CONTEMPORARY MANAGEMENT STRATEGY FOR MAJOR INFERIOR VENA-CAVAL INJURIES

Injuries of the inferior vena cava (IVC) require prompt and definitive action. To evaluate our current management strategy, we reviewed 38 p atients with IVC trauma treated from 1983 through 1990. Sixteen were i njured by gunshots, eight by stabs, and 14 by blunt mechanisms. Thirty of the 38 survived (79%). All were awake on presentation, although 45 % were hypotensive (systolic blood pressure <90 mm Hg). The mean Injur y Severity Score was 27. At laparotomy all demonstrated active retrope ritoneal bleeding or an expanding hematoma. The caval injury was retro hepatic in 12 (three involving the hepatic veins), suprarenal in seven , pararenal in nine, and infrarenal in ten. Among the eight deaths, fi ve had retrohepatic injuries, two pararenal injuries, and one had an i nfrarenal injury. Surgical repair was accomplished in 33, 26 (79%) via lateral venorrhaphy and seven via polytetrafluoroethylene patch repai r. The right chest was entered with diaphragmatic division in 8 of 12 cases with retrohepatic injuries. Two atrial-caval shunts were used an d both patients survived. Twenty follow-up studies (at greater-than-or -equal-to 3 months) were performed in which three patients demonstrate d IVC occlusion, and one had a Budd-Chiari-like syndrome. We conclude that inferior vena caval injury remains a highly lethal injury. Succes sful outcome depends on prompt volume restoration, a stratified select ive management approach, and avoidance of hypothermia. Prosthetic vena caval reconstruction represents an acceptable alternative.