Asian Cardiovasc Thorac Ann 2000;8:178-179
© 2000 Asia Publishing EXchange Pte Ltd
Control of Persistent Inferior Vena Caval Bleeding
Bhupesh D Shah, MCh,
Deena Shah, MD,
Sakuntala Calla, MD,
Mehul Shah, MCh,
Varsha Shah, MCh
Department of Cardiothoracic Surgery
U.N. Mehta Institute of Cardiology and Research Centre
Civil Hospital
Ahmedabad, Gujarat, India
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For reprint information contact: Bhupesh D Shah, MCh Tel: 91 79 664 1601 Fax: 91 79 656 1094 email: rbshah{at}wilnetonline.net B/1 Anisha Flats, Dhumketu Marg, Mahalaxmi Cross Road, Paldi, Ahmedabad 380007, Gurajat, India.
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Abstract
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A technique to control inferior vena caval bleeding by clockwise rotation of the inferior vena cava after skeletization, is described. This gave excellent hemostatic control and the inferior vena cava was stitched in this position. On follow-up, there was no evidence of compromised inferior vena caval drainage.
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Introduction
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Great vessel and cardiac chamber injuries may occur during open heart surgery and control of bleeding in such cases is a surgical challenge. This is especially true for inferior vena cava (IVC) injuries, particularly if they are not directly approachable.
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Case Report
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Atrial septal defect closure through a manubrium-sparing sternotomy was undertaken in a 22-year-old man. Cardiopulmonary bypass (CPB) was instituted using a Bentley 10 Plus bubble oxygenator (Baxter Healthcare Corp., Irvine, CA, USA). The superior vena cava and the IVC were cannulated with Medtronic 24 and 31 cannulae, respectively (Medtronic, Inc., Minneapolis, MN, USA). Both cavae were dissected and looped with umbilical tape. Cold crystalloid cardioplegia and mild hypothermia (34°C) were used for myocardial protection. A large posteriorly situated secundum atrial septal defect was closed with a pericardial patch during a total crossclamp time of 23 minutes. While coming off CPB, torrential venous bleeding was observed from the posterior part of the IVC near the cavoatrial junction, but the site of injury could not be properly visualized due to the extent of the bleeding. External vein suturing was attempted with 5/0 Prolene (Surgical Specialities Corp., Reading, PA, USA) to control the bleeding while on CPB, but this was unsuccessful. Therefore, it was decided to institute deep-hypothermic circulatory arrest using the same oxygenator, in view of the emergency.
The circulating hematocrit was 27%, it was brought down to 23% using crystalloids. Intravenous methylprednisolone (1 g), mannitol (70 mL of 20% solution), and thiopental sodium (1.4 g) were given for cerebral and renal protection. Cooling was carried out at a rate of 1°C per minute until the core temperature was 20°C. After crossclamping, cold blood cardioplegia was used for myocardial protection and two-thirds of the estimated circulating blood volume was drained into the venous reservoir. The IVC cannula was removed for better exposure. The right atrium was opened through the previous atriotomy site. A tear was found in the posterior part of the IVC near the cavoatrial junction, measuring approximately 2.5 cm transversely. The stitches from the previously attempted vein suturing were seen but approximation of the torn IVC edges was incomplete. These stitches were removed and the IVC was repaired from the lumen with 5/0 Prolene. CPB was reinstituted after 10 minutes, at a low flow of 0.5 L•m–2 through the superior vena caval cannula. The right atrium was resutured and the IVC cannula was reinserted. Slow rewarming was started. Careful deairing was performed and the aortic crossclamp was released after 28 minutes, at a temperature of 24°C. The patient was weaned from bypass after a total CPB time of 5 hours and 36 minutes.
While coming off CPB, continuous venous bleeding was noticed from the same site. External vein suturing was reattempted with pericardial pledgets using 4/0 Prolene. This failed to control the bleeding. The whole pericardial reflection of the diaphragmatic portion of the IVC was dissected and skeletization of the IVC was undertaken from the right atrium to the hepatic veins. The IVC was rotated clockwise by 60° (as viewed from the head), using two stay sutures. This was well tolerated with no bleeding, hemodynamic instability, or hepatomegaly. After a 15-minute observation period, the IVC was sutured in this position using 3/0 Prolene with pericardial pledgets (Figures 1 to 3
). The postoperative course was smooth and there was no hepatic, renal, or neurological com-promise. The patient was discharged on the 7th day, with no evidence of IVC obstruction.
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Figure 1. Normal anatomy. D = diaphragmatic muscle, HV = hepatic vein, IVC = inferior vena cava, RA = right atrium.
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Figure 2. Skeletization of the inferior vena cava. 1 = right atrium, 2 = inferior vena caval opening in the diaphragm, 3 = diaphragm, 4 = hepatic vein.
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Discussion
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The IVC is divided into intrapericardial, suprahepatic and infrahepatic portions. Any surgical procedure around the intrapericardial and suprahepatic IVC is difficult because of the complexity of vascular access in this area. Various direct and indirect techniques have been employed to repair the IVC, such as direct vein suturing, pericardial patching, cavoatrial shunting, balloon occlusion, direct repair with deep-hypothermic circulatory arrest, and hepatoatrial anastomosis with venovenous bypass.1–3 Such techniques are complex and time consuming and repair may not be successful. In this patient, external vein suturing, direct intraluminal repair, and external vein suturing with pericardial pledgets were carried out sequentially but each was unsuccessful in controlling the bleeding.
The idea behind rotation is to reduce the diameter of the IVC, which has a plicating effect on the wall. The direction of rotation is determined by the site of tear. The intrapericardial IVC is approximately 50% shorter laterally than the medial aspect. This is because the pericardial reflection is oblique (inferomedially). In cases of posterior and left lateral tears, better plication is achieved by clockwise rotation. With right lateral tears, better hemostasis will be achieved by anticlockwise rotation. In addition, while placing sutures to maintain clockwise rotation, mild angulation can also be given in a direction that leads to reduction in wall stress in the area of the repair. The important factors during this procedure are to ensure that the IVC lumen is not compromised by more than 50% and there is no hepatomegaly on abdominal palpation, which would indicate hepatic vein or IVC obstruction. Therefore, the patient should be carefully observed after taking trial sutures before final repair. This technique may be lifesaving in a desperate situation; bleeding from an IVC tear is notoriously difficult to control.
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References
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Ravikumar S, Stahl WM. Intraluminal balloon catheter occlusion for major vena cava injuries. J Trauma 1985; 25:458–60.[Medline]
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Baumgartner F, Milliken J, Scudamore C, Nair C, Gelman J, Scott R, et al. Extracorporeal methods of vascular control for difficult IVC procedures. Am Surg 1996;62:246–8.[Medline]
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Zogno M, Danieli G, Pardini A, Fucci C, Ferrari M, Caradonna E, et al. Hepato-atrial anastomosis as emergency treatment for traumatic rupture of suprahepatic inferior vena cava and hepatic veins. Eur J Cardio-thorac Surg 1990;4:675–7.[Abstract]
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Abstract
Introduction
