Survival After Intrapericardial IVC Rupture and Traumatic Aortic Transection

Injury Extra 43 (2012) 134–136

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Case Report

Survival after intrapericardial IVC rupture and traumatic aortic transection

a, b b c d a

J.W. Duijff *, F. Meikle , A. El-Gamel , C. Holdaway , M. Swarbrick , G.R. Christey

Department of Trauma and General Surgery, Waikato Hospital, Hamilton, New Zealand

Department of Cardiothoracic Surgery, Waikato Hospital, Hamilton, New Zealand

Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand

Department of Radiology, Waikato Hospital, Hamilton, New Zealand

A R T I C L E I N F O

speed. He was thrown approximately 6 m from his bike. On

Article history: arrival, he had a blood pressure of 97/62 mmHg and heart rate of

À1

Accepted 5 July 2012 97 min . Shortly after, his blood pressure dropped to 40/

20 mmHg. Chest X-ray showed a large haemothorax on the right

(Fig. 1) for which a chest tube was placed. This drained 1500 ml

immediately but then stopped draining. He was intubated.

Because of persistent haemodynamic instability the massive

transfusion protocol (containing red blood cells, fresh frozen

1. Introduction

plasma and platelets in a 1-1-1 ratio) was activated. He received

1 g of Tranexamic acid twice while in the ED. The FAST scan was

Trauma to the great vessels in the chest is life-threatening

normal and the abdomen soft and non-distended. A second chest

[4,11]. These injuries are usually caused by blunt trauma with a

X-ray revealed a large mediastinal haematoma as well as a large

signiﬁcant deceleration force [11], but can also arise from

haemothorax on the left (Fig. 2). The right-sided chest drain

iatrogenic injuries or penetrating trauma [5]. A large British study

drained another 400 ml after log-rolling the patient. The

found blunt traumatic aortic rupture to be present in 20% of car

decision was made to take him to theatre. A clamshell

occupant deaths with a scene survival chance of 2–5% [11]. Initial

thoracotomy was performed. A fracture of the manubrium with

workup in the trauma room consists of a chest X-ray and FAST

associated transection of both internal mammary pedicles was

scanning. If the patient is stable enough to undergo further

noted. Exploration of the left chest revealed a transection of the

examination, a CT scan with intravenous contrast can give more

aorta, with rupture into the left hemithorax (a small tear in the

accurate information as to the exact location and extent of the

mediastinal pleura was present). The transection, at this point,

injury. Endovascular repair of blunt thoracic aortic trauma is

was assumed to be at the typical position in the aortic isthmus,

rapidly becoming standard of care, although long-term follow-up

distal to the left subclavian. Temporary haemostasis could be

data is not yet available [4]. However, angiography may not be

achieved by packing the left mediastinum with several large

always readily available in every hospital, or not available at all.

abdominal swabs bundled into the space between the aorta and

Many larger hospitals are building hybrid angiography/operating

the lung. The patient was at this point peri-arrest and not

suites nowadays. For repair of intrathoracic IVC injuries atriocaval

improving. Intra-operative TOE revealed a large pericardial

shunting [13] as well as cardiopulmonary bypass and hypothermic

effusion with features of tamponade. The pericardium was

circulatory arrest have been used as an adjunct in the treatment

opened and was found to contain a large volume of venous

[1,9]. Our literature search discovered only one previous report of a

blood. A large laceration in the intrapericardial inferior vena

patient that survived a combined inferior vena cava (IVC) and

cava was found, just superior to the diaphragm. Hemostasis was

thoracic aorta injury [13].

achieved digitally. However, the patient continued to deterio-

rate and given impending cardiac arrest as well as difﬁculty

2. Case

controlling the bleeding from the IVC, cardiopulmonary bypass

was established using direct aortic and right atrial cannulation.

A 67-year-old man, with a history of ischaemic heart disease

Haemorrhage was being circulated back into the bypass circuit

treated with stenting, was seen by the trauma team in the

in an auto-transfusion fashion. The patient was actively cooled

emergency department of our provisional level 1 trauma centre

to 18 8C. The defect in the IVC was closed with a bovine

after he had crashed his motorbike into a turning car at high

pericardial patch under deep hypothermic circulatory arrest.

During rewarming (while still on full cardiopulmonary bypass)

angiography was performed and the aortic transection was

* Corresponding author at: Oude Kerkstraat 9a, 2611 HT Delft, The Netherlands.

indeed found to be located just distal to the left subclavian

Tel.: +31 6 39201369.

E-mail address: [email protected] (J.W. Duijff). artery. Measurements were done with a calibrated catheter and

J.W. Duijff et al. / Injury Extra 43 (2012) 134–136 135

Fig. 1. Chest X-ray showing a right haemothorax.

the diameter of the proximal aorta was 27 mm. Endovascular

stenting of the aorta was now performed using a

1 1 TM

34 mm 152 mm Cook Zenith TX2 with Pro-form stent

Â Fig. 3. CT chest showing the stent graft deployed in the aorta. Just proximal to the

graft (a 30-mm stent was not available), taking care not to stent, the origin of the left subclavian artery is patent.

overstent the left subclavian artery (Fig. 3). The chest was

packed. The patient was taken to ICU for further stabilisation. In

total, he received a total of 59 red blood cell units, 54 fresh

frozen plasma units and 10 units of platelets, 18 units of Ten weeks after the crash, the patient was transferred to the

cryoprecipitate, and recombinant factor VIIa 2.0 mg twice hospital rehabilitation facility, where he has continued to improve.

during the ﬁrst 24 h. The chest was closed 72 h later. At present, 1 year and 2 months after the crash, he is back home

A CT scan of the brain showed intraventricular haemorrhage, and doing well.

which was managed conservatively, and a type 2 C2 fracture. Other

orthopaedic injuries included a Gustilo grade IIIa compound femur 3. Discussion

fracture, comminuted tibial plateau fracture, bilateral comminuted

patella fractures and bilateral forearm fractures. His injury severity As far as we know, this is only the second reported case of a

score amounted to 50. The neck was initially managed with Halo- patient surviving the combination of aortic transection and IVC

traction and later by C1-2 fusion with 2 screws through a dorsal rupture [13]. This is logical, since patients with this set of injuries

approach. External ﬁxators were placed on both legs and, after will rarely survive long enough for presentation to a hospital. This

multiple washouts, deﬁnitive ﬁxation followed several weeks patient presented exactly 1 h after the crash, which is a much

later. An IVC ﬁlter was used for thromboprophylaxis and a surgical shorter time compared to the patient from the report by Seoudi

tracheotomy was performed later. et al., who arrived 4 h after a motor vehicle collision [13].

Angiography, although used increasingly to treat aortic injury

[4], would probably not have been able to deal with the injury to

the right side of the chest. The angiography suite in our hospital is

not a hybrid theatre. Furthermore, angiography services are not

always as readily available as the operating theatre. Because there

were exsanguinating injuries to multiple compartments in the

chest the decision was made to take this patient to the operating

theatre.

A unilateral anterolateral thoracotomy gives only very limited

access to one pleural cavity and some of the pericardium. A median

sternotomy would give reasonable access to the hilar structures. A

posterolateral thoracotomy is performed in a lateral position: if

there is exsanguination into the other pleural cavity there is no

way to control this. Therefore, the exact nature of this patient’s

injuries being unknown, but bilateral, a clamshell thoracotomy

was used to achieve maximum exposure to all three compartments

of the thorax.

The aortic injury was discovered ﬁrst. Because the tear in the

left mediastinal pleura was only small and blood pressure was very

low at that moment, successful packing could be performed.

The IVC tear could be more or less controlled digitally but this

made repair impossible. The patient was peri-arrest at this time

Fig. 2. Chest X-ray showing endotracheal tube, right intercostal drain, wide

mediastinum, and left haemothorax. despite packing of the aorta and massive transfusion. By actively

136 J.W. Duijff et al. / Injury Extra 43 (2012) 134–136

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Conﬂict of interest statement

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