Injury Extra 43 (2012) 134–136 Contents lists available at SciVerse ScienceDirect Injury Extra jou rnal homepage: www.elsevier.com/locate/inext 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 a Department of Trauma and General Surgery, Waikato Hospital, Hamilton, New Zealand b Department of Cardiothoracic Surgery, Waikato Hospital, Hamilton, New Zealand c Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand d 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 1572-3461/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2012.07.005 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  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 References cooling the patient under cardiopulmonary bypass his vital organs could be adequately protected from further hypoxic [1] Baumgartner F, Milliken J, Scudamore C, Nair C, Gelman J, Scott R, et al. injury. Furthermore, circulatory arrest provided a controlled Extracorporeal methods of vascular control for difficult IVC procedures. Am bloodless field allowing the IVC tear to be patched with ease. In Surg 1996;62:246–8. [2] Burch JM, Feliciano DV, Mattox KL. The atriocaval shunt. Facts and fiction. Ann previous reports atrio-caval shunting (which involves inserting a Surg 1988;207:555–68. chest drain through the right atrium into the IVC beyond the site [3] Demetriades D, Velmahos GC, Scalea TM, Jurkovich GJ, Karmy-Jones R, Teixeira of injury with the injury site excluded by a vessel snugger in the PG, et al.