- Email: [email protected]
Cavopulmonary Bypass to Facilitate Infrahepatic Vena Cava Gunshot Wound Repair
2026
CASE REPORT LIAO ET AL CAVOPULMONARY BYPASS IN IVC WOUND REPAIR
FEATURE ARTICLES
the English literature [1–5]. We believe that this case report is the first adult ARVT that has ever been reported. The ARVT is an abnormal pathway that has its orifice above (or in) the upper portion of the right sinus of Valsalva, just to the left of the orifice of the right coronary artery, and entering the infundibulum of the right ventricle [2]. The pathogenesis of ARVT is unclear and it is believed to be similar to the more common aortico-left ventricular tunnel. The explanations are related to the following: (1) that the tunnel represents an anomalous coronary artery, (2) that the tunnel represents a dissecting aneurysm related to Marfan’s disease, and (3) that it is due to a congenital weakness in the region of the right sinus of Valsalva [1, 2]. Before the operation, it is extremely important for a successful surgical intervention to clear the anatomy of the coronary artery. We believe that our case is the first ARVT case to use computed tomographic angiography instead of catheterization to evaluate the anatomy of the coronary artery before the operation. Most of the 10 ARVT cases reported in the English literature had used catheterization to evaluate the anatomy of the coronary artery, with the exception of one autopsy case [1] and one case that used nuclear magnetic resonance imaging [5]. Computed tomographic angiography can precisely evaluate not only the details of the ARVT but also the coronary artery (ie, the tunnel communicates the aortic root [above the right coronary sinus] with the right ventricular infundibulum) (Fig 2); the origin of ARVT at the aortic aspect was 11.2 ⫻ 4.2 mm2 and at the right ventricle aspect it was 6.4 ⫻ 7.4 mm2 (with the coronary arteries being identified as separate structures). Furthermore, a successfully surgical intervention was performed and the postoperative recovery was uneventful, even though only 5 ARVT patients were survivors among 9 patients who were reported among the English literature [1–5]. Another reason for our successful operation was that our case was relative simple; the coronary arteries were not involved in this patient and the size of the right ventricle was normal before the operation.
References 1. Bharati S, Lev M, Cassels DE. Aortico-right ventricular tunnel. Chest 1973;63:198 –202. 2. Vargas FJ, Molina A, Martinez JC, Ranzini MA, Vazquez JC. Aortico-right ventricular tunnel. Ann Thorac Surg 1998;66: 1793–5. 3. Talwar S, Choudhary UJ, Kothary SS, Airan B. Aortico-right ventricular tunnel. Int J Cardiol 1999;70:201–5. 4. Hruda J, Sobotka-Plojhar MA, Rossum ACV. Aortico-right ventricular tunnel with pulmonary stenosis in a neonate. Heart 2001;86:316. 5. Hruda J, Hazekamp MG, Sobotka-Plojhar MA, Ottenkamp J. Repair of aorto-right ventricular tunnel with pulmonary stenosis and an anomalous origin of the left coronary artery. Eur J Cardiothorac Surg 2002;21:1123–5. © 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2010;89:2026 – 8
Cavopulmonary Bypass to Facilitate Infrahepatic Vena Cava Gunshot Wound Repair George P. Liao, Benjamin Braslow, MD, C. William Schwab, MD, and Y. Joseph Woo, MD Division of Cardiovascular Surgery, Division of Traumatology, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
Traumatic injuries to the inferior vena cava continue to be associated with high mortality. The management of these injuries has been technically challenging and highly variable, often depending on factors that include the anatomic complexity and the severity of the insult. We report the first case in which a patient with massive exsanguination from an infrahepatic vena cava gunshot wound underwent successful repair with the aid of a novel variant active venovenous bypass circuit between the inferior vena cava and the pulmonary artery. (Ann Thorac Surg 2010;89:2026 – 8) © 2010 by The Society of Thoracic Surgeons
T
he management of traumatic injuries to the inferior vena cava (IVC) is technically challenging and highly variable, depending on the context of the insult, and continues to be associated with a high rate of mortality. We present a case in which the repair of an exsanguinating gunshot wound to the IVC was facilitated by a novel active venovenous bypass circuit between the distal IVC and the pulmonary artery. A 16-year-old male was brought emergently to our hospital’s trauma bay after sustaining a gunshot wound to the left posterior flank, just above the iliac crest. An abdominal roentgenogram showed the missile in the right upper quadrant near the dome of the liver, suggesting a transabdominal trajectory. On presentation, he was awake, alert, and neurologically intact, but he was tachycardic (heart rate in the 130s) and hypotensive (systolic blood pressure ⬃ 100 mm Hg). A focused ultrasonographic evaluation of his abdomen was positive for free intra-abdominal fluid, likely blood. The patient underwent rapid sequence intubation and received intravenous volume resuscitation, along with blood products according to our hospital’s trauma exsanguination protocol, followed by urgently being moved to the operating room for an emergency laparotomy. An abdominal entry was made through a generous midline laparotomy, extending from the xiphoid to the pubis, in which massive intraperitoneal bleeding was evident. After four-quadrant packing, a large centrally retroperitoAccepted for publication Oct 8, 2009. Address correspondence to Dr Woo, Department of Surgery, Division of Cardiothoracic Surgery, 6th Floor, Silverstein Bldg, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2009.10.014
neal, expanded hematoma was discovered that extended down into the left pelvis. Despite further packing, significant bleeding continued and the patient became hemodynamically unstable. An emergent left anterolateral thoracotomy was performed to apply a distal thoracic aortic cross clamp to achieve hemodynamic control. A Cattell-Brasch maneuver (ie, right-to-left medial visceral rotation maneuver) revealed a large, complex, anterolateral infrahepatic vena cava wound just caudad of the liver parenchyma. Local control with sponge sticks to facilitate visualization proved unsuccessful. As the patient became progressively more unstable, an emergency consultation with the cardiovascular surgery service was made for potential circulatory assist implementation. With the extremely high IVC flows causing rapid exsanguination with any maneuvering, it became immediately apparent that a venovenous bypass circuit was needed to limit flow in the injured segment of the vena cava and facilitate the repair of the highly complex near retrohepatic IVC injury. Although the left heart was already exposed through the left thoracotomy, the right atrium, which is a common site for inserting a venovenous bypass cannula for inflow, was not readily visible and was thus not easily accessible. Instead of extending the left thoracotomy into a highly invasive and morbid full transverse bilateral thoracosternotomy (clam shell) for full cardiac exposure, which would sacrifice both internal thoracic arteries in this young patient, it was decided to use the easily accessible left main pulmonary artery as a variant active venovenous bypass site. Because this was an isolated rightsided bypass circuit, with no oxygenator, and no risk of cerebral systemic particulate emboli, a very low dose of heparin was permissible. After the administration of 5,000 units of heparin, a pursestring was placed at the junction of the main and left pulmonary arteries. A second pursestring was then placed in the vena cava, just inferior to the injury. Two number 20 wire-wrapped cannulas were then introduced through the Seldinger wire technique. After connecting the cannulas to a centrifugal pump, the variant venovenous (cavopulmonary) bypass circuit was successfully created (Fig 1). The initiation of bypass at 2 L/min resulted in immediate decompression of the infrahepatic vena cava and permitted easy direct repair of the complex IVC gunshot wound injury using 4-0 polypropylene sutures. After the repair, the circuit was discontinued, the patient was decannulated, and the anticoagulation was reversed. The total bypass time was 9 minutes. Given the significant blood loss, injuries to abdominal visceral and solid organs, hypothermia, and clinical coagulopathy, damage control techniques were implemented [1]. After angiographic evaluation of the liver and pelvis based on the bullet’s trajectory, the patient was sent to the intensive care unit for further resuscitation to re-establish normal physiology. For the next several weeks, the patient underwent multiple explorations, washouts, and definitive visceral repairs, and managed as an open abdomen with a
CASE REPORT LIAO ET AL CAVOPULMONARY BYPASS IN IVC WOUND REPAIR
2027
Fig 1. The cavopulmonary, variant active venovenous bypass approach used to facilitate the repair of an exsanguinating infrahepatic vena cava gunshot wound (inset: magnified view demonstrating cannula placement at the junction of the main and left pulmonary arteries).
planned ventral hernia. He required fasciotomies for the development of lower extremity compartment syndromes and was successfully treated without sequelae for a pericardial effusion that developed during empiric anticoagulation after the caval repair. He was discharged in excellent condition to a rehabilitation facility 42 days after his initial admission, and he was found to be in superb health and without complications related to his bypass on follow-up at 3 months postdischarge.
Comment Traumatic abdominal injuries involving the IVC are highly lethal, and often result from penetrating wounds [2]. Mortality is highly influenced by the location rather than the mechanism of insult, and has been reported to be as high as 100% when injuries are suprahepatic or retrohepatic, versus up to 60% in infrahepatic injuries, as in this present case [3, 4]. Often, primary repair is possible for small injuries with good anatomic exposure, via proximal and distal control or applying a side-biting vascular clamp [5]. Injuries in readily exposed regions of the retroperitoneum may involve more complex repairs with synthetic or homologous tissue patching [6]. Retrohepatic and juxtahepatic caval injuries, as in the present case, are the most difficult to expose, because this short segment is bordered by the liver superiorly, renal veins inferiorly, and portal veins anteriorly. In these cases, the hemodynamic instability of the patient secondary to hemorrhage often necessitates either a median sternotomy for anatomic exposure or cavoatrial shunt placement to bypass the injured segment during repair, or both. Complications of primary repair include thrombus for-
FEATURE ARTICLES
Ann Thorac Surg 2010;89:2026 – 8
2028
CASE REPORT LINDENMANN ET AL PERICARDIAL RUPTURE AND CARDIAC HERNIATION
FEATURE ARTICLES
mation at the injury repair site and stenosis, although patients have been reported to tolerate suprarenal lumen reductions down to 25%. In select cases, complete infrarenal ligation has been applied to obtain hemostatic control without significant sequelae due to the abundance of collateral circulation [7]. The venovenous bypass concept, namely the cavoatrial shunt, has been used for a wide variety of applications, from IVC trauma to liver transplants, neoplasms, and even the Budd-Chiari and superior vena cava syndromes [8]. Cavopulmonary bypass, on the other hand, has historically been applied mostly to congenital heart surgery. This is the first reported case in which an active venovenous bypass was applied to the pulmonary artery instead of the right atrium in the setting of a severe traumatic IVC injury. In retrospect, the decision for a cavopulmonary approach arose from an injury site complicating exposure and hemodynamic control, and because a left thoracotomy had already been established. Since left thoracotomies are still currently performed, either initially in the emergency department or in the operating room, the cavopulmonary approach may reduce the number of unnecessary additional perpendicular median sternotomies or bilateral thoracosternotomies, both of which increase morbidity and postoperative consequences. In cases of trauma, the right heart is less amenable to aggressive fluid resuscitation compared with the left heart, resulting in right-sided volume overload, ventricular dilatation, and acute tricuspid regurgitation. The cavopulmonary approach bypasses and thus protects the right heart from such stress, and this approach also benefits from the pulmonary valve, which reduces backflow into the operative field, unlike the nonfunctioning, remnant adult Eustachian valve in the cavoatrial approach. In summary, we believe this is the first reported case in which a variant active venovenous bypass was successfully executed to facilitate the repair of an exsanguinating, catastrophic penetrating infrahepatic vena cava injury.
References 1. Rotondo MF, Schwab CW, McGonigal MD, et al. “Damage control”: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993;35:375– 83. 2. Kuehne J, Frankhouse J, Modrall G, et al. Determinants of survival after inferior vena cava trauma. Am Surg 1999;65: 976 – 81. 3. Huerta S, Bui TD, Nguyen TH, et al. Predictors of mortality and management of patients with traumatic inferior vena cava injuries. Am Surg 2006;72:290 – 6. 4. Baeshko AA, Klimovich VV, Voevoda MT, et al. Injury of inferior vena cava. Khirurgiia (Mosk) 2006:12–9. 5. Klein SR, Baumgartner FJ, Bongard FS. Contemporary management strategy for major inferior vena caval injuries. J Trauma 1994;37:35– 42. 6. Formisano V, Di Muria A, Muto G, et al. Inferior vena cava gunshot injury: case report and a review of the literature. Ann Ital Chir 2006;77:173–7. 7. Buckman RF, Pathak AS, Badellino MM, Bradley KM. Injuries of the inferior vena cava. Surg Clin North Am 2001;81:1431– 47. 8. Gagner R, Scudamore CH, Buczkowski AK, Patterson EJ, Chung S. Veno-veno bypass of the inferior vena cava in trauma, tumor, and transplantation. Surg Technol Int 1998; VII:255– 8. © 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2010;89:2028 –30
Traumatic Pericardial Rupture With Cardiac Herniation Joerg Lindenmann, MD, Veronika Matzi, MD, Nicole Neuboeck, MD, Christian Porubsky, MD, Beatrice Ratzenhofer, MD, Alfred Maier, MD, and Freyja-Maria Smolle-Juettner, MD Division of Thoracic and Hyperbaric Surgery, Department of Surgery, and Department of Anesthesiology, Medical University of Graz, Graz, Austria
If undiagnosed, traumatic pericardial rupture with herniation of the heart may have fatal consequences. We report two cases of multiple trauma with pericardial rupture, which was missed in the preoperative diagnoses of both patients, in spite of suggestive signs on computed tomographic scans. One patient had unexplained, persistent hemodynamic instability; the second patient had cardiac arrest during laparotomy for minor hepatic laceration. In both, the left-sided rupture of the pericardium with cardiac herniation into the pleural space was found and corrected in an emergency intervention. Both patients recovered completely. (Ann Thorac Surg 2010;89:2028 –30) © 2010 by The Society of Thoracic Surgeons
P
ericardial rupture occurs at a rate of approximately 3% after blunt chest trauma [1]. Depending on the size and site of the rupture, cardiac herniation and consecutive mechanical encroachment may evolve. Although diagnosis based on clinical findings or on chest roentgenogram is difficult [2], a computed tomographic (CT) scan usually shows distinct features [1, 3]. We present two cases of pericardial rupture with herniation of the heart, in which diagnosis was missed initially, in spite of suggestive findings on CT scans.
Case Reports Patient 1 A 47-year-old man had a high-velocity car accident. When he arrived at the hospital, an emergency fluoroscopy revealed bilateral pneumothorax. Suction drainages were inserted and his saturation rose from 92% to 99%. An emergency CT scan showed craniocerebral injury, fractures of the femur, pelvis and spine, and sternal and left serial rib fractures, atelectasis of the left lower lobe, and an anterior left pneumothorax (Fig 1). The postinterventional roentgenogram displayed a peculiar cardiac silhouette (Fig 2). Arterial hypotension and tachycardia persisted in spite of intravascular fluid substitution and administration of catecholamines. Because of cardiovascular instability, surgical treatment of the extrathoracic injuries was postponed. When Accepted for publication Oct 19, 2009. Address correspondence to Dr Lindenmann, Division of Thoracic and Hyperbaric Surgery, Medical University Graz, Auenbruggerplatz 29, Graz, A-8036, Austria; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2009.10.048
CASE REPORT LIAO ET AL CAVOPULMONARY BYPASS IN IVC WOUND REPAIR
FEATURE ARTICLES
the English literature [1–5]. We believe that this case report is the first adult ARVT that has ever been reported. The ARVT is an abnormal pathway that has its orifice above (or in) the upper portion of the right sinus of Valsalva, just to the left of the orifice of the right coronary artery, and entering the infundibulum of the right ventricle [2]. The pathogenesis of ARVT is unclear and it is believed to be similar to the more common aortico-left ventricular tunnel. The explanations are related to the following: (1) that the tunnel represents an anomalous coronary artery, (2) that the tunnel represents a dissecting aneurysm related to Marfan’s disease, and (3) that it is due to a congenital weakness in the region of the right sinus of Valsalva [1, 2]. Before the operation, it is extremely important for a successful surgical intervention to clear the anatomy of the coronary artery. We believe that our case is the first ARVT case to use computed tomographic angiography instead of catheterization to evaluate the anatomy of the coronary artery before the operation. Most of the 10 ARVT cases reported in the English literature had used catheterization to evaluate the anatomy of the coronary artery, with the exception of one autopsy case [1] and one case that used nuclear magnetic resonance imaging [5]. Computed tomographic angiography can precisely evaluate not only the details of the ARVT but also the coronary artery (ie, the tunnel communicates the aortic root [above the right coronary sinus] with the right ventricular infundibulum) (Fig 2); the origin of ARVT at the aortic aspect was 11.2 ⫻ 4.2 mm2 and at the right ventricle aspect it was 6.4 ⫻ 7.4 mm2 (with the coronary arteries being identified as separate structures). Furthermore, a successfully surgical intervention was performed and the postoperative recovery was uneventful, even though only 5 ARVT patients were survivors among 9 patients who were reported among the English literature [1–5]. Another reason for our successful operation was that our case was relative simple; the coronary arteries were not involved in this patient and the size of the right ventricle was normal before the operation.
References 1. Bharati S, Lev M, Cassels DE. Aortico-right ventricular tunnel. Chest 1973;63:198 –202. 2. Vargas FJ, Molina A, Martinez JC, Ranzini MA, Vazquez JC. Aortico-right ventricular tunnel. Ann Thorac Surg 1998;66: 1793–5. 3. Talwar S, Choudhary UJ, Kothary SS, Airan B. Aortico-right ventricular tunnel. Int J Cardiol 1999;70:201–5. 4. Hruda J, Sobotka-Plojhar MA, Rossum ACV. Aortico-right ventricular tunnel with pulmonary stenosis in a neonate. Heart 2001;86:316. 5. Hruda J, Hazekamp MG, Sobotka-Plojhar MA, Ottenkamp J. Repair of aorto-right ventricular tunnel with pulmonary stenosis and an anomalous origin of the left coronary artery. Eur J Cardiothorac Surg 2002;21:1123–5. © 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2010;89:2026 – 8
Cavopulmonary Bypass to Facilitate Infrahepatic Vena Cava Gunshot Wound Repair George P. Liao, Benjamin Braslow, MD, C. William Schwab, MD, and Y. Joseph Woo, MD Division of Cardiovascular Surgery, Division of Traumatology, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
Traumatic injuries to the inferior vena cava continue to be associated with high mortality. The management of these injuries has been technically challenging and highly variable, often depending on factors that include the anatomic complexity and the severity of the insult. We report the first case in which a patient with massive exsanguination from an infrahepatic vena cava gunshot wound underwent successful repair with the aid of a novel variant active venovenous bypass circuit between the inferior vena cava and the pulmonary artery. (Ann Thorac Surg 2010;89:2026 – 8) © 2010 by The Society of Thoracic Surgeons
T
he management of traumatic injuries to the inferior vena cava (IVC) is technically challenging and highly variable, depending on the context of the insult, and continues to be associated with a high rate of mortality. We present a case in which the repair of an exsanguinating gunshot wound to the IVC was facilitated by a novel active venovenous bypass circuit between the distal IVC and the pulmonary artery. A 16-year-old male was brought emergently to our hospital’s trauma bay after sustaining a gunshot wound to the left posterior flank, just above the iliac crest. An abdominal roentgenogram showed the missile in the right upper quadrant near the dome of the liver, suggesting a transabdominal trajectory. On presentation, he was awake, alert, and neurologically intact, but he was tachycardic (heart rate in the 130s) and hypotensive (systolic blood pressure ⬃ 100 mm Hg). A focused ultrasonographic evaluation of his abdomen was positive for free intra-abdominal fluid, likely blood. The patient underwent rapid sequence intubation and received intravenous volume resuscitation, along with blood products according to our hospital’s trauma exsanguination protocol, followed by urgently being moved to the operating room for an emergency laparotomy. An abdominal entry was made through a generous midline laparotomy, extending from the xiphoid to the pubis, in which massive intraperitoneal bleeding was evident. After four-quadrant packing, a large centrally retroperitoAccepted for publication Oct 8, 2009. Address correspondence to Dr Woo, Department of Surgery, Division of Cardiothoracic Surgery, 6th Floor, Silverstein Bldg, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2009.10.014
neal, expanded hematoma was discovered that extended down into the left pelvis. Despite further packing, significant bleeding continued and the patient became hemodynamically unstable. An emergent left anterolateral thoracotomy was performed to apply a distal thoracic aortic cross clamp to achieve hemodynamic control. A Cattell-Brasch maneuver (ie, right-to-left medial visceral rotation maneuver) revealed a large, complex, anterolateral infrahepatic vena cava wound just caudad of the liver parenchyma. Local control with sponge sticks to facilitate visualization proved unsuccessful. As the patient became progressively more unstable, an emergency consultation with the cardiovascular surgery service was made for potential circulatory assist implementation. With the extremely high IVC flows causing rapid exsanguination with any maneuvering, it became immediately apparent that a venovenous bypass circuit was needed to limit flow in the injured segment of the vena cava and facilitate the repair of the highly complex near retrohepatic IVC injury. Although the left heart was already exposed through the left thoracotomy, the right atrium, which is a common site for inserting a venovenous bypass cannula for inflow, was not readily visible and was thus not easily accessible. Instead of extending the left thoracotomy into a highly invasive and morbid full transverse bilateral thoracosternotomy (clam shell) for full cardiac exposure, which would sacrifice both internal thoracic arteries in this young patient, it was decided to use the easily accessible left main pulmonary artery as a variant active venovenous bypass site. Because this was an isolated rightsided bypass circuit, with no oxygenator, and no risk of cerebral systemic particulate emboli, a very low dose of heparin was permissible. After the administration of 5,000 units of heparin, a pursestring was placed at the junction of the main and left pulmonary arteries. A second pursestring was then placed in the vena cava, just inferior to the injury. Two number 20 wire-wrapped cannulas were then introduced through the Seldinger wire technique. After connecting the cannulas to a centrifugal pump, the variant venovenous (cavopulmonary) bypass circuit was successfully created (Fig 1). The initiation of bypass at 2 L/min resulted in immediate decompression of the infrahepatic vena cava and permitted easy direct repair of the complex IVC gunshot wound injury using 4-0 polypropylene sutures. After the repair, the circuit was discontinued, the patient was decannulated, and the anticoagulation was reversed. The total bypass time was 9 minutes. Given the significant blood loss, injuries to abdominal visceral and solid organs, hypothermia, and clinical coagulopathy, damage control techniques were implemented [1]. After angiographic evaluation of the liver and pelvis based on the bullet’s trajectory, the patient was sent to the intensive care unit for further resuscitation to re-establish normal physiology. For the next several weeks, the patient underwent multiple explorations, washouts, and definitive visceral repairs, and managed as an open abdomen with a
CASE REPORT LIAO ET AL CAVOPULMONARY BYPASS IN IVC WOUND REPAIR
2027
Fig 1. The cavopulmonary, variant active venovenous bypass approach used to facilitate the repair of an exsanguinating infrahepatic vena cava gunshot wound (inset: magnified view demonstrating cannula placement at the junction of the main and left pulmonary arteries).
planned ventral hernia. He required fasciotomies for the development of lower extremity compartment syndromes and was successfully treated without sequelae for a pericardial effusion that developed during empiric anticoagulation after the caval repair. He was discharged in excellent condition to a rehabilitation facility 42 days after his initial admission, and he was found to be in superb health and without complications related to his bypass on follow-up at 3 months postdischarge.
Comment Traumatic abdominal injuries involving the IVC are highly lethal, and often result from penetrating wounds [2]. Mortality is highly influenced by the location rather than the mechanism of insult, and has been reported to be as high as 100% when injuries are suprahepatic or retrohepatic, versus up to 60% in infrahepatic injuries, as in this present case [3, 4]. Often, primary repair is possible for small injuries with good anatomic exposure, via proximal and distal control or applying a side-biting vascular clamp [5]. Injuries in readily exposed regions of the retroperitoneum may involve more complex repairs with synthetic or homologous tissue patching [6]. Retrohepatic and juxtahepatic caval injuries, as in the present case, are the most difficult to expose, because this short segment is bordered by the liver superiorly, renal veins inferiorly, and portal veins anteriorly. In these cases, the hemodynamic instability of the patient secondary to hemorrhage often necessitates either a median sternotomy for anatomic exposure or cavoatrial shunt placement to bypass the injured segment during repair, or both. Complications of primary repair include thrombus for-
FEATURE ARTICLES
Ann Thorac Surg 2010;89:2026 – 8
2028
CASE REPORT LINDENMANN ET AL PERICARDIAL RUPTURE AND CARDIAC HERNIATION
FEATURE ARTICLES
mation at the injury repair site and stenosis, although patients have been reported to tolerate suprarenal lumen reductions down to 25%. In select cases, complete infrarenal ligation has been applied to obtain hemostatic control without significant sequelae due to the abundance of collateral circulation [7]. The venovenous bypass concept, namely the cavoatrial shunt, has been used for a wide variety of applications, from IVC trauma to liver transplants, neoplasms, and even the Budd-Chiari and superior vena cava syndromes [8]. Cavopulmonary bypass, on the other hand, has historically been applied mostly to congenital heart surgery. This is the first reported case in which an active venovenous bypass was applied to the pulmonary artery instead of the right atrium in the setting of a severe traumatic IVC injury. In retrospect, the decision for a cavopulmonary approach arose from an injury site complicating exposure and hemodynamic control, and because a left thoracotomy had already been established. Since left thoracotomies are still currently performed, either initially in the emergency department or in the operating room, the cavopulmonary approach may reduce the number of unnecessary additional perpendicular median sternotomies or bilateral thoracosternotomies, both of which increase morbidity and postoperative consequences. In cases of trauma, the right heart is less amenable to aggressive fluid resuscitation compared with the left heart, resulting in right-sided volume overload, ventricular dilatation, and acute tricuspid regurgitation. The cavopulmonary approach bypasses and thus protects the right heart from such stress, and this approach also benefits from the pulmonary valve, which reduces backflow into the operative field, unlike the nonfunctioning, remnant adult Eustachian valve in the cavoatrial approach. In summary, we believe this is the first reported case in which a variant active venovenous bypass was successfully executed to facilitate the repair of an exsanguinating, catastrophic penetrating infrahepatic vena cava injury.
References 1. Rotondo MF, Schwab CW, McGonigal MD, et al. “Damage control”: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993;35:375– 83. 2. Kuehne J, Frankhouse J, Modrall G, et al. Determinants of survival after inferior vena cava trauma. Am Surg 1999;65: 976 – 81. 3. Huerta S, Bui TD, Nguyen TH, et al. Predictors of mortality and management of patients with traumatic inferior vena cava injuries. Am Surg 2006;72:290 – 6. 4. Baeshko AA, Klimovich VV, Voevoda MT, et al. Injury of inferior vena cava. Khirurgiia (Mosk) 2006:12–9. 5. Klein SR, Baumgartner FJ, Bongard FS. Contemporary management strategy for major inferior vena caval injuries. J Trauma 1994;37:35– 42. 6. Formisano V, Di Muria A, Muto G, et al. Inferior vena cava gunshot injury: case report and a review of the literature. Ann Ital Chir 2006;77:173–7. 7. Buckman RF, Pathak AS, Badellino MM, Bradley KM. Injuries of the inferior vena cava. Surg Clin North Am 2001;81:1431– 47. 8. Gagner R, Scudamore CH, Buczkowski AK, Patterson EJ, Chung S. Veno-veno bypass of the inferior vena cava in trauma, tumor, and transplantation. Surg Technol Int 1998; VII:255– 8. © 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2010;89:2028 –30
Traumatic Pericardial Rupture With Cardiac Herniation Joerg Lindenmann, MD, Veronika Matzi, MD, Nicole Neuboeck, MD, Christian Porubsky, MD, Beatrice Ratzenhofer, MD, Alfred Maier, MD, and Freyja-Maria Smolle-Juettner, MD Division of Thoracic and Hyperbaric Surgery, Department of Surgery, and Department of Anesthesiology, Medical University of Graz, Graz, Austria
If undiagnosed, traumatic pericardial rupture with herniation of the heart may have fatal consequences. We report two cases of multiple trauma with pericardial rupture, which was missed in the preoperative diagnoses of both patients, in spite of suggestive signs on computed tomographic scans. One patient had unexplained, persistent hemodynamic instability; the second patient had cardiac arrest during laparotomy for minor hepatic laceration. In both, the left-sided rupture of the pericardium with cardiac herniation into the pleural space was found and corrected in an emergency intervention. Both patients recovered completely. (Ann Thorac Surg 2010;89:2028 –30) © 2010 by The Society of Thoracic Surgeons
P
ericardial rupture occurs at a rate of approximately 3% after blunt chest trauma [1]. Depending on the size and site of the rupture, cardiac herniation and consecutive mechanical encroachment may evolve. Although diagnosis based on clinical findings or on chest roentgenogram is difficult [2], a computed tomographic (CT) scan usually shows distinct features [1, 3]. We present two cases of pericardial rupture with herniation of the heart, in which diagnosis was missed initially, in spite of suggestive findings on CT scans.
Case Reports Patient 1 A 47-year-old man had a high-velocity car accident. When he arrived at the hospital, an emergency fluoroscopy revealed bilateral pneumothorax. Suction drainages were inserted and his saturation rose from 92% to 99%. An emergency CT scan showed craniocerebral injury, fractures of the femur, pelvis and spine, and sternal and left serial rib fractures, atelectasis of the left lower lobe, and an anterior left pneumothorax (Fig 1). The postinterventional roentgenogram displayed a peculiar cardiac silhouette (Fig 2). Arterial hypotension and tachycardia persisted in spite of intravascular fluid substitution and administration of catecholamines. Because of cardiovascular instability, surgical treatment of the extrathoracic injuries was postponed. When Accepted for publication Oct 19, 2009. Address correspondence to Dr Lindenmann, Division of Thoracic and Hyperbaric Surgery, Medical University Graz, Auenbruggerplatz 29, Graz, A-8036, Austria; e-mail: [email protected].
0003-4975/$36.00 doi:10.1016/j.athoracsur.2009.10.048