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Replacement of infrarenal inferior vena cava using a spiral saphenous vein graft
(Portuguese PDF version)

Marcelo Fernandes Lima,¹ Ilídio Almeida Lima,² Marcos Velludo Bernardes,² Paulo Gabriel Melo Brandão,³
Fabíola Alencar Vargas,³ Denise Moreira Camelo,³ Roose Diane Padilha dos Santos³

1. Vascular Surgery Specialist. Vascular Surgeon, ANGIOMED - Angiologia de Manaus Ltda., Manaus, AM, Brazil.
2. Vascular Surgeon, ANGIOMED - Angiologia de Manaus Ltda., Manaus, AM, Brazil.
3. Medical student, Universidade Federal do Amazonas (UFAM), Manaus, AM, Brazil.

Correspondence:
Marcelo F. Lima
Av. Joaquim Nabuco, 1359-B, Centro
CEP 69020-031 - Manaus, AM
Brazil
Tel.: +55 (92) 233.2230
Fax: +55 (92) 232.6956
E-mail: mlima@argo.com.br

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ABSTRACT

The authors report on a case of replacement of an inferior vena cava segment injured by blunt trauma below the renal veins using a spiral saphenous vein graft. The patient had no signs of venous hypertension of the legs at discharge with graft patency documented by duplex scan. Although simple ligation of inferior vena cava can be performed at this level with relative safety, the authors recommend repair of the inferior vena cava whenever possible as an attempt to avoid the development of chronic venous hypertension in the lower extremities. Complex repairs must be avoided on hemodynamically unstable patients due the prolonged surgical time required, giving priority to the "damage control", a concept used in trauma surgery.

Key-words: grafts, inferior vena cava, trauma.
Palavras-chave: enxerto, veia cava inferior, trauma.

J Vasc Br 2004;3(3):261-4

Despite all the technological advances that have been reached in vascular surgery in the last decades, especially after the Korean and the Vietnam wars, vascular traumas still contribute highly to the high morbimortality rates of trauma in general. Although most of vascular injuries can be managed in a quite simple manner, through well established techniques such as primary suture, synthetic or autogenous vein grafts interpositions, and vessels ligation, complex injuries may require the use of alternative techniques that, although not used on a daily basis, provide satisfactory results when adequately managed.

We describe the case of a patient with infrarenal inferior vena cava (IVC) injury secondary to abdominal contusion. She was submitted to emergency surgical treatment with primary suture of the lesion and critical stenosis of the segment as a result. In a second surgical approach, we opted for a vessel repair through interposition of autogenous vein graft using a spiral great saphenous vein graft.

CASE REPORT

A female patient, 40 years-old, victim of a structure collapse, entered a surgical emergency department with blunt abdominal trauma presenting an extensive transverse laceration of the abdominal wall detected through topography of the hypogastric region, from one iliac crest to the other. The inspection revealed peritoneal laceration with exposure of the cavitary content. The patient was hemodynamically stable, arterial pressure 120 x 80 mmHg, conscious and normally breathing. After collection of blood samples for laboratory tests, blood typing and venous access the patient was submitted to an exploratory laparotomy, which revealed extensive laceration of the abdominal wall muscles, distal jejunal segment injury and left retroperitoneal hematoma, with infra-renal IVC laceration. Enterectomy of the injured segment and entero-enteroanastomosis for the reconstruction of the intestinal transit was performed. The IVC lesion was sutured, but due to multiple lacerations in the IVC lesion, the segment presented critical stenosis (Figure 1). As the patient was hemodynamically unstable and the abdominal wall was difficult to close due to the extensive muscular trauma, she was submitted to an abdominal ostomy procedure and reevaluated after hemodynamic stabilization.

On physical examination, a firm, tender pulsatile mass, measuring around 4 cm, was found, located in the mesogastric region. Hemogram results revealed Hb = 15 g/dl, Ht = 44,5%, white blood cell count = 11.400/ul, and platelet = 319.000/ul.

Abdominal computerized tomography (CT) revealed a sacular aneurysm of the infra-renal abdominal aorta with the larger diameter measuring 4.7 cm, and stretched bladder with increased prostate volume (Figure 1).

Figure 1 - Infra-renal vena cava with obstructive stenosis after suture of multiple lacerations.

After 4 days in the hospital, the patient presented with a bilateral inferior limb root edema, which is a sign of IVC obstruction. Another surgical procedure was carried out for the reconstruction of the IVC with a spiral great saphenous vein graft, taken from the patients' right thigh. The graft was made on a 32F chest drainage tube by using continuous polypropylene suture 6-0 (Figure 2). It was termino-terminal anastomosed between the two extremities of the IVC with polypropylene 5-0, after resection of the segment with stenosis and removal of thrombi of the bilateral iliac-caval segment through manual compression and Fogarty catheter balloon inflation (Figure 3). Due to renal overload caused by myoglobinuria resultant from extensive muscular crush injury, we did not perform the angiographic control after surgery, once the patient would be submitted to another surgery for cavity closure. In this procedure the patency of the conduit and of the previously thrombosed segments were assessed.

Figure 2 - Spiral great saphenous vein graft performed on a 36F chest tube.

Figure 3 - Interposition of spiral graft after ressection of the occluded inferior vena cava segment with termino-terminal anastomosis.

The patient recovered with complete edema regression in the 72 postoperative hours, when she was submitted to another surgical procedure for resection of skin and subcutaneous cellular tissue (SCT), which were necrosed in the low abdominal wall. She was maintained with abdominal ostomy for other 12 days, with gradual approximation of the incision borders.

Thirty-two days after the IVC reconstruction, a duplex scan study was performed and showed phasic flow with conduit patency (Figure 4). The patient was discharged from hospital after 34 days without residual edema of inferior limbs. After 90 days of the surgical procedure, the patient showed to be without clinical signs of venous hypertension in the lower limbs.

Figure 4 - Duplex scan after 32 postoperative days showing the patent graft and phasic flow of the inferior vena cava.

DISCUSSION

The mortality rate of the IVC trauma is of 33 to 66%. The infra-renal segment is the most frequently injured and in 33 to 66% of cases it is severely damaged.¹ Factors that contribute to mortality are hypotension, associated injuries and complications related with massive blood reposition.¹ In general, the most common injury mechanism is violation of the abdominal cavity by gunshots or stabs. Incidence varies according to geographic region and blunt trauma is less frequently reported.² Usually, patients present with severe hypovolemic shock, developing severe hemodynamic instability in the intraoperatory period. As these patients do not tolerate prolonged surgeries, the unstable hemodynamics is a key factor for choosing the most adequate treatment for the injury that may be found under surgical exploration.³ The concept of "damage control" in trauma surgery has decreased the intra-operatory mortality rates of these patients, as anatomic and more complex procedures are temporarily sacrificed in order to address bleeding control and major injuries.^4-7

Fortunately, most of IVC injuries can be handled with simple suture, however, some of them require the use of more complex repair techniques. It is up to the surgeon to decide upon repair or ligation in the management of the injured vessel. Ligation, however, must be avoided in segments above the renal vein due to high morbimortality rates.

The vascular trauma surgeon counts on a wide variety of resources available for IVC injuries repair, of these, the spiral grafts of autogenous veins, especially the internal saphenous vein (ISV), are quite attractive options. Some of their beneficial characteristics are: usual availability of the autogenous material, which is internally composed of endothelium, the low morbity rate associated with its withdrawal, adaptability to the injured vessel caliber and, theoretically, its resistance to infections, what enables it to be used in highly contaminated fields. It must be noticed, however, that the confection of these grafts is not always possible as it requires a prolonged surgery period which, depending on the patients' conditions, is not feasible.^8-10

The applicability of this technical resource became evident after the classical experiment by Chiu et al.,¹¹ whose aim was to find an alternative for patients with superior vena cava syndrome (SVCS). Although the use of spiral vein grafts (SVG) is more frequently indicated for SVC reconstruction, showing excellent results in terms of clinical conditions improvement and patency rates reported in the literature,^12-15 their use in many other situations, such as IVC and iliac and femoral veins reconstruction.

The use of SVG is also reported as an arterial substitute for aortic segment repair in the celiac trunk¹⁶ and in the descending aorta, for the replacement of infected Dacron prosthesis.¹⁷ Sometimes, another fact that may prevent the use of the SVG technique is the absence of an adequate vein to make the graft, either because the ISV was taken off in a varices surgery, or is used as an arterial substitute and even because of previous thrombophlebitic events. According to Chiu et al., the following formula gives the VSI extension necessary to perform a spiral graft: l = R/r x L, let 1 be the vein extension that will be ressecated, R the radius of the receptor vessel, r the radius of the donor vessel and L the extension of the segment to be replaced.¹¹

Jost et al. have reported on the use of SVG in five patients with traumatic venous injuries in the iliac-femoral region, with 67% patency after 10 months follow-up. Pappas et al. have performed this technique in six patients, of a total of 45 with complex venous injuries. Five were reconstructions of the common femoral vein and one of the popliteal vein, with 50% grafts patency 30 after days of the reconstruction surgery.³ Gloviczki et al. have performed the SVG technique in two patients, with occlusion after 3 months in one case and indefinite patency evidenced by image tests in the other case.⁸

The ligation of the infra-renal segment of IVC is a safe procedure, although the literature shows different results as for morbity associated with this procedure. It should be noticed, however, that this group of patients can develop severe venous hypertension in the segment above the ligation, many times disabling the patient. This facts should not be taken for granted, specially if the socio-economic condition of the patients and country condemn them to survive at the expense of charity, preventing them to be included in the formal work market and in social activities. For these reasons, the flow restoration with the IVC repair should be attempted as much as possible, although venous reconstructions in these situations are not frequently performed, with consequent lack of trustful data about their clinical development, patency, and risk factors of occlusion of vascular grafts performed.¹⁸

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