From the Research
Management of a Grade 5 inferior vena cava (IVC) injury requires immediate surgical intervention with damage control principles, prioritizing proximal and distal control of the IVC and employing techniques such as primary repair, patch repair, or ligation as necessary to control hemorrhage and preserve life 1. The initial approach involves rapid exposure through a midline laparotomy, followed by direct manual compression to control hemorrhage while mobilizing the appropriate structures for vascular control.
- Key considerations include:
- The level and extent of the injury, which can significantly impact the choice of repair technique and overall prognosis.
- The hemodynamic status of the patient at presentation, with hypotensive patients requiring immediate attention to volume restoration and hemorrhage control.
- The presence of associated injuries, which can complicate management and impact outcomes. For suprarenal IVC injuries, the liver may need to be mobilized using the Cattell-Braasch maneuver to facilitate exposure and repair.
- The repair technique depends on the extent of injury, with options including:
- Primary repair with 4-0 or 5-0 polypropylene sutures for smaller defects.
- Patch repair using autologous vein, bovine pericardium, or synthetic materials for more complex injuries.
- Ligation of the IVC as a life-saving measure in cases of extensive destruction, particularly below the renal veins. Massive transfusion protocol should be initiated with balanced blood products (1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets) to address coagulopathy and support the patient's hemodynamic status 2.
- Damage control strategies include temporary shunting or packing if definitive repair isn't immediately possible, with the goal of stabilizing the patient and controlling life-threatening hemorrhage. Postoperatively, patients require intensive care monitoring with attention to coagulopathy, hypothermia, acidosis, and compartment syndrome, as these injuries carry high mortality (40-80%) due to exsanguination, with survival depending on injury location, associated injuries, and time to definitive care 3.