There are some major vessels that can be ligated in extreme situations, meaning life saving. Inferior vena cava (IVC) is one of them. Others can be ligated to allow some specific surgical procedure, like renal vein between IVC and gonadal vessels. However, just because it is possible to do does not mean you should do it freely. There are consequences following ligation...
Mechanism of IVC injury is penetrating trauma in about 79,4% of cases, 66,6% from firearm. Mortality rate goes from 20 to 66%, and 30-50% of patients die before reaching an emergency department. In Portugal this scenario is rare. Hope it keeps that way...
Surgical management of an IVC injury is challenging because of difficulty in exposing injury site through an active haemorrhage or expanding retroperitoneal haematoma. Additionally, bleeding control is of major importance in an unstable patient with an IVC injury. Time is life! In that setting, there is still a debate about which is the best approach: ligation or repair. Traditionally the preferred method is IVC repair, leaving ligation to critically ill patients, coagulophatic, acidotic, hypothermic, and in damage-control situations. Ligation may be the better option in some patients, but it is a hard decision due to potential complications coming from ligation.
Wether ligation improves survival comparing to repair was the objective of a recently published paper in the Journal of The American College of Surgeons by Matsumoto et al from the Division of Trauma of the University of California, San Diego, USA. The authors performed a retrospective analysis of 1316 patients treated with IVC injury between 2007 and 2014. Because patients submitted to ligation were significantly sicker (spine injury, extremity injury, non-IVC abdominal injury) than repair patients, they used a propensity score to match groups' characteristics and compare results. After the matching they found two groups of 310 patients each: ligation group and repair group.
"The results showed that ligation was associated with no survival benefit and increased complications and hospital LOS."
Matsumoto et al.
In-hospital mortality was higher in ligation group before matching (p=0,009), but there was no statistical difference after matching (0,623). Survival rates were similar in both groups, with majority of deaths occurring within the first 3 days. Surgical site infection was also similar. Ligation group had more complications than repair group, namely: extremity compartment syndrome (p=0,004); deep venous thrombosis (p<0,001); pulmonary embolism (p=0,17). Hospital length of stay (LOS) was also increased in ligation group (p=0,002). Additionally, Matsumoto et al could not find any specific characteristic that could indicate a benefit in ligation.
In fact this is a major problem when we talk about IVC repair or ligation in a trauma. There are no stablished indications for ligation. There are no guidelines to help the surgeon decide. Although there seems to be no benefit in ligation, we must not forget that in the entire group of patients included before matching, ligation was used mostly in sicker patients, in patients with higher Injury Severity Score and with concomitant injuries. Surgeons must keep in mind that the major objective in a IVC injury scenario is to stop the bleeding, which must be accomplished quickly and effectively. Try and try, and try again to repair an IVC injury in a severe physiologic compromise patient with several other non-IVC abdominal injuries will probably lead the patient to death. In that setting, IVC ligation might be the best option, I think.
The major objective in an IVC injury is to stop the bleeding, quickly and effectively.
An interesting sentence is made by the authors: "Ligation might become more common with the spreading influence of damage-control operations". Not all trauma patients or emergent patients need pure damage-control. Not all patients are war patients with extreme injuries who need extreme measures. Surgeon must individualize the decision, and not go with the flow and avoid a IVC ligation "boom".
To repair an injury affecting >50% of IVC circumference is time (and life) consuming. Ligation should be used in large defects.
Anatomic location of injury must also be taken into consideration. Suprarrenal, retrohepatic and intrapericardic IVC injuries have a poorer outcome and cannot be ligated, with the risk of a congestive nephropaty. For retrohepatic injuries the best treatment option is endovascular stenting. Although the authors could not perform an anatomic location analysis, they state that infrarenal IVC injuries have a better survival rate, associated with an easier access. Matsumoto et al also discuss the influence of anatomic extent of injury. In fact, to repair an injury affecting >50% of IVC circumference a venous or prosthesis patch is needed, which is time (and life) consuming in a critically ill patient. So, ligation should be used in large defects.
About complications reported there is no surprise. Lower extremity compartment syndrome is more common after ligation as is DVT. The authors did not report more fasciotomy after ligation like in other published studies. They concluded that lower extremity swelling is an uncommon long-term complication if simple measures are taken early: leg elevation and elastic compression stockings. One important complication that was more common after ligation was pulmonary embolism (PE). In my idea this makes little sence because IVC was ligated. The authors did not explain or present an eventual reason for this finding. DVT from other locations? Fat embolism due to bone fractures? Air embolism?...
In summary, IVC injury repair looks to be the standard approach, and ligation offers no survival benefit with higher rate of complications. However, decision making should strongly depend on the surgeon and the patient status. I believe ligation has a place in critically ill patients (hypothermic, acidotic, coagulopathic), with several concomitant injuries (spine injury, severe extremity injuries, non-IVC abdominal injuries), and with injuries affecting >50% of IVC circumference. Decision is not easy, and it is even harder because there are no guidelines to help us decide.
Decide to ligate or repair an IVC injury is pure surgery, is surgery without a net, is a moment of art based on medical knowledge.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon