- Email: [email protected]
Insertion of a retrohepatic vena cava balloon shunt through the saphenofemoral junction
Insertion of a Retrohepatic Vena Cava Balloon Shunt Through the Saphenofemoral Junction Oliver J. McAnena,
Mch, FRCSI,
Ernest E. Moore,
Vascular control of the injured retrohepatic vena cava is invariably a surgical challenge. Herein, we describe the technical aspects of inserting a vena cava balloon shunt through the saphenofemoral junction. The advantages of this approach include relative simplicity, maintenance of perihepatic tamponade, and avoiding emergent thoracotomy in the critically injured patient.
ascular isolation of the injured retrohepaticvena cava V is perhaps the most challenging maneuver in trauma surgery. Indeed, the mortality for blunt trauma to the juxtahepatic inferior vena cava and major hepatic vein complex exceeds 95 percent and for penetrating wounds approaches 80 percent [l-4]. Hemorrhage may be temporarily controlled by occluding the inferior vena cava above and below the liver, but the precipitous reduction in venous return is poorly tolerated in the critically injured patient. Consequently, a variety of suprarenal inferior vena cava shunts have been devised to avoid compromise of venous flow from the kidneys and lower torso during caval occlusion. The atriocaval shunt, devised by S&rock and colleagues [5] at the San Francisco General Hospital, has been the most widely used device to date [6,fl. Unfortunately, atriocaval shunt placement requires a thoracotomy, which releases perihepatic tamponade, and involves manipulation of a cold acidotic heart which is predisposed to ventricular dysrhythmia. For these reasons, we prefer an inferior vena cava balloon shunt that is inserted through the saphenofemoral junction and have used this catheter routinely at the Denver General Hospital since 1976 [I -#,8]. In addition to retrohepatic inferior vena cava trauma, this catheter has been employed in patients undergoing elective hepatic resection in whom the tumor encroached on the retrohepatic inferior vena cava. THE RETROHEPATIC The Moore-Filcher
VENA
MD,
Frederick A. Moore,
MD, Denver, Colorado
(9 mm outside diameter, 7 mm inside diameter) polyvinyl cannula that is 66 cm in length with a 9 cm latex balloon affxed to the distal end (Figure 1). Erevious autopsy studies and subsequent clinical experience have shown that an averagesized adult woman can accommodate this 28F catheter through the saphenofemoral junction. This autopsy study also provided the basis for the 66-cm catheter length; three black circular lines on the proximal catheter correspond to the distal line (30 cm from base of balloon) in a small adult, middle (35 cm) in an average sized adult, and proximal (40 cm) in a large adult. The occluding balloon is inflated through a proximal port to exclude the retrohepatic inferior vena cava into which the hepatic veins empty. In addition to three main hepatic veins, there are an indefinite number of dorsal hepatic veins draining directly into the inferior vena cava; the distance from the right suprarenal vein to the right hepatic vein varies from 2.5 to 8 cm and is the rationale for the g-cm balloon [9]. A series of six pairs of side holes proximal to the balloon allow the catheter to serve as a shunt for the return of lower torso venous blood. The large-bore catheter also provides an efficient conduit for massive blood administration (1,500 ml/min at 10 cm water pressure) directed to the right heart [8]. TECHNIQUE FOR CATHETER INSERTION Early recognition of a retrohepatic inferior vena cava injury associated with major hepatic trauma is critical to avoid the vicious cycle leading to a refractory coagulopathy. The clinical subtleties are beyond the scope of this report and well delineated elsewhere [Z-8]. In this scenario, hepatic vascular inflow occlusion is accomplished by a Pringle maneuver, a Rummel tourniquet tightened
CAVA SHUNT
IVC shunt (GA-194, Bard Cardiopulmonary Division, Biller& MA) consists of a 28F From the Ikprtment of Surgery, Denver General Hospital and the University of Cobrado Health Sciences Center, Denver, Colorado. Requests for rqxints should be addressed to Ernest E. Moore, MD, Department of Surgery, Denver General Hospital, Denver, Colorado 80204-4507.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 158 NOVEMBER 1989
463
Rummel
Rummel Femoral vein
Femoral artery
Major hepatic veins
Pringle maneuver
Balloon inflating tube Y 3-way
44%
stopcock
THE AMERICAN JOURNAL OF SURGERY
hwbeancomplatad. VOLUME 158
NOVEMBER 1989
Suprahepatic
IVC Pringle maneuver
ngUre4.~aGradeVlhfef
hJlxy, hepalic VaacuIar hflow
-bWbya
Rlnf#emanwveralKllheHverdelecl
-~w-pscklng.~
InfeMf vena cava (NC) shunt banoon,MaledwIlhsaIheeohllbn, txmqkbe hepauc VaacuIar 0xcIusloll pfbf lo mqmsw ol Ihe vena caval
rent.
around the porta hepatis, and the liver compressed with gauze packing to minimize ongoing blood loss. The saphenofemoral junction is explored through a standard groin incision (Figure 2). A vertical incision is preferred because it can be extended quickly in either direction to adjust to the normal variation in venous anatomy [101. The saphenofemoral junction is most frequently located 3 to 5 cm lateral to the pubic tubercle at the level of the inguinal crease. Of course, the femoral arterial pulse, if palpable, is lateral to the femoral vein. Regional venous tributaries are ligated and the fossa ovalis divided to fully visualize the saphenofemoral junction and provide access to the femoral vein for placement of vascular loops. The inferior vena cava shunt is attached to a large-bore (4.9 mm inside diameter) extension tubing (cyst0 irrigating set no. 2C4002, Travenol, Deerfield, IL) connected with a 5-in-1 straight connector (no. 15-5658, Seamless, Ocala, FL) and primed with saline solution in preparation for insertion. When aggressive fluid replacement is no longer required or when the shunt is used for elective hepatic resections, a dilute heparin solution (1 unit/ml) is
used with the infusate to prevent clot formation within the catheter (Figure 3). The saphenous vein, as well as the proximal and distal femoral vein, is then occluded with Rummel tourniquets. A venotomy is begun on the anterior surface of the saphenous vein, paralleling the course of the vein. If the diameter of the saphenous vein is too small to accommodate the catheter, the incision is simply extended on to the femoral vein (Figure 2). The side-ports of the catheter are manually occluded as the shunt is advanced slowly through the iliac system. Resistance at this level may require a gentle twisting to reach the inferior vena cava. The shunt is inserted to the appropriate black line on the proximal catheter, that is, distal line in a small patient, middle line in an average-sized patient, and proximal line in a large patient. Having reached thii arbitrary level, the balloon is inflated with 30 ml of normal saline. The catheter position is then realigned according to the location of the partially filled balloon; that is, the proximal margin of the balloon should be at the inferior edge of the liver (Figure 4). Tamponade of the retrohepatic inferior vena cava is
THE AMERICAN JOURNAL OF SURGERY
VOLUME 158 NOVEMBER 1989
465
completed with an additional 20 to 40 ml inflation of the balloon. Potential mechanical problems include balloon migration either cephalad into the right heart impeding venous return or caudally such that the hepatic veins are no longer occluded. The risk of malposition is minimized by periodic palpation of the balloon position. Inadvertent overinflation of the balloon may also impede outflow through the distal port as well as result in balloon rupture. Because of the latter, the balloon should never be inflated with air as air embolism may occur. There is also a potential for thrombosis and clot embolization from the catheter associated with low infusion rates, and this is the reason for dilute heparin administration through the catheter in such cases. CATHETER REMOVAL After inferior vena cava repair, the balloon is slowly deflated to ensure all caval defects are repaired. The Rummel tourniquet encircling the distal femoral vein is then loosened, and the shunt withdrawn. The venotomy site is repaired primarily, and the groin wound managed in a standard fashion. Due to the extent of hepatic parenchyma exposed, we have not administered postoperative anticoagulation for the saphenofemoral venotomy. In
466
THE AMERICAN JOURNAL OF SURGERY
fact, we have not observed venous sequelae in our patients to date.
REFERENCES 1, Cogbill TH, Moore EE, Jurkovich GJ, Feliciano DV, Morris JA, Mucha P. Severe hepatic trauma: a multicenter experience with 1,355 liver injuries. J Trauma 1988; 28: 1433-8. 2. Elerding S, Aragon W, Moore EE. Fatal hepatic hemorrhage after trauma. Am J Surg 1979; 138: 883-8. 3. Millikan JS, Moore EE, Cogbill TH, Kashuk JL. Inferior vena cava injuries-a continuing challenge. J Trauma 1983;23: 207-12. 4. Moore EE. Critical decisions in the management of hepatic trauma. Am J Surg 1984; 148: 712-6. 5. S&rock T, Blaisdell FW, Mathewson C. Management of blunt trauma to the liver and hepatic veins. Arch Surg 1968;96: 698-704. 6. Burch JM, Feliciano DV, Mattox KL. The atriocaval shunt: facts and fiction. Ann Surg 1988; 207: 555-68. 7. Kudsk KA, Sheldon GF, Lim RC. Atrial-caval shunting (ACS) after trauma. J Trauma 1982; 22: 81-S. 8. Pilcher DB, Harman PK, Moore EE. Retrohepatic vena cava balloon shunt introduced via the saphenofemoral junction. J Trauma 1977; 17: 837-41. 9. Nakamura S, Tsuxuki T. Surgical anatomy of the hepatic veins and the inferior vena cava. Surg Gynecol Obstet 1981; 152: 43-50. 10. Royle JP, Eiiner R, Fell G. The saphenofemoral junction. Surg Gynecol Obstet 1981; 152: 282-4.
VOLUME 158 NOVEMBER 1989
Mch, FRCSI,
Ernest E. Moore,
Vascular control of the injured retrohepatic vena cava is invariably a surgical challenge. Herein, we describe the technical aspects of inserting a vena cava balloon shunt through the saphenofemoral junction. The advantages of this approach include relative simplicity, maintenance of perihepatic tamponade, and avoiding emergent thoracotomy in the critically injured patient.
ascular isolation of the injured retrohepaticvena cava V is perhaps the most challenging maneuver in trauma surgery. Indeed, the mortality for blunt trauma to the juxtahepatic inferior vena cava and major hepatic vein complex exceeds 95 percent and for penetrating wounds approaches 80 percent [l-4]. Hemorrhage may be temporarily controlled by occluding the inferior vena cava above and below the liver, but the precipitous reduction in venous return is poorly tolerated in the critically injured patient. Consequently, a variety of suprarenal inferior vena cava shunts have been devised to avoid compromise of venous flow from the kidneys and lower torso during caval occlusion. The atriocaval shunt, devised by S&rock and colleagues [5] at the San Francisco General Hospital, has been the most widely used device to date [6,fl. Unfortunately, atriocaval shunt placement requires a thoracotomy, which releases perihepatic tamponade, and involves manipulation of a cold acidotic heart which is predisposed to ventricular dysrhythmia. For these reasons, we prefer an inferior vena cava balloon shunt that is inserted through the saphenofemoral junction and have used this catheter routinely at the Denver General Hospital since 1976 [I -#,8]. In addition to retrohepatic inferior vena cava trauma, this catheter has been employed in patients undergoing elective hepatic resection in whom the tumor encroached on the retrohepatic inferior vena cava. THE RETROHEPATIC The Moore-Filcher
VENA
MD,
Frederick A. Moore,
MD, Denver, Colorado
(9 mm outside diameter, 7 mm inside diameter) polyvinyl cannula that is 66 cm in length with a 9 cm latex balloon affxed to the distal end (Figure 1). Erevious autopsy studies and subsequent clinical experience have shown that an averagesized adult woman can accommodate this 28F catheter through the saphenofemoral junction. This autopsy study also provided the basis for the 66-cm catheter length; three black circular lines on the proximal catheter correspond to the distal line (30 cm from base of balloon) in a small adult, middle (35 cm) in an average sized adult, and proximal (40 cm) in a large adult. The occluding balloon is inflated through a proximal port to exclude the retrohepatic inferior vena cava into which the hepatic veins empty. In addition to three main hepatic veins, there are an indefinite number of dorsal hepatic veins draining directly into the inferior vena cava; the distance from the right suprarenal vein to the right hepatic vein varies from 2.5 to 8 cm and is the rationale for the g-cm balloon [9]. A series of six pairs of side holes proximal to the balloon allow the catheter to serve as a shunt for the return of lower torso venous blood. The large-bore catheter also provides an efficient conduit for massive blood administration (1,500 ml/min at 10 cm water pressure) directed to the right heart [8]. TECHNIQUE FOR CATHETER INSERTION Early recognition of a retrohepatic inferior vena cava injury associated with major hepatic trauma is critical to avoid the vicious cycle leading to a refractory coagulopathy. The clinical subtleties are beyond the scope of this report and well delineated elsewhere [Z-8]. In this scenario, hepatic vascular inflow occlusion is accomplished by a Pringle maneuver, a Rummel tourniquet tightened
CAVA SHUNT
IVC shunt (GA-194, Bard Cardiopulmonary Division, Biller& MA) consists of a 28F From the Ikprtment of Surgery, Denver General Hospital and the University of Cobrado Health Sciences Center, Denver, Colorado. Requests for rqxints should be addressed to Ernest E. Moore, MD, Department of Surgery, Denver General Hospital, Denver, Colorado 80204-4507.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 158 NOVEMBER 1989
463
Rummel
Rummel Femoral vein
Femoral artery
Major hepatic veins
Pringle maneuver
Balloon inflating tube Y 3-way
44%
stopcock
THE AMERICAN JOURNAL OF SURGERY
hwbeancomplatad. VOLUME 158
NOVEMBER 1989
Suprahepatic
IVC Pringle maneuver
ngUre4.~aGradeVlhfef
hJlxy, hepalic VaacuIar hflow
-bWbya
Rlnf#emanwveralKllheHverdelecl
-~w-pscklng.~
InfeMf vena cava (NC) shunt banoon,MaledwIlhsaIheeohllbn, txmqkbe hepauc VaacuIar 0xcIusloll pfbf lo mqmsw ol Ihe vena caval
rent.
around the porta hepatis, and the liver compressed with gauze packing to minimize ongoing blood loss. The saphenofemoral junction is explored through a standard groin incision (Figure 2). A vertical incision is preferred because it can be extended quickly in either direction to adjust to the normal variation in venous anatomy [101. The saphenofemoral junction is most frequently located 3 to 5 cm lateral to the pubic tubercle at the level of the inguinal crease. Of course, the femoral arterial pulse, if palpable, is lateral to the femoral vein. Regional venous tributaries are ligated and the fossa ovalis divided to fully visualize the saphenofemoral junction and provide access to the femoral vein for placement of vascular loops. The inferior vena cava shunt is attached to a large-bore (4.9 mm inside diameter) extension tubing (cyst0 irrigating set no. 2C4002, Travenol, Deerfield, IL) connected with a 5-in-1 straight connector (no. 15-5658, Seamless, Ocala, FL) and primed with saline solution in preparation for insertion. When aggressive fluid replacement is no longer required or when the shunt is used for elective hepatic resections, a dilute heparin solution (1 unit/ml) is
used with the infusate to prevent clot formation within the catheter (Figure 3). The saphenous vein, as well as the proximal and distal femoral vein, is then occluded with Rummel tourniquets. A venotomy is begun on the anterior surface of the saphenous vein, paralleling the course of the vein. If the diameter of the saphenous vein is too small to accommodate the catheter, the incision is simply extended on to the femoral vein (Figure 2). The side-ports of the catheter are manually occluded as the shunt is advanced slowly through the iliac system. Resistance at this level may require a gentle twisting to reach the inferior vena cava. The shunt is inserted to the appropriate black line on the proximal catheter, that is, distal line in a small patient, middle line in an average-sized patient, and proximal line in a large patient. Having reached thii arbitrary level, the balloon is inflated with 30 ml of normal saline. The catheter position is then realigned according to the location of the partially filled balloon; that is, the proximal margin of the balloon should be at the inferior edge of the liver (Figure 4). Tamponade of the retrohepatic inferior vena cava is
THE AMERICAN JOURNAL OF SURGERY
VOLUME 158 NOVEMBER 1989
465
completed with an additional 20 to 40 ml inflation of the balloon. Potential mechanical problems include balloon migration either cephalad into the right heart impeding venous return or caudally such that the hepatic veins are no longer occluded. The risk of malposition is minimized by periodic palpation of the balloon position. Inadvertent overinflation of the balloon may also impede outflow through the distal port as well as result in balloon rupture. Because of the latter, the balloon should never be inflated with air as air embolism may occur. There is also a potential for thrombosis and clot embolization from the catheter associated with low infusion rates, and this is the reason for dilute heparin administration through the catheter in such cases. CATHETER REMOVAL After inferior vena cava repair, the balloon is slowly deflated to ensure all caval defects are repaired. The Rummel tourniquet encircling the distal femoral vein is then loosened, and the shunt withdrawn. The venotomy site is repaired primarily, and the groin wound managed in a standard fashion. Due to the extent of hepatic parenchyma exposed, we have not administered postoperative anticoagulation for the saphenofemoral venotomy. In
466
THE AMERICAN JOURNAL OF SURGERY
fact, we have not observed venous sequelae in our patients to date.
REFERENCES 1, Cogbill TH, Moore EE, Jurkovich GJ, Feliciano DV, Morris JA, Mucha P. Severe hepatic trauma: a multicenter experience with 1,355 liver injuries. J Trauma 1988; 28: 1433-8. 2. Elerding S, Aragon W, Moore EE. Fatal hepatic hemorrhage after trauma. Am J Surg 1979; 138: 883-8. 3. Millikan JS, Moore EE, Cogbill TH, Kashuk JL. Inferior vena cava injuries-a continuing challenge. J Trauma 1983;23: 207-12. 4. Moore EE. Critical decisions in the management of hepatic trauma. Am J Surg 1984; 148: 712-6. 5. S&rock T, Blaisdell FW, Mathewson C. Management of blunt trauma to the liver and hepatic veins. Arch Surg 1968;96: 698-704. 6. Burch JM, Feliciano DV, Mattox KL. The atriocaval shunt: facts and fiction. Ann Surg 1988; 207: 555-68. 7. Kudsk KA, Sheldon GF, Lim RC. Atrial-caval shunting (ACS) after trauma. J Trauma 1982; 22: 81-S. 8. Pilcher DB, Harman PK, Moore EE. Retrohepatic vena cava balloon shunt introduced via the saphenofemoral junction. J Trauma 1977; 17: 837-41. 9. Nakamura S, Tsuxuki T. Surgical anatomy of the hepatic veins and the inferior vena cava. Surg Gynecol Obstet 1981; 152: 43-50. 10. Royle JP, Eiiner R, Fell G. The saphenofemoral junction. Surg Gynecol Obstet 1981; 152: 282-4.
VOLUME 158 NOVEMBER 1989