Use of an Atriocaval Shunt in a Trauma Patient: First Reported Case in Hawai‘i

Abstract

Background

Traumatic injuries to the retrohepatic vena cava are typically fatal. Emergent access to this area is difficult and patients typically exsanguinate before the injury can be identified and fixed.

Objective

To report the use of an atriocaval shunt in the repair of an injury to the retrohepatic vena cava from a gunshot wound.

Case Report

A 24-year-old man was shot in his right chest suffering a penetrating injury to the liver and inferior vena cava. Surgical repair was performed with the aid of an atriocaval shunt fashioned from a chest tube. He survived and recovered without incident.

Conclusion

Atriocaval shunting may be a life-saving option for uncontrolled hemorrhage from injuries to the retrohepatic vena cava.

Introduction

Injuries to the retrohepatic inferior vena cava (IVC) and hepatic veins in trauma are associated with extremely high mortality. In order to repair such an injury before a patient exanguinates, the surgeon must have a plan. The atriocaval shunt was first described by Schrock et al in 1968 as a means of controlling hemorrhage from this type of injury.¹ Herein, we report the successful use of an atriocaval shunt (ACS) in a trauma patient with a penetrating injury to the retrohepatic IVC. To the best of our knowledge this is the first reported case in Hawai‘i.

Case Report

A 24-year-old man was shot in the right chest during an attempted car jacking. He was able to drive himself to medical attention. On initial examination by the trauma team his airway was intact, he had bilateral breath sounds and was hemodynamically stable. The presumed entrance wound entered the right chest at the anterior axillary line 6 cm below the nipple. Chest radiograph showed the bullet overlying the thoracic vertebrae. Focused assessment with sonography in trauma (FAST) examination revealed hemoperitoneum.

Consent was obtained, a right tube thoracostomy tube was placed and he was electively intubated. Exploratory laparotomy revealed a defect in the right diaphragm, a hemostatic injury to the dome of the right lobe of the liver and a large nonpulsatile, nonexpanding zone 1 hematoma. Upon exploring the hematoma we encountered massive hemorrhage from the retrohepatic IVC. After a right visceral medialization, we performed a median sternotomy for improved exposure. We were unable to expose the defect and thus performed an atriocaval shunt using a 40 French chest tube with extra vent holes. We were able to identify the 1.5 cm defect, control the hemorrhage and repair the defect primarily with nonabsorbable suture.

His abdomen and the diaphragmatic defect were closed primarily on post-operative day number two. He recovered uneventfully and was discharged on post-operative day number 7.

Discussion

The concept and use of the ACS was first described by Schrock et al in 1968.¹ Since then there have been several case reports and small case series describing its use. The technique and associated pitfalls have been previously described in detail.² In brief, a 36 French chest tube (or a 9mm endotracheal tube) with an extra side vent hole is inserted through the right atrium into the IVC after incision of the atrial appendage and secured with a purse-string stitch. The shunt is then secured with tourniquets at the intrapericardial and suprarenal vena cava. In theory, if performed correctly and combined with a Pringle maneuver (temporary occlusion of the porta hepatis), the ACS should control almost all bleeding. It is based on the anatomic observation that only the hepatic veins, right adrenal vein, and inferior phrenic veins enter the IVC above the level of the renal veins.¹ In actuality, it only reduces bleeding by 40–60%.³

Problems that may occur with this technique are related to exposure and tube placement. In order to place the tube into the right atrium the surgeon must have access to the chest, ideally via a median sternotomy. If the proper equipment is not in the room or if the surgeon is unfamiliar with this approach, access to the right atrium may be delayed. In addition, if the renal veins are not well exposed or visualized, placing the lower tourniquet below the renal veins may lead to continued hemorrhage from the defect.

Placement of the tube can sometimes be problematic. The shunt must bypass the defect and not protrude through the defect causing further injury. The vents must also be positioned proximal and distal to the tourniquet, or blood will be shunted through the defect rather than around it.

Survival in patients in which the ACS is performed is low. One of the largest and most comprehensive case series is from Burch, Feliciano and Mattox who used the ACS in 31 patients.² The mechanism was penetrating trauma in 27 patients with only 6 survivors (19%), all of which had gunshot wounds to the retrohepatic IVC. Kudst et al reported the use of the ACS in 18 patients of which only 4 survived (22%).⁴ In large part, the dismal prognosis in these patients is attributable to the severe nature and location of the injury. These patients often present in extremis with severe hemorrhagic shock and additional life-threatening injuries. However, lack of quick access to equipment, difficulties in adequate exposure, and improper shunt placement may also contribute.

Alternatives to the ACS have been reported. Pilcher et al described a balloon shunt inserted through the saphenofemoral junction to occlude the IVC, but current use is limited.⁵ Complete vascular isolation has been described, which involves cross-clamping the supraceliac aorta, the suprarenal and intrapericardial IVC, and the porta hepatis.⁶ However, this is poorly tolerated in a hypovolemic patient. A direct transhepatic approach was reported by Pachter et al with good success, but as Burch et al maintains, this success may be best attributable to the surgeon's skill rather than the technique.⁷ Several case reports indicate success with complete venovenous bypass, the idea born from its use in liver transplantation.^8,9 If the equipment and expertise is available this may be a viable option.

In this situation, the shunt worked well, but it did not significantly reduce the amount of hemorrhage. The real benefit was in the tactile sensation it provided. We were able to palpate the chest tube through the IVC and identify the defect. We were then able to place a Satinsky clamp, stop the hemorrhage and repair the 1.5 cm defect in the IVC.

It is also important to consider whether we could have treated this injury conservatively. Prior to exploration of this zone 1 hematoma, the patient was stable and the hematoma was nonpulsatile and nonexpanding. Traditional teaching and current practice maintains that all zone 1 hematomas, whether from blunt or penetrating injuries, should be explored. However, this has been challenged.

Buckman et al wrote, “There is no evidence that injuries of the retrohepatic or immediate subhepatic vena cava, associated with spontaneously contained hematomas, require repair to prevent recurrent hemorrhage or thromboembolic complications.”¹⁰ His point is well taken. There is increasing literature to support the nonoperative management of even grade IV and V injuries with major venous injuries.¹¹ In addition, interventional radiologic techniques are also evolving. Angiography and embolization or venous stenting with or without perihepatic packing may avoid the need for operative shunting techniques altogether in patients with a stable hematoma.

Conclusion

Traumatic injuries to the retrohepatic vena cava are difficult to treat and are typically fatal. While not a perfect solution, in certain situations the use of an atriocaval shunt may prove a life-saving intervention.