Eur J Cardiothorac Surg 2002;22:319-320
© 2002 Elsevier Science NL
Open heart surgery for posttraumatic inferior vena caval thrombosis
Hiromichi Fujii*,
Hirokazu Ohashi,
Yasushi Tsutsumi,
Masateru Onaka
Department of Cardiovascular Surgery, Fukui Cardiovascular Center, Shinbo 2-228, Fukui city, 910-0833 Japan
Received 24 January 2002;
received in revised form 23 April 2002;
accepted 29 April 2002.
* Corresponding author. Tel.: +81-766-54-5660; fax: +81-766-53-2132
e-mail: fcc20{at}lilac.ocn.ne.jp
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Abstract
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A 40-year-old woman was diagnosed as intrahepatic hematoma after blunt abdominal trauma. One month later computed tomography (CT) revealed the inferior vena caval thrombus extending into the right atrium. Emergency thrombectomy was performed under cardiopulmonary bypass. We believe that the thrombus, which was derived from laceration of the hepatic vein, extended through the inferior vena cava into the right atrium, and was the eve of pulmonary embolization. CT study should be repeated, once the intrahepatic hematoma was recognized. We emphasize that we should recognize the existence of such complication to prevent the catastrophic result.
Key Words: Inferior vena caval thrombosis • Trauma • Open heart surgery
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1. Introduction
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We report a successfully operated case of inferior vena caval thrombosis with extension into the right atrium after blunt abdominal trauma. This is the second reported case that the thrombectomy was performed under cardiopulmonary bypass (CPB). The diagnosis and treatments of this lesion are discussed.
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2. Case report
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A 40-year-old woman was admitted to another hospital following a traffic accident. Computed tomography (CT) revealed an intrahepatic hematoma near the middle hepatic vein. Because the hematoma had not ruptured into the abdominal cavity, conservative therapy was chosen. She was not under contraception therapy before and after traffic accident. Thirty days after injury, CT revealed a low-density area in the inferior vena cava (IVC) and the right atrium, which was not found in the previous study. The patient was transferred to our hospital for further evaluation and treatment. Echocardiography revealed an abnormal mobile mass that extended into the right atrium from the IVC (Fig. 1
). Lung perfusion scintigraphy was unremarkable. A diagnosis was made of posttraumatic inferior vena caval thrombosis extending into the right atrium without pulmonary embolism (PE).
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Fig. 1. Echocardiogram reveals a mobile mass in the right atrium (arrow). RA, right atrium; LA, left atrium; RV, right ventricle; and LV, left ventricle.
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An emergency operation was performed through a median sternotomy. CPB was established via an arterial cannula in the ascending aorta and via superior vena caval and right femoral venous cannulae. Although atriotomy on the beating heart was attempted, brisk blood flow from the IVC obscured surgical field. Therefore, the patient was cooled to a rectal temperature of 28°C, and the thrombus in the right atrium was removed during 2 min of circulatory arrest. After 4 min of reperfusion, thrombectomy via the middle hepatic vein was performed successfully during 2 additional minutes of circulatory arrest (Fig. 2
). The intima of the middle hepatic vein appeared as irregular surface. The patient was weaned from CPB uneventfully.
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Fig. 2. Photograph of thrombus removed from the inferior vena cava, the middle hepatic vein, and the right atrium.
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The patient was extubated without difficulty on the day of operation. Anticoagulant and antiplatelet therapy was begun on postoperative day 2, and recovery was uneventful. Abdominal ultrasonography revealed no blood flow in the middle hepatic vein and showed its obstruction. CT showed no recurrence.
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3. Discussion
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Several cases with inferior vena caval thrombosis after blunt abdominal trauma are reported in the literature, and its pathologic mechanism are explained as: (1) the venous endothelial injury secondary to compression or shearing forces [1], (2) caval stasis secondary to compression by retroperitoneal hematoma [2] and, (3) a hypercoagulable state after major trauma [3].
In the present case, intrahepatic hematoma was found shortly after the injury, and it seems to be caused by the rupture of the middle hepatic vein. No abnormal findings were found in the IVC at this early point. One month later inferior vena caval thrombosis formation was noticed. Therefore we believe that the thrombus, which was produced from this laceration, extended from the middle hepatic vein through the IVC and to the right atrium. This pathologic process is quite unique, and no report like this case is seen in the literature.
We believe that CT study should be repeated later, even if the earlier study showed no abnormal findings, because inferior vena caval thrombosis usually is found 2–7 weeks after injury in the reported cases [1–5].
Inferior vena caval thrombosis has been treated with surgery [5], Greenfield filter [4], heparinization [1], and percutaneous transluminal angioplasty (PTA) [3]. Knudson et al. [6] reported that the incidence of PE after multiple traumas is 6.2% in spite of prophylaxis. The incidence of PE with inferior vena caval thrombosis is as high as 57% (4/7) [1,2,4,5]. In the literature, one without aggressive treatment of the four patients died of massive thromboembolism of the main pulmonary artery. The mortality is 25%. The three patients survived, but in one patient surgical treatment was performed and the other two patients were treated by heparinization. PE can be fatal, so treatment should be started as soon as the diagnosis is made. If the condition of the patient allows open heart surgery, thrombectomy with CPB should be performed promptly. Although Grmoljez et al. reported the first case of thrombectomy under CPB without circulatory arrest, circulatory arrest should provide better exposure. Because the middle hepatic vein was involved in this case, brief circulatory arrest was required. If thrombectomy cannot be accomplished quickly, the procedure should be performed during circulatory arrest with deep hypothermia.
Recurrent inferior vena caval thrombosis has not been reported. In the present case, the intrahepatic hematoma and rough venous intima remained after surgery. We thought that the risk of recurrence was high and started anticoagulant and antiplatelet therapy on postoperative day 2. We emphasize that it is essential to recognize the existence of such a rare case to diagnose and treat the patient successfully after blunt abdominal injury.
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References
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- Campbell D.N., Liechty R.D., Rutherford R.B. Traumatic thrombosis of the inferior vena cava. J Trauma 1981;21:413-415.[Medline]
- Takeuchi M., Maruyama K., Nakamura M., Chikusa H., Yoshida T., Muneyuki M., Nakano T. Posttraumatic inferior vena caval thrombosis: case report and review of the literature. J Trauma 1995;39:605-608.[Medline]
- Patel N.H., Bradshaw B., Meissner M.H., Townsend M.F. Posttraumatic Budd-Chiari syndrome treated with thrombolytic therapy and angioplasty. J Trauma 1996;40:294-298.[Medline]
- Nagy K.K., Duarte B. Post-traumatic inferior vena caval thrombosis: case report. J Trauma 1990;30:218-221.[Medline]
- Grmoljez P.F., Donovan J.F., Willman V.L. Traumatic inferior vena caval obstruction. J Trauma 1976;16:746-748.[Medline]
- Knudson M.M., Collins J.A., Goodman S.B., MaCrory D.W. Thromboembolism following multiple trauma. J Trauma 1992;32:2-11.[Medline]
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Abstract
1. Introduction
