepatic vein that enters from the patient's right side and drains directly into this lower segment of the retrohepatic IVC. At this point, the IVC continues upward toward the right heart and is incompletely surrounded anteriorly and laterally by the liver parenchyma in the bare area of the liver (figure 3). (See 'Retrohepatic' below.)

●Suprahepatic – The vena cava moves more anteriorly as it exits the liver and approaches the pericardium at the level of the eighth thoracic vertebra. The suprahepatic IVC is a short 1 to 3 cm segment of vein above the liver but below the diaphragm into which the hepatic veins (two or three) will drain. The vena cava then passes through the caval diaphragmatic hiatus. (See 'Suprahepatic/Intrapericardial' below.)

●Intrapericardial – The portion of the IVC in the chest measures about 2 to 3 cm in length. The intrapericardial portion of the IVC has a relatively thick wall. The back wall is fixed to the pericardium via a membrane that is easily dissected, making it accessible to circumferential control.

IVC exposure by level

Infrarenal/pararenal — The infrarenal IVC is the most commonly injured segment. The infrarenal IVC can be exposed by using a right-sided medial visceral rotation (ie, Cattell-Braasch maneuver). (See "Overview of the diagnosis and initial management of traumatic retroperitoneal injury", section on 'Right medial visceral rotation'.)

The inferior vena cava is exposed through the division of the white line of Toldt, followed by the medial mobilization of the right colon in the avascular plane. Taking down the hepatic flexure then allows exposure of the second part of the duodenum, which must be mobilized as a Kocher maneuver to allow complete exposure of the pararenal IVC. Complete mobilization of the cecum up to the base of the small bowel may allow exposure of the infrarenal IVC and infrarenal aorta that would also allow exposure of injuries involving both structures. The right gonadal vein may be sacrificed to expose the anterior and posterior surface of the IVC. Prior to doing so, one must always bear in mind that saving this structure might be valuable for providing collateral drainage in the face of potential ligation of the more distal IVC.

Initial vascular control may be as inelegant as direct pressure in the region of the injury (eg, manual pressure or using sponge sticks) until the proximal and distal portion of the vessel is dissected out for more definitive control (see 'Damage control surgery' above). It is notable that to obtain exposure of the injured vena cava, one will always need more room on the IVC than one anticipated. Adequate vessel dissection is important for control of bleeding first, and then sufficient room for reconstruction will be required to repair it safely and under direct vision.

The lumbar veins tend to be short and thin-walled and are often branching vessels within a few centimeters of the wall of the IVC. When dividing these vessels, it is important to use three ties, one on each of the branches and one flush with the wall of the IVC to provide sufficient space to be able to divide the lumbar vessel safely. The authors will often place an additional ligating clip distal to the tie on the distal lumbar vein to ensure good hemostasis, as it often retracts away into the retroperitoneum after division and out of the visual field. A single large lumbar vein that enters the back of the pararenal IVC is almost always present, and it must be either ligated or at least controlled with a clip to provide adequate hemostasis if the intent is to open the pararenal IVC. The renal veins must also be well controlled with doubly looped vessel loops or vascular clamps; the flow through these vessels is brisk and incomplete occlusion will lead to continued blood loss.

Suprarenal/subhepatic — Surgical exposure of the suprarenal IVC is accomplished by performing a Kocher maneuver with duodenal mobilization.

The right adrenal vein is a short, wide vein that enters into the right lateral aspect of the suprarenal IVC. Anterior mobilization of the caudate lobe is often quite helpful to gain additional exposure of the suprarenal IVC prior to determining the need for a lateral to medial mobilization of the right lobe of the liver. This will require careful exposure and ligation of the small, short drainage veins from the caudate that empty directly into the IVC. These may require 3-0 silk ties on the liver side and a small Ligaclip or fine polypropylene suture on the IVC side to facilitate division of the veins and elevation of the caudate lobe beneath the retractor. The advantage of using a tangential Ligaclip can be a disadvantage if further manipulation dislodges that clip. The suture tends to be more definitive if time permits.

Retrohepatic — Retrohepatic caval injuries, particularly those at the junction of the hepatic veins, are often life-threatening (picture 1). Proximal and distal control of the IVC can be difficult since the vena cava wall is thin in this location.

Exposure of the retrohepatic IVC requires mobilization of the right lobe of the liver from lateral to medial with division of the falciform and right triangular ligaments to allow entry into the bare area of the liver. At this point, the retrohepatic cava comes into view, and there are multiple short veins that drain directly into this 15 to 20 cm segment of the IVC that may require division if further lateral to medial exposure be required. The cephalad extent of the dissection will reveal the right hepatic vein, which will be partly intraparenchymal and flattened out as the right lobe is folded and compressed medially to aid in mobilization. The surgeon should always be on the lookout for a low-lying large right hepatic vein that enters the lower retrohepatic cava from the right lateral direction as the surgeon moves up alongside the suprarenal IVC. We discourage ligating this low-lying vein unless essential to the dissection and repair. This is often seen on a preoperative CT scan of the abdomen if that was available for review.

Maneuvers that can be used to control bleeding and repair retrohepatic vena cava injury include the following:

●Hepatic isolation – If bleeding cannot be controlled with hepatic packing, hepatic isolation is a technique that can be used to facilitate IVC repair. Hepatic isolation occludes the inflow and outflow vessels of the liver. This provides a relatively clean field in which to perform IVC repair. However, venous return to the heart is severely reduced as a result, which can lead to cardiac arrest.

●Atriocaval shunting – The Schrock or atriocaval shunt is a technique that is designed to help control bleeding from a retrohepatic caval injury while simultaneously allowing blood flow from the lower extremities and the kidneys to return to the right side of the heart (figure 4). Theoretically, this will provide a relatively clean field to facilitate repair of the injury and maintain intravascular volume. The shunt may be devised from a chest tube or an endotracheal tube and takes some facility with the anatomy to properly prepare and position the shunt.

●Cardiopulmonary bypass – Cardiopulmonary bypass with venous cannulas in the right common femoral vein and the superior vena cava will allow for the potential of a clean field, harvesting of shed blood back into the bypass circuit, and the potential for cooling of the patient with the intent for hypothermic cardiac arrest if it is required, which is not often needed. However, most patients will not survive the time it takes for this procedure.

Suprahepatic/Intrapericardial — The suprahepatic IVC can be clamped below the diaphragm as part of complete vascular control of the liver (figure 5).

If additional, more cephalad exposure is needed, the diaphragm can and should be divided. To do so safely, it is wise to perform a sternotomy. A vertical incision through the diaphragm after sternotomy will expose the transition between the suprahepatic IVC and the intrapericardial IVC. The pericardium can then be opened to control the 2 to 3 cm of intrapericardial IVC. There is a muscular wall to the vessel at this point, which lends itself to easy dissection posteriorly for circumferential control. This exposure allows for ease of access for cardiopulmonary bypass should it be indicated or even direct repair. The hepatic veins themselves can be short and wide and must be carefully controlled with vessel loops or clamps, should the need arise.

Clamping the IVC — The method of vascular control is determined by the size of the defect and the level of the injury.

There is a tendency to use the Satinsky side-biting clamp, which surprisingly still requires an adequate amount of vessel exposure both in the longitudinal and lateral extent to clamp and control the bleeding and then allow a sufficiently deep bite of suture to coapt the edges of the vessel. Often, the Satinsky will coapt the edges of the vessel, but sometimes it does not leave enough room for good tissue bites with the suture. The compression of the sides of the injured vessel may also make it difficult to see and tease apart to avoid placing the suture through the back or side wall and reducing the lumen even more.

APPROACH TO VENA CAVA INJURY

Open repair techniques — The choice of open repair technique will be dictated primarily by the size and location of the defect (eg, preservation of hepatic veins). Many options exist including simple primary repair, patch venoplasty, interposition grafting, selective shunting, and IVC ligation.

Hemostatic agents and gentle pressure or some simple sutures, on occasion with the help of pledgets, can be effective, as this is a low-pressure vessel. For large injuries, care must be taken to prevent significant luminal narrowing leading to thromboembolic events, including complete occlusion.

In a review of the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry, IVC injuries were managed with open repair (70 percent) or ligation (30 percent; infrarenal 37 percent, suprarenal 13 percent) [1].

Primary repair — Primary repair is limited to injuries that are no more than 50 percent the circumference of the vessel to avoid narrowing the vessel. Many surgeons find it helpful to use sequential application of Allis clamps to temporarily control the edges of an IVC laceration prior to definitive suture repair.

The authors favor a long (52 cm) nonabsorbable 3-0 monofilament suture on an MH needle that allows a single pass to incorporate both sides of the vessel rather than multiple passes when time may be of the essence. To some surgeons, this may seem like a large needle, but the advantage is that it does not get lost in a pool of blood or in a deep and limited field at the site of the injury as would a smaller needle on a 5-0 or 6-0 suture. If the field is relatively clean, a 4-0 suture on an SH needle or CV needle are alternatives.

At times, the initial procedure requires primary repair but in doing so, a significant narrowing of the inferior vena cava may result. This will not dilate with time and often we will leave the abdomen open as part of the overall damage-control approach and return the following day to patch the IVC narrowing (see 'Patch repair or interposition grafting' below) as soon as the patient is physiologically stable. In some cases, that damage control primary suture repair has thrombosed in the short time between the index procedure and the first return to the operating room. In those cases, we have found that complete control of the IVC and common iliac veins with thrombectomy of the iliocaval segment will be easily performed with restoration of luminal patency after patching. The thrombus is relatively fresh and not incorporated into the vessel wall making it easy to clear completely [6].

Patch repair or interposition grafting — For injures >50 percent the circumference of the vessel, patch repair or interposition grafting will reduce the likelihood of future stenosis but require the patient to be reasonably hemodynamically stable to undertake the repair. For patients in extremis, vena cava ligation as part of a damage control approach is an option. (See 'Damage control surgery' above and 'Vena cava ligation' below.)

The options for patch material include a vein patch for smaller defects, and for larger and perhaps irregularly shaped defects as well as those for which there is an urgency to complete because of patient instability, options include polyethylene terephthalate (eg, Dacron, Hemashield), polytetrafluoroethylene (PTFE; Gore-Tex cardiovascular patch), and bovine pericardial patch (2 cm x 9 cm cut to size).

Donor vein would routinely be obtained from the great saphenous in the groin where the diameter is greatest. The compliance of pericardial patch is stiffer and less forgiving than autologous vein. In larger vessels like the IVC, there is some flexibility in using pericardial patch material that might not be allowed in smaller, more compliant veins (eg, iliac veins). We try to use an all-autogenous approach within a contaminated field, but on occasion this is not possible. The pericardial patch, although biologic tissue, is not as resistant to infection as autogenous vein. Larger defects in the IVC that involve significant destruction of tissue might require a panel vein of saphenous vein, or interposition grafting with autogenous left renal vein, internal jugular vein, or common iliac vein.

Synthetic PTFE patch has been used as well, although infection in the presence of bowel contamination is a real concern. The risk may be reduced with the use of an omental wrap and/or closure of the retroperitoneum. If time permits and autologous tissue is required due to contamination or size needs, then a cadaveric femoral vein or aorta may suffice. This will require a minimum of 25 to 45 minutes for thawing and preparation, so planning accordingly is required. An additional option for the reconstruction of the IVC is replacement with a 12 to 14 mm externally reinforced PTFE graft.

Endovenous repair — An endovenous approach using covered stenting across the injured segment may be an alternative to open surgical management for iatrogenic injuries and possibly minimal traumatic injuries. In a systematic review, 26 patients with operative injury to the IVC or iliac veins treated using endovascular stents were identified [7]. All procedures were technically successful at achieving control of hemorrhage; however, procedural complications occurred in 15.4 percent of cases, including three cases of acute thrombus formation and one case of stenosis caudal to the initial stent edge requiring additional stenting. Many technical aspects of this form of treatment are unresolved such as the ideal size and type of stent-graft, the need for and duration of postprocedural antithrombotic therapy, and appropriate surveillance. In addition, long term outcomes have not been studied for this population.

Vena cava ligation — On occasion, there will be such an extensive injury to the infrarenal vena cava and the patient is in such a crisis that one has a choice of a temporary intraluminal shunt or ligation of the IVC. The latter can be a lifesaving intervention. The venous collateral circulation in the retroperitoneum is extensive, as there are direct connections between the IVC and the intramuscular ascending lumbar veins into the azygous and hemiazygous systems [8]. Postoperatively, bilateral lower extremity compression and elevation is required to reduce edema and the potential of severe sequelae such as compartment syndrome and venous hypertension.

POSTOPERATIVE CARE AND FOLLOW-UP — Following IVC ligation, bilateral lower extremity compression wraps and elevation are a must. In addition, the patient is anticoagulated once significant bleeding risk subsides.

Most patients who have undergone IVC ligation do well, provided they have received appropriate therapy. Phlegmasia is very rare. (See "Phlegmasia and venous gangrene".)

MORTALITY AND COMPLICATIONS — For patients with IVC injury who survive long enough to be operated upon, mortality remains high, ranging from 30 to 50 percent [1]. Approximately half of patients die in the first 24 hours of care due to the sequelae of massive transfusion and/or multisystem organ failure. Despite the improved prehospital care and transportation and advances in surgical techniques and perioperative care, mortality rates for IVC trauma have remained unchanged [9].

The finding of free blood in the peritoneal cavity due to IVC injury is associated with a poor prognosis related to difficulty identifying and controlling the injury (eg, lumbar vein avulsion) [1,2,10-12]. In a review of the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) registry, overall mortality for traumatic IVC injury was 42 percent, higher for suprarenal compared with infrarenal injury (66 versus 33 percent, respectively) [1]. Compared with infrarenal IVC injury, suprarenal injury was associated with blunt mechanism (53 versus 32 percent); lower admission systolic blood pressure, pH, and Glasgow Coma Scale; higher injury severity score; and higher thorax and abdomen Abbreviated Injury Scale scores.

Mortality is increased for IVC ligation compared with IVC repair, driven mostly by the difference in mortality for suprarenal IVC injury; mortality is similar for infrarenal IVC ligation versus repair [13]. In an earlier review of the National Trauma Database from 2007 to 2014 that compared the IVC ligation with repair, ligation of the infrarenal IVC was also not associated with increased mortality or lower extremity amputation, but was associated with a higher incidence of acute kidney injury and the need for fasciotomy [14].

Mortality is also increased for blunt compared with a penetrating mechanism of injury [13].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Abdominal compartment syndrome" and "Society guideline links: General issues of trauma management in adults".)

SUMMARY AND RECOMMENDATIONS

●IVC injury – Inferior vena cava (IVC) injury can be particularly challenging to manage. Despite its protected location, the IVC is a commonly injured vascular structure. (See 'Introduction' above.)

●Mechanism of injury – The IVC can be injured via blunt or penetrating mechanisms anywhere along the length of the IVC because of external trauma or from iatrogenic mechanisms. Among traumatic injuries, penetrating injury is overall more common. Penetrating injuries may be a result of low-velocity stab wounds, in which the injury will be confined to the tract itself, to highly destructive wounds from a high-velocity military ordnance. Blunt injuries are related to sudden deceleration events that may avulse structures from the IVC. (See 'Mechanism of injury' above.)

●Trauma presentation – Patients with IVC injury present with symptoms and signs of abdominal bleeding from penetrating injury or retroperitoneal hematoma from blunt or iatrogenic injury, neither of which is specific. Patients with retroperitoneal hematoma may be normotensive or slightly hypotensive with tachycardia and may respond transiently to resuscitation. Intra-abdominal bleeding may be detected on Focused Assessment with Sonography for Trauma (FAST) examination, which may be related to IVC injury but cannot be differentiated from other sources of bleeding. (See 'Trauma evaluation' above.)

●Diagnosis – IVC injury may be suspected based on the mechanism of injury and clinical signs or associated injuries, but the diagnosis requires demonstration of the injury either on direct inspection in the operating room or on vascular imaging, typically abdominal CT. (See 'Diagnosis' above.)

•In the operating room, findings of dark blood pooling in and around the liver or zone I retroperitoneal hematoma raise suspicion for IVC injury. Exploration of the region confirms the diagnosis.

•CT scan may identify hemoperitoneum or retroperitoneal hematoma, but neither of these are specific for IVC injury. Radiologic findings on abdominal CT scan include vena cava contour abnormalities, active extravasation, pseudoaneurysm, and pericaval hematoma.

●IVC anatomy and surgical exposure – Knowledge of the anatomy of the IVC is crucial to appropriate exposure, the techniques for which depend upon the anatomic level (infrarenal, pararenal, suprarenal, subhepatic, retrohepatic, suprahepatic, intrapericardial). Techniques for these exposures are detailed above. (See 'IVC exposure by anatomic level' above.)

●Damage control and resuscitation – A damage control approach may be necessary to identify and control bleeding in a hemodynamically unstable patient. IVC bleeding can generally be controlled with direct pressure using abdominal packs or more focused pressure using sponge sticks. Another option for vascular control is balloon occlusion of the IVC from a femoral venous access. Once bleeding is controlled, injuries can be managed according to damage control principles. (See 'Damage control surgery' above.)

●Approach to vena cava injury – Traumatic IVC injury is most often repaired using open surgical techniques given that many IVC injuries are discovered during abdominal exploration. Endovenous stenting may be an option for traumatic injuries but is more often attempted for iatrogenic injury. (See 'Approach to vena cava injury' above.)

Options for open IVC repair include simple primary repair, patch venoplasty, and interposition grafting. The choice of repair technique depends primarily on the size of the defect and location to some extent (eg, preservation of hepatic veins).

•For injuries that involve <50 percent of the IVC circumference, primary repair can usually be accomplished.

•For injuries that involve >50 percent of the IVC circumference, primary repair is likely to lead to stricture, which can subsequently thrombose. Thus, patch repair or interposition grafting are used. A vein patch or can be used for smaller defects, whereas prosthetic patch or graft material is used for larger/longer defects.

•For patients in extremis, particularly patients with multisystem injuries, IVC ligation may be the only option.

●Mortality and complications – Mortality for IVC injury remains high (between 30 and 50 percent) despite improved prehospital care and advances in surgical techniques and perioperative care. Complications associated with IVC injury include venous thromboembolism. (See 'Mortality and complications' above.)