Injury Extra (2005) 36, 337—340

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CASE REPORT

Blunt trauma to the intrapericardial inferior venacava: A case report and review of the literature

Sergio Huerta *, Matthew O. Dolich, Allen J. Cohen

Departments of Surgery and Radiological Sciences, 101 City Drive, Bldg. 10,Rt. 81, University of California, Irvine, Orange, CA 92868, USA

Accepted 21 January 2005

Case report

A 45-year-old woman was involved in a high-speedrear-endmotor vehicle collision andwas transportedby ambulance to our level I trauma centre. Shearrived to the emergency department with a heartrate of 116 beats per minute, and a systolic bloodpressure of 70 mm Hg without jugular venousdistention. Her initial Glasgow Coma Scale was 11.She was intubated in the emergency department.She had bilateral breath sounds, and weak but palp-able femoral pulses. Her hypotension respondedappropriately to initial resuscitation with 4 l of crys-talloid and two units of packed red blood cells(PRBC). Initial chest X-ray demonstrated a widenedmediastinum. Subsequent radiographs revealed aquestion of a left pneumothorax for which a tubethoracostomy was performed. Initial focused assess-ment by ultrasound for trauma (FAST) examinationdemonstrated no free intraperitoneal fluid; however,a followupultrasound showed a small amount of fluidin Morison’s pouch. There was no evidence of peri-cardial effusion. The patient’s haemodynamic statusnormalized and she was transported for computedtomography (CT). Her chest CTwas remarkable for a

* Corresponding author. Tel.: +1 714 456 5532;fax: +1 714 456 7202.

E-mail address: shuerta@uci.edu (S. Huerta).

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periaortic haematoma along the descending thoracicaorta with pericardial blood (Fig. 1B and C) andmultiple rib fractures. Abdominal CT also demon-strated a small amount of free fluidwithout evidenceof solid organ injury (Fig. 1B). During CT imaging thepatient developed recurrent hypotension despiteongoing aggressive resuscitation. This findingtogether with the CT observation prompted us totake the patient to the operating room intendingto perform a pericardial window as the small amountof free fluid observed by CT-abdomen did not explainthe degree of hypotension. A pericardial windowwasperformed and demonstrated the presence of grossblood. Thus, a median sternotomy was immediatelyundertaken. This revealed a 3 cm laceration ofthe intrapericardial IVC at its junction with the rightatrium. This injury was primarily repaired using4-0 non-absorbable monofilament sutures withpledgets. Because of the intrapericardial injuryidentified and the small amount of fluid in detectedby CT-abdomen. An exploratory laparotomy was per-formed to exclude an intrahepactic IVC injury. Thisdemonstrated a linear tear in the liver along thefalciform ligament. This injury was managed by acombination of electrocautery and applicationof topical haemostatic agents. No other intra-abdominal injuries were noted. Postoperative aorticangiography revealed no evidence of thoracic aorticinjury. Her post-operative course was notable for

rved.

338 S. Huerta et al.

Figure 1 Radiographic testing obtained during initial management. Chest X-ray demonstrates a widened mediastinum(A). Computed tomography (CT) of the chest demonstrates pericardial fluid (B) and a questionable aortic arch injury (C).CT of the abdomen showed free fluid above the diaphragm (D).

ventilator-associated pneumonia requiring anti-biotics. She ultimately experienced full recoveryand was discharged to home on post-operative daynumber 37.

Discussion

Although the inferior vena cava is protected by itscentral location, it is vulnerable to both penetratingand blunt trauma. As many as 40% of abdominalvascular injuries involve the IVC4,5,8,11,20 with areported mortality of 21—61%.3,9,10,12 The IVC isanatomically divided into five sections: infrarenal,perirenal, suprarenal, retrohepatic and intraperi-cardial, each of which has implications for exposure,management, and outcome. There appears to be arelationship between the site of injury andmortalityrate, with progressively worse outcome correlatingwith proximity of the injury to the heart.18 Forinstance, injuries of the infrarenal IVC carry a 33%mortality risk while injuries of the intrapericardialIVC have a 50—100% mortality rate.18

The intrapericardial portion of the IVC is only afew centimetres in length, which probably accountsfor the rarity of this injury. Penetrating injuries canaffect any segment of the IVC. However, the intra-

pericardial and retrohepatic segments of the IVC aremost vulnerable to blunt trauma.2 Lacerations ofthe intrapericardial IVC from blunt trauma are likelythe result from the fixation of the IVC to the dia-phragm and anterior displacement of the heart fromrapid decelerating forces. Intrapericardial IVClacerations may conceivably occur from downwarddisplacement of the liver with fixation of the IVC tothe diaphragm, which is presumably the samemechanism that produces retrohepatic IVC injuries.

The pericardial encasement of the intrapericar-dial IVC may result in immediate cardiac tamponadeif sufficient haemorrhage is caused by the injury.However, a small laceration accompanied by hypo-tension may allow soft clot formation at the injuredsite, which may prevent cardiac tamponade.

In this report, we present a patient who probablyformed a soft clot at her inferior vena cava lacera-tion; therefore, no fluid was visualized during theinitial FAST examination. This injury became clini-cally apparent following resuscitation resulting inintravascular expansion, soft clot dislodgment, andfluid accumulation in the pericardial cavity. Thesechanges were followed by hypotension and impend-ing cardiac tamponade.

We suspect that the majority of patients withintrapericardial IVC injuries die in the field from

Blunt trauma to the intrapericardial inferior vena cava 339

Table 1 Review of the literature of intrapericardial IVC injuries

Study n Mortality (%) Mechanism

Pachter et al.16 10 50 —Omert et al.15 6 83 —Rosengart et al.18 3 100 —Tochii et al.19 2 100 52 yo M MVA 35 yo M jumped from buildingVan de Wal20 2 50 Both patients restrained MVA

Case reportsPresent report 1 0 45 yo W restrained MVANinomiya et al.13 1 0 63 yo M stroked by steel frameClements et al.4 1 0 17 yo M unrestrained MVABeer et al.1 1 0 30 yo M MVAFey et al.6 1 0 43 yo M MVAFrezza et al.7 1 0 20 yo W restrained MVAPicard et al.17 1 0 30 yo M penetrating trauma

High mortality is uniformly observed.

exsanguination or cardiac tamponade. Survivorslikely experience a period of haemostasis at the siteof injury.

The present case is similar to previously reportedpatients where successful management of thisinjury has been described (Table 1). A review ofthe literature yielded very few case series with amortality ranging from 50 to 100% (Table 1). As in thecurrent presentation, the literature documents afew case reports with successful outcomes. Deathfrom this injury is unlikely to be reported. Thus,mortality from this injury seems to be well above50%, as reported in the small case series rather thanisolated case reports.

There are several techniques described for therepair of IVC injuries. Appropriate management isdependent on the segment of the cava injured. Theretrohepatic segment of the IVC seems to present thegreatest technical challenge due to its difficult expo-sure. Packing, hepatic vascular isolation, atrio-cavalshunting, active shunting, and cardiopulmonarybypass have all been described.2,3,5,12,14,17,18 Manage-ment of injury to the intrapericardial inferior venacava, however, represents a particular challenge.Median sternotomy must be performed to obtainappropriate exposure. A case with complete avulsionof the intrapericardial IVC was successfully managedwith an atrio-caval bypass.7 Atrial caval active shuntplacement with inferior cannula insertion beyond theinferior vena cava was utilized in a case where morethan50%of the vesselwas lacerated.17Reconstructionof the intrapericardial IVC under cardio-pulmonarybypass was successfully performed by Ninomiyaet al.13 However, as most cases who are able to reachthe hospital alive have only partial laceration of theintrapericardial IVC, primary closure of the lacerationwith non-absorbable sutures, as described in the pre-sent case, should result in satisfactory haemostasis.

Intrapericardial IVC injuries remain a surgicalchallenge. Resuscitation resulting in deteriorationof a patient sustaining decelerating injuries shouldprompt suspicion for this injury. A high index ofsuspicion with targeted diagnostic studies (i.e. anegative fast scan with recurrent hypotension inspite of ongoing fluid resuscitations) should guideimmediate surgical intervention, which is critical tothe successful management of intrapericardial IVCinjuries.

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