Inferior Vena Cava Trauma
	Date: Wed, 20 Aug 1997 10:16:02 -0400 (EDT) From: David Napoliello [Nappio@aol.com] During workup of a 19 y/o male, s/p head on mva, intubated for airway management, we found on surveillance CT scan that not only did he have a high grade spleen injury, there was also a question of IVC extravisation. Inferior Vena Cavagram showed a large, contained posterior pseudoaneurysm of the suprarenal IVC. He dropped his pressure only once and was responsive to crystalloid and 2 U Prbc, and remained hemodynamically stable with a hgb-14. Due to the high mortality of Atrial caval shunts and circulatory arrest in this setting,,,we chose not to attempt IVC repair. As prophylaxis against undo physiologic stress and coagulopathy,,,he did undergo laparotomy and splenectomy without incident and remains intubated under observation in our ICU. Does anyone know of any definitive reports on conservative management of IVC injury? and should treatment with a stent-graft be considered? and if so, when should it be implemented?now when the patient is stabilized or should it be reserved only in the face of conservative failure? Thank you. David Napoliello, M.D. Penn State-Geisinger
	Date: Wed, 20 Aug 1997 18:44:14 -0500 (CDT) From: John A. Aucar, M.D. [jaucar@bcm.tmc.edu] This is a very important question that I have not found a definitive answer about. If anyone has published a significant case series on non operative management of large IVC injuries, it has escaped me. I have seen a number of IVC and iliac vein injuries at the Ben Taub, some in stable patients with contained hematomas. I do not recall diagnosing the condition with a pre op cavagram but this sounds like a reasonable idea (if truly stable). In some cases I have probably completed the job that the car or the bullet failed to do. I some cases, probably based on a momentary lapse in my baseline stupidity, I have left a large retroperitoneal hematoma alone. Some of those patients did well and I'm left wondering how big the venous disruption might have been. I suspect that Vena Cava and large vein injuries are more common than we think and some retroperitoneal hematomas that are never explored would likely have caused exsanguination. In some other cases venous repair was likely necessary for survival. Telling them apart is the problem. We have discussed this in conferences and I feel that not exploring venous injuries, especially behind the liver is very acceptable in stable patients. I would not be inclined to mess around with radiographic interventions, since these could also make a stable injury worse. I am purposefully not making a very strong statement because there is no real data here, just conjecture. So far I commend your wise and non meddlesome restraint (if things go bad, I may retract that commendation). I once had plans with Tim Buchman in St. Louis to collect a multi institutional series of Vena Cava injuries to examine the factors pertinent to survival. Your question has rekindled my interest, however, that project is currently clotted off. Let us know how he does. JAA
	Date: Wed, 20 Aug 1997 11:56:51 -0500 From: William B. Schroder MD [wschroder@cctr.umkc.educom] Tough question. Don't have much experience, but if the caval injury is a linear tear, you could probably fix it with less of a to-do than you describe. If its a bigger injury and you're worried about temporary occlusion of the supra-renal IVC (I probably wouldn't be), then using a biomedicus pump to shunt femoral venous blood to the jugular vein would be a good option. OTOH, if this is a retro-hepatic caval injury, I'd be much more reluctant to operate. A stent-graft is so unproven even in the arterial system, and is so likely to clot in the venous system, that I doubt you'd be interested in treating caval thrombosis or budd-chiari as a trade off. WBS
	Date: Mon, 04 Aug 1997 13:06:17 -0400 From: Eric Frykberg M.D. David--Regarding the IVC injury you described--Norm Rich published a nice study of IVC injuries conservatively managed some years ago, showing what we all know to be true--they do well, and he had a relatively long followup--Here, of course, we are talking about blunt trauma. There is no indication to do anything more--the biggest danger to the patient now is our inherent wish to always want to DO something, and always to make OURSELVES feel better rather than be of benefit to the patient. Don't succumb to this temptation by putting in a stent, which then subjects the patient to a needless risk of morbidity for nothing more than your own piece of mind. Any intervention you do should have a proven benefit, and if you can not cite evidence to show benefit, don't do it--there are those who feel just the opposite, that it is ok to subject the patient to such risks and intervene UNLESS they can be proven wrong, which of course turns the scientific method on its head. Rich's data makes sense, given the low pressure system of the IVC--on the arterial side, this is much more of a concern. I have yet to ever see or hear of a report of delayed hemorrhage from untreated venous injuries. Have you? Eric Frykberg, M.D. Jacksonville, Fl