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Ligation of the Inferior Vena Cava Above the Renal Veins
[961
Co.
LIGATIOX OF 'THE IKFERIOR VE"\:A CAVA ABOVE THE REN:tL JOHN R WEAR, ,TR.* Fror11. the Sect·iun of Urology, University Hospital, Ann Arbor, Mich .
Ligation of the inferior 1•ena cant below the renal veins has become an accepted surgical proeedure in recent years. This has been done in instances of throm bophlebitis of the veins of the pelvis or lower extremities where pulmonary cmboli have occLHn'cl. The operation has also been performed where extPnsive urological or gPneral surgical procedures necessitatr: the resection of a portion of this vessel during the removal of a neoplasm. Accidental tramna to the inferior vena cava resulting in sudden rnassivc hemorrhage has been treated 1Yith ligation below the renal veins. Some surgeons advocate such ligation in preference to lateral suture repair because of difficulty getting good closure of this thin walled structure. The ability of patients to tolerate and survive a ligation at tbis Je\·el with minimal sequeJ!ae has been well clonimentecl. It has long been held, however, that ligation of the inferior vena cava above the adrenal and/or renal VC'ins was certain to result in death. Experimental studies on animals in this regard have been clone by less than a dozen men and many of their reports have been published in thE' French literature. Their results have been conflicting and designation of the 1mxlominant collateral venous channels in the surviving anirnals has varied. An experimental study was undertaken to determine if dogs would survive ligation of the inferior vena cava above the renal veins and to observe the collateral circulation brought into this procedure.
distension of the veins belo" the point of and a minimal to moderate amount of }w,n1orrlrnge into the perircnal and retrop<'ri1,oni\1 I. tissues. No thromboses were found and there no apparent collateral circulation of any nrngmtucle. The surviving animal went througl1 a tory phase of renal failure: c:lrnmderized oliguria and azotemia. The urinary cmtpui less than :300 cc for C'ach of the first to 1600 cc on the fifth stabilized at 7.'50 cc day. The blood urea nitrogen rose from per cent to 62.0 mg. per ecnt 1-m the second po~i..operative day and was down to 2;3.2 .mg. cent by thP seventh Wl\S no significant change in the serum lytes during this period. Operative followed by sacrifice of the on the tenth operative day revealed I) minimal distension the superficial veins of the anterior abdon:innl wall, 2) slight cyanosis of the kidneys, ,1) prominent capsular veins which coalesced into network over botb kidneys, 4) lumbar nnd adrenal veins the flow of which filled the vena cava above the point (li!atation of the vertebral rhagP into the perirenal or 7) no ascites nor edema of the and 8) no thromboses. DlSCUSSl,lN
MosL of the animal mortality
Fi VP adult mongrel were subjected to ligation of the inferior vcna eava between the adrenal and renal veins. Four of these animals died in a. shock~like state withm 3tl hours of tlrn procedure. Autopsy findings included marked congestion and of the kidneys, for publict1tion FebruaTy 6, l961
at annual meeting of ::'-J orl:h Central Section of American lTrological Association, Inc., Frenck Lick, Ind., October 19-22, 1960. 'Present address: DeJJartment of Urology, University Hospital, Madison, Wis 301
creased venous return to the cardiac output, and shock. Some have incriminated adrenal infarction as the cause of these this is not borne 0L1t the l). Note the similar survival rates whet],e,. ligation is performed above thP adrenal above the renal veins. "This would also sugge6L that the adrenal veins are not of ma.JO!"
302
JOHN B. WEAR, JR.
tance in the collateral circulation following inferior vena cava ligation. From a practical standpoint it may be recalled that in the human the left adrenal vein rarely enters the inferior vena cava as a separate vessel above the left renal vein. Deaths in the early postoperative period could not have been due to uremia since this takes 8 to 10 days to develop following bilateral nephrectomy. Deaths in the later postoperative period have been due to renal failure or septic complications. From the previous discussion it is obvious that survival depends in large part upon the presence of pre-existing collateral venous channels. Table 2 depicts the rating of vessels of collateral circulation consolidated from reports of ten investigators on over fifty animals and patients who survived obstruction of the inferior vena cava above the renal veins. Our surviving animal demonstrated collateral vessels in groups 1, 2, 5, and 7. The pathological Fenal lesion in surviving animals has been well described by many authors. It begins with cloudy swelling and early degeneration of the epithelium of the proximal convoluted tubule. This may progress to dissolution of the tubular epithelium and may subsequently involve the distal convoluted tubule although the glomeruTABLE l. Results of ligation of the inferior vena cava in dogs Above the Adrenal Veins Year
Done
1904 1911 1929 1940 1952 1955 1957 1960
Above the Renal Veins
Investigator
Gosset and Lecene Bej an and Cohn Polkey Whittenberger and Huggins Ripstein and associates Massotte and Cardusi Lejeune-Ledant Wear
Totals ....... .........
Surv. Done -- --
Surv.
0
0
-2 0
4 0 0
0 0 0
8 5 2
8 1 0
42
18
0
0
8
5
0
0
12 0
10
0 1 - - - - --- - 22 10 33 66 0
0 5
----·---~
Per cent survival. .....
50%
45%
TABLE 2. Consolidated rating of major veins of collateral circulation Rating
Major Venous Systems
References
1.
Lumbar, segmental, iliolumbar and ascending lumbar veins Vertebral, intervertebral, and spinal veins Azygos and hemiazygos veins Epigastric and internal mammary veins Renal capsular veins Spermatic or ovarian veins Adrenal veins Inferior mesenteric vein and the portal system
13
2. 3. 4. 5. 6. 7. 8.
8 7 6 5 2 2 2
!us is usually not affected. Since any portion of the renal tubule m.ay become involved the process should not be considered a "lower nephron nephrosis." Survival from the phase of acute renal failure depends upon the extent of irreversible renal damage and upon the return of an adequate number of functioning nephrons. CLINICAL REPORTS
Such eminent surgeons as Kocher and Billroth are reported to have accidentally ligated the inferior vena cava below the renal veins in the 1880's. By 1910 there were 10 case reports in the literature of ligation at this level and the mortality rate was 40 per cent. Many other cases of lig~tion and/or operative trauma to the lower third of the inferior vena cava have since been reported with mortality rates of less than 5 per cent. It is interesting to note that among the early cases of injury to the inferior vena cava the vast majority of such instances occurred during a right nephrectomy performed by the transabdominal route for either neoplasm or a tuberculous pyohydronephrosis. One of the first reports of injury to the inferior vena cava above the renal veins was published by Ripstein and Miller1 in 1949. During a right nephrectomy a portion of the vessel was excised and the defect was closed by direct lateral suture. Following this procedure the lumen was so compromised that the inferior vena cava remained collapsed above that point. The patient survived after hemodialysis was used in the treatment of 1 Ripstein, C. B. and Miller, C. G.: Obstruction of the inferior vena cava above the renal veins. Ann. Surg., 130: 958-962, 1949.
LJGA'I'ION OF lNFI<;lUOR VK,A CAVA._
the postop<--:rntin--: 1·pnal faili.ue which was char,wt.erizPd by an nourn·ot<'ill nitrngen peak of 172 mg. per cent arnl 7 of amuia. Petkovic and :rnsociakR 2 in l 9i57 prescmtcd n, r·as<" ol' n vnlsion of tlw rernil vein from the inJerior n--:rn1, ciwa during ,1 right nephn,'ctomy for tul1erc11lons pyoh~·dronephrn,,is. Lateral suture was followed a dinirnl cmirse suggestive of thrombosis of the rnforior vena ca1·a and tlie left n,nal vein. The IJloo
Perhaps the rn.ost Profe~sor Bolot <'ik
and (i11 1959) tore the inferior ,·pna cant u.ncl were compelkd to ligate this ve:ssd both
NUAT:\!ARY
:,ho\'<: and bd01v tlw left renal 1·c:in. Altbough a ovarian ,·ein mi~ noted to Lw present they elected to perform a ldt s11kuo-renal shunt am! Uw patient ~nrvin·d \1·ithot1t ,sequellae after three uf marked olignrin, n, bloocl nrca nitrogen twak ol' J .50 mg. per cent and a 2 1veck period of diuresis. ,\lknlt1j, i\I. and Cvetkovic, B. · cave ,w eourn dC' la nephrectr:rnsiioire. ,J. urnl. K.: Inferior 1D59.
An expt:rirncntaJ ,'itudy a11tl wvi<'\\ of the litu·,1,· tnrr :11·t prcseutc:d lig:tt,io11 of Uw iilk rior ,Tna toaY11 al101·c: tll/c reual n'i1rn. Sun·i q,J;-; ,;, 0
!Joth animals and Jrnman~ lrnn' heen n·po1t,,,l satisfact01·)r outcome ll,JJJlt'a.rn to dcpu,c! u IH'Jl t,h,, prrseuc·e of adequate c:oliu/,,.·rn,! ,·enmis chmrnels awl npon the t1·eat1m'11t :11' t,]1, acute n·rnil fnilnre.
·1 De!.rie, P .. Is the oblite1·e1tio11 of the inf;:no; ye110 c:ava above the n:n,11 veinK fote1P from Fr.) Press() rnAd , 64: 10\J,-,, 1%(i.
Co.
LIGATIOX OF 'THE IKFERIOR VE"\:A CAVA ABOVE THE REN:tL JOHN R WEAR, ,TR.* Fror11. the Sect·iun of Urology, University Hospital, Ann Arbor, Mich .
Ligation of the inferior 1•ena cant below the renal veins has become an accepted surgical proeedure in recent years. This has been done in instances of throm bophlebitis of the veins of the pelvis or lower extremities where pulmonary cmboli have occLHn'cl. The operation has also been performed where extPnsive urological or gPneral surgical procedures necessitatr: the resection of a portion of this vessel during the removal of a neoplasm. Accidental tramna to the inferior vena cava resulting in sudden rnassivc hemorrhage has been treated 1Yith ligation below the renal veins. Some surgeons advocate such ligation in preference to lateral suture repair because of difficulty getting good closure of this thin walled structure. The ability of patients to tolerate and survive a ligation at tbis Je\·el with minimal sequeJ!ae has been well clonimentecl. It has long been held, however, that ligation of the inferior vena cava above the adrenal and/or renal VC'ins was certain to result in death. Experimental studies on animals in this regard have been clone by less than a dozen men and many of their reports have been published in thE' French literature. Their results have been conflicting and designation of the 1mxlominant collateral venous channels in the surviving anirnals has varied. An experimental study was undertaken to determine if dogs would survive ligation of the inferior vena cava above the renal veins and to observe the collateral circulation brought into this procedure.
distension of the veins belo" the point of and a minimal to moderate amount of }w,n1orrlrnge into the perircnal and retrop<'ri1,oni\1 I. tissues. No thromboses were found and there no apparent collateral circulation of any nrngmtucle. The surviving animal went througl1 a tory phase of renal failure: c:lrnmderized oliguria and azotemia. The urinary cmtpui less than :300 cc for C'ach of the first to 1600 cc on the fifth stabilized at 7.'50 cc day. The blood urea nitrogen rose from per cent to 62.0 mg. per ecnt 1-m the second po~i..operative day and was down to 2;3.2 .mg. cent by thP seventh Wl\S no significant change in the serum lytes during this period. Operative followed by sacrifice of the on the tenth operative day revealed I) minimal distension the superficial veins of the anterior abdon:innl wall, 2) slight cyanosis of the kidneys, ,1) prominent capsular veins which coalesced into network over botb kidneys, 4) lumbar nnd adrenal veins the flow of which filled the vena cava above the point (li!atation of the vertebral rhagP into the perirenal or 7) no ascites nor edema of the and 8) no thromboses. DlSCUSSl,lN
MosL of the animal mortality
Fi VP adult mongrel were subjected to ligation of the inferior vcna eava between the adrenal and renal veins. Four of these animals died in a. shock~like state withm 3tl hours of tlrn procedure. Autopsy findings included marked congestion and of the kidneys, for publict1tion FebruaTy 6, l961
at annual meeting of ::'-J orl:h Central Section of American lTrological Association, Inc., Frenck Lick, Ind., October 19-22, 1960. 'Present address: DeJJartment of Urology, University Hospital, Madison, Wis 301
creased venous return to the cardiac output, and shock. Some have incriminated adrenal infarction as the cause of these this is not borne 0L1t the l). Note the similar survival rates whet],e,. ligation is performed above thP adrenal above the renal veins. "This would also sugge6L that the adrenal veins are not of ma.JO!"
302
JOHN B. WEAR, JR.
tance in the collateral circulation following inferior vena cava ligation. From a practical standpoint it may be recalled that in the human the left adrenal vein rarely enters the inferior vena cava as a separate vessel above the left renal vein. Deaths in the early postoperative period could not have been due to uremia since this takes 8 to 10 days to develop following bilateral nephrectomy. Deaths in the later postoperative period have been due to renal failure or septic complications. From the previous discussion it is obvious that survival depends in large part upon the presence of pre-existing collateral venous channels. Table 2 depicts the rating of vessels of collateral circulation consolidated from reports of ten investigators on over fifty animals and patients who survived obstruction of the inferior vena cava above the renal veins. Our surviving animal demonstrated collateral vessels in groups 1, 2, 5, and 7. The pathological Fenal lesion in surviving animals has been well described by many authors. It begins with cloudy swelling and early degeneration of the epithelium of the proximal convoluted tubule. This may progress to dissolution of the tubular epithelium and may subsequently involve the distal convoluted tubule although the glomeruTABLE l. Results of ligation of the inferior vena cava in dogs Above the Adrenal Veins Year
Done
1904 1911 1929 1940 1952 1955 1957 1960
Above the Renal Veins
Investigator
Gosset and Lecene Bej an and Cohn Polkey Whittenberger and Huggins Ripstein and associates Massotte and Cardusi Lejeune-Ledant Wear
Totals ....... .........
Surv. Done -- --
Surv.
0
0
-2 0
4 0 0
0 0 0
8 5 2
8 1 0
42
18
0
0
8
5
0
0
12 0
10
0 1 - - - - --- - 22 10 33 66 0
0 5
----·---~
Per cent survival. .....
50%
45%
TABLE 2. Consolidated rating of major veins of collateral circulation Rating
Major Venous Systems
References
1.
Lumbar, segmental, iliolumbar and ascending lumbar veins Vertebral, intervertebral, and spinal veins Azygos and hemiazygos veins Epigastric and internal mammary veins Renal capsular veins Spermatic or ovarian veins Adrenal veins Inferior mesenteric vein and the portal system
13
2. 3. 4. 5. 6. 7. 8.
8 7 6 5 2 2 2
!us is usually not affected. Since any portion of the renal tubule m.ay become involved the process should not be considered a "lower nephron nephrosis." Survival from the phase of acute renal failure depends upon the extent of irreversible renal damage and upon the return of an adequate number of functioning nephrons. CLINICAL REPORTS
Such eminent surgeons as Kocher and Billroth are reported to have accidentally ligated the inferior vena cava below the renal veins in the 1880's. By 1910 there were 10 case reports in the literature of ligation at this level and the mortality rate was 40 per cent. Many other cases of lig~tion and/or operative trauma to the lower third of the inferior vena cava have since been reported with mortality rates of less than 5 per cent. It is interesting to note that among the early cases of injury to the inferior vena cava the vast majority of such instances occurred during a right nephrectomy performed by the transabdominal route for either neoplasm or a tuberculous pyohydronephrosis. One of the first reports of injury to the inferior vena cava above the renal veins was published by Ripstein and Miller1 in 1949. During a right nephrectomy a portion of the vessel was excised and the defect was closed by direct lateral suture. Following this procedure the lumen was so compromised that the inferior vena cava remained collapsed above that point. The patient survived after hemodialysis was used in the treatment of 1 Ripstein, C. B. and Miller, C. G.: Obstruction of the inferior vena cava above the renal veins. Ann. Surg., 130: 958-962, 1949.
LJGA'I'ION OF lNFI<;lUOR VK,A CAVA._
the postop<--:rntin--: 1·pnal faili.ue which was char,wt.erizPd by an nourn·ot<'ill nitrngen peak of 172 mg. per cent arnl 7 of amuia. Petkovic and :rnsociakR 2 in l 9i57 prescmtcd n, r·as<" ol' n vnlsion of tlw rernil vein from the inJerior n--:rn1, ciwa during ,1 right nephn,'ctomy for tul1erc11lons pyoh~·dronephrn,,is. Lateral suture was followed a dinirnl cmirse suggestive of thrombosis of the rnforior vena ca1·a and tlie left n,nal vein. The IJloo
Perhaps the rn.ost Profe~sor Bolot <'ik
and (i11 1959) tore the inferior ,·pna cant u.ncl were compelkd to ligate this ve:ssd both
NUAT:\!ARY
:,ho\'<: and bd01v tlw left renal 1·c:in. Altbough a ovarian ,·ein mi~ noted to Lw present they elected to perform a ldt s11kuo-renal shunt am! Uw patient ~nrvin·d \1·ithot1t ,sequellae after three uf marked olignrin, n, bloocl nrca nitrogen twak ol' J .50 mg. per cent and a 2 1veck period of diuresis. ,\lknlt1j, i\I. and Cvetkovic, B. · cave ,w eourn dC' la nephrectr:rnsiioire. ,J. urnl. K.: Inferior 1D59.
An expt:rirncntaJ ,'itudy a11tl wvi<'\\ of the litu·,1,· tnrr :11·t prcseutc:d lig:tt,io11 of Uw iilk rior ,Tna toaY11 al101·c: tll/c reual n'i1rn. Sun·i q,J;-; ,;, 0
!Joth animals and Jrnman~ lrnn' heen n·po1t,,,l satisfact01·)r outcome ll,JJJlt'a.rn to dcpu,c! u IH'Jl t,h,, prrseuc·e of adequate c:oliu/,,.·rn,! ,·enmis chmrnels awl npon the t1·eat1m'11t :11' t,]1, acute n·rnil fnilnre.
·1 De!.rie, P .. Is the oblite1·e1tio11 of the inf;:no; ye110 c:ava above the n:n,11 veinK fote1P from Fr.) Press() rnAd , 64: 10\J,-,, 1%(i.