Traumatic inferior vena cava dissection

We report a case of inferior vena cava dissection following blunt abdominal trauma that was managed by our vascular surgery unit in December 2014. These injuries are rarely seen but can have significant consequences. Our management of this case is described and the available literature is reviewed. We report a case of inferior vena cava dissection following blunt abdominal trauma that was managed by our vascular surgery unit in December 2014. These injuries are rarely seen but can have significant consequences. Our management of this case is described and the available literature is reviewed. Dissection of the inferior vena cava (IVC) is rarely reported. These injuries may be missed if the patient is asymptomatic and does not undergo imaging studies. High-energy blunt abdominal trauma is the most common mechanism of injury. The management of an IVC dissection is individualized, depending on the extent of damage to the vena cava. The treatment can vary from conservative management with anticoagulation alone to endovascular or open surgery. Written consent was obtained from the patient for the use of all the case details including images. A 25-year-old woman, previously well, was brought into the emergency department following a high-speed motor vehicle accident. She was a back-seat passenger. On arrival, the patient was stable with a blood pressure of 126/70 mm Hg and pulse of 100 beats/min; she was comfortably breathing, with normal oxygen saturation. She had sustained the following injuries: a Gustilo-Anderson grade I open tibia fracture on the right, a pelvic fracture, an orbital fracture, and an extraperitoneal bladder injury. On examination, her abdomen was soft, with no peritonism or any evidence of intra-abdominal pathology. After stabilization of the fractures, a computed tomography (CT) scan of the abdomen and pelvis was performed. The CT scan revealed an intimal flap in the infrarenal IVC (Fig 1). The defect extended from the confluence of the iliac veins to the renal veins and extended into the lumen of the right renal vein (Fig 2). Both true and false lumens were patent. The left renal vein was not involved. Other findings on the CT scan were a sacral fracture extending into the sacroiliac joint and bilateral inferior and superior pubic rami fractures. The extraperitoneal bladder injury was confirmed by means of cystography.Fig 2Dissection extending to the right renal vein.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The patient was taken to the operating room for débridement and external fixation of the tibia fracture and placement of a Steinmann pin to assist with traction. Postoperatively, she was admitted to the high care unit for monitoring. An infusion of 1000 IU/h of unfractionated heparin was started 6 hours postoperatively. The infusion rate was titrated against the activated partial thromboplastin time, aiming for a value of 60 to 80 seconds. This was changed to a twice-daily 60-mg subcutaneous dose of low-molecular-weight heparin (enoxaparin sodium) after 24 hours. The bladder and orbital injuries were treated conservatively, and skeletal traction was applied. Her condition remained stable. After 4 days, she was discharged to the general ward to continue enoxaparin therapy. Bed rest and traction were continued for treatment of the orthopedic injuries. She was also issued with class II graded compression stockings. A duplex ultrasound examination was done on day 6 to assess the IVC, specifically to determine if there was any evidence of progression of the defect and whether any thrombus had formed. The defect remained stable with no associated thrombus formation. The rest of her hospital stay was uneventful. She was discharged on day 33 to complete a total of 6 weeks of enoxaparin therapy at home. During follow-up at the vascular outpatient clinic, she remained asymptomatic, and no abnormalities were noted on examination. The external fixation was removed after 3 months with a good result. A final follow-up examination was done at 12 months. She reported that shortly after discharge, she occasionally had bilateral lower extremity swelling. The swelling occurred after standing for long periods, involved only the lower leg, and was relieved by rest and elevation. These symptoms had since resolved. She did not have any other complications. An ultrasound investigation was done during the 12-month follow-up. The IVC remained patent without any evidence of thrombus formation. The intimal flap could not be seen (Fig 3). IVC dissection is a rare but potentially fatal injury. There are only a few reported cases in the literature. Traumatic IVC dissection seems to occur mainly in the setting of high-energy blunt abdominal trauma. There are, however, cases of IVC dissection reported secondary to endovascular procedures and tumor surgery.1Puwanant S. Roger L. Kalra M. Farley D.R. Chandrasekaran K. Incidental detection of inferior vena caval dissection by intraoperative high frequency vascular duplex ultrasonography.Echocardiography. 2007; 24: 269-271Crossref PubMed Scopus (3) Google Scholar The anatomic position of the IVC prevents it from being injured unless there are significant forces involved. The mechanism of injury in most trauma-related cases seems to be motor vehicle, motorcycle, and pedestrian vehicle incidents.2Singh S.P. Canon C.L. Treat R.C. Crowe D.R. O'Dell R.H. Koehler R.E. Traumatic dissection of the inferior vena cava.AJR Am J Roentgenol. 1997; 168: 253-254Crossref PubMed Scopus (13) Google Scholar, 3Piffaretti G. Carrafiello G. Piacentino F. Castelli P. Traumatic IVC injury repair: the endovascular alternative.Endovascular Today. November 2013; : 39-43Google Scholar, 4Vaidya S.S. Bhargava P. Marder C.P. Dighe M.K. Inferior vena cava dissection following blunt abdominal trauma.Emerg Radiol. 2010; 17: 339-342Crossref PubMed Scopus (7) Google Scholar These patients usually also have numerous other injuries, especially multiple pelvic fractures.2Singh S.P. Canon C.L. Treat R.C. Crowe D.R. O'Dell R.H. Koehler R.E. Traumatic dissection of the inferior vena cava.AJR Am J Roentgenol. 1997; 168: 253-254Crossref PubMed Scopus (13) Google Scholar The IVC wall has less developed layers and is less susceptible to atheromatous lesions compared with the aorta, so dissection occurs less often. It is possible that many cases are not detected because of the lack of clinical features, and unless they are associated with rupture, they may be hemodynamically stable. With the ever-increasing availability and use of CT scanning in the trauma setting, more cases of IVC dissection may be seen. In our case, the dissection was seen incidentally on CT; the initial indication for the scan was the pelvic fracture and to exclude other blunt abdominal injuries. Symptoms and signs may be absent if there is still good flow in the lumen of the IVC despite the dissection. If there is no rupture, thrombosis, or embolism, the injury may go unnoticed. The intimal flap will increase the risk for thrombus formation and possible pulmonary embolism. The venous system has a relatively low pressure, so progression of the dissection will be less likely. Even with complete obstruction of the IVC, patients may still do well. There have been numerous cases of uncontrollable IVC hemorrhage that was managed by ligation, and these patients generally have a favorable outcome.5Sullivan P.S. Dente C.J. Patel S. Carmichael M. Srinivasan J.K. Wyrzykowski A.D. et al.Outcome of ligation of the inferior vena cava in the modern era.Am J Surg. 2010; 199: 500-506Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 6Votanopoulos K.I. Welsh F.J. Mattox K.L. Suprarenal inferior vena cava ligation: a rare survivor.J Trauma. 2009; 67: 179-180Crossref Scopus (7) Google Scholar Bilateral lower limb swelling is common after ligation, but fasciotomy is seldom necessary. A retrospective review over 10 years done by Hansen et al from Minneapolis showed that the overall prognosis of IVC injuries is poor, and an overall mortality as high as 55% was reported.7Hansen C.J. Bernadas C. West M.A. Ney A.L. Muehlsredt S. Cohen M. et al.Abdominal vena cava injuries: outcomes remain dismal.Surgery. 2000; 128: 572-578Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Penetrating trauma to the IVC was the most common injury. They did not specifically mention dissection and blunt injury. Hemodynamic instability is often present with a rupture of the IVC due to significant hemorrhage. In a review by Netto et al8Netto F.A. Tien H. Hamilton P. Rizoli S.B. Chu P. Maggisano R. et al.Diagnosis and outcome of blunt caval injuries in the modern trauma Centre.J Trauma. 2006; 61: 1053-1057Crossref PubMed Scopus (28) Google Scholar from Sunnybrook Health Sciences Centre in Ontario, 10 patients were identified who had blunt abdominal vena cava injuries in a 6-year period. One of only three survivors had an intimal flap with pericaval hematoma. This patient was successfully treated nonoperatively. The management of IVC dissection has been varied and treatment individualized in each case. In cases in which the dissection caused significant thrombus formation and the risk of life-threatening embolism was present, an IVC filter was placed and subsequently removed some time later.4Vaidya S.S. Bhargava P. Marder C.P. Dighe M.K. Inferior vena cava dissection following blunt abdominal trauma.Emerg Radiol. 2010; 17: 339-342Crossref PubMed Scopus (7) Google Scholar In a case in which tumor thrombectomy from the IVC resulted in a dissection, there was no visible thrombus and the patient was treated with antiplatelet therapy.1Puwanant S. Roger L. Kalra M. Farley D.R. Chandrasekaran K. Incidental detection of inferior vena caval dissection by intraoperative high frequency vascular duplex ultrasonography.Echocardiography. 2007; 24: 269-271Crossref PubMed Scopus (3) Google Scholar In our case, as no thrombus was present, there was no indication to place an IVC filter. To prevent thrombus formation, the patient was treated by means of therapeutic anticoagulation, initially with an unfractionated heparin infusion and then by subcutaneous low-molecular-weight heparin. IVC dissection is rare but potentially fatal. The choice of treatment has to be individualized according to the specific features of each case. We report a case of traumatic IVC dissection. The patient remained stable throughout the hospital stay. There was no rupture or pericaval hematoma present. The IVC remained patent and no thrombus was seen on imaging. The patient was treated with anticoagulation and graded compression stockings. On follow-up, there were no clinical features of pulmonary embolism or venous hypertension, and the patient had returned to her baseline function. Anticoagulation alone was effective in this case.

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