Successful Treatment of Dual Juxtahepatic Inferior Vena Cava Injuries Using Formal Atriocaval Shunt: A Case Report and Review of the Literature

Repair of penetrating retrohepatic inferior vena cava (IVC) injuries continues to challenge trauma surgeons due to difficulty in accessing the injury, hemorrhage prior to the repair, and associated high mortality rates. Complication by suprahepatic vena cava injuries portends an increased risk of an unfavorable outcome. Over time, overall survival has been relatively unchanged, and the morbidity and mortality associated with these injuries continue to be very high. First proposed by Shrock et al. in 1968, atriocaval shunt placement remains the gold standard approach for the temporary bypass of these lesions by controlling bleeding from the retrohepatic IVC to allow time for repair prior to exsanguination and death. Despite familiarity with this management strategy for decades, these injuries remain infrequent but continue to have poor survival due to their complexity. There are only rare examples of the use of this approach resulting in successful discharge from the hospital. We present a case report of survival after the successful deployment of an atriocaval shunt in a patient who sustained multiple gunshot wounds to his right thoraco-abdomen, left chest, and upper and lower extremities. He ultimately survived to discharge from the hospital. We provide a brief review of the current literature and propose future approaches to repairs of juxtahepatic IVC injuries.

A temporary bypass used in end-to-end anastomosis of major vessels without stopping blood flow in the segment under repair

The authors developed an original set of tools and a method of carrying out end-to-end anastomosis on major vessels, without stopping blood circulation in the vascular segment being repaired. The proposed set of tools includes 10 tubes (temporary vascular grafts) made of medical silicone with external diameters from 8 to 26 mm. The length of each tube is not less than 10 cm, and the wall thickness is 1.2 mm. A spiral notch with a step of 1.2 mm is made on the outer surface of the tubes, to a depth of 1 mm. The set of tools also includes a set of metal hollow half cylinders with a through hole made in the middle, designed to extract the temporary shunt of the appropriate diameter. Before the formation of a vascular anastomosis, a silicone tube is selected, the outer diameter of which corresponds to the inner diameter of the damaged vessel. It is necessary to cut off a length of the tube, so that 23 cm of it could be introduced into the lumen of the proximal and distal segments of the damaged vessel. A stay-suture is laid in the center of the temporary bypass, on a site of its wall between two neighboring spiral notches. The ends of the temporary bypass, pre-filled with saline solution, are introduced into the distal and proximal ends of the divided vessel and are firmly fixed in the lumen of the vessel with two elastic bands. After placing the temporary bypass in the lumen of the damaged vessel, the blood flow is restored. Using the intraluminar temporary shunt as a scaffold, the edges of the vessel are approximated and stitched to its entire circumference, tying the first and last stitches of this seam. The last additional suture is placed in the area of the stay-suture overlying the wall of the temporary vascular shunt and is not tightened. A half-cylinder is placed above the untightened vascular suture and a stay-suture is placed at its opening. After that, tightly pressing the metal hollow half-cylinder to the vascular wall, and applying traction to the ends of the stay-suture the mechanical destruction of the silicone tube along the line of the spiral incision ensues. As a result, the tube is transformed into a double silicone rod, which is pulled through a through hole in the metal half-cylinder floor. After the extraction of the tube, the anastomosis is completed by tying a knot on the provisional suture. To simulate the proposed method, 10 operations were performed using a closed experimental circuit that completely simulates the real situation of restoring a damaged major vessel. The time of the operation, the technical features of the intervention, as well as the volume of blood loss, which was estimated by reducing the volume of blood circulating in the experimental circuit, were evaluated. Experimental testing with the use of a model simulating the situation of restoring a damaged major vessel, demonstrated the effectiveness of the developed method of applying a vascular end-to-end anastomosis with the use of a destructible temporary bypass; the average time of the operation was 10 minutes, and the volume of blood loss did not exceed 5 ml. The proposed set of tools and method can be effectively used in case of major vessels injury. The technique completely excludes the need for interrupting blood flow through the sutured vessel; it allows to reduce the volume of blood loss in vascular trauma, minimizes the time of ischemia in the area of blood supply to the damaged artery or venous stagnation of the drained segment (when suturing a vein), as well as to facilitate the imposition of a vascular suture to surgeons who do not have sufficient qualification in vascular surgery.

Use of the temporal bypass technique in the treatment of thoracic and thoracoabdominal aortic aneurysms

The OBJECTIVE was to analyze the experience of using a vascular prosthesis as a temporary bypass for spinal cord and visceral organs ischemia prevention during the clamping time in surgical reconstruction of thoracic and thoracoabdominal aortic aneurysm.MATERIAL AND METHODS. The study included 60 patients with the pathology of aortic arch, descending and thoracoabdominal aorta (TAAA) from 1997 to 2018. Among them, 42 (11 %) patients were diagnosed with TAAA I–IV types according to E. S. Crawford classification, 18 (32 %) – with the aortic arch aneurysm and the descending thoracic aorta. Planned interventions were performed in 43 (72 %) patients, emergency – in 17 (28 %). A temporary bypass made from vascular prosthesis with a diameter from 15 to 20 mm was used in 29 (48 %) cases as a protection of internal organs and the spinal cord against ischemia, and in 31 (52 %) surgical cases the reconstruction was performed with a cross clamping method.RESULTS. 30 days mortality was 16.6 % (n=10), total hospital mortality was 28.3 % (n=17). The mortality was 23.2 % (n=10) after planned interventions, and 41 % (n=7) – in emergency interventions. When using a temporary bypass during planned operation 9.3 % (n=4) of the patients died within 30 days, while cross clamping method without visceral protection showed 13.9 % death rate (n=6). Acute renal failure developed in 7 (11.6 %) cases and it was observed more often in the group without using of temporary bypass technique. The spinal cord ischemia turning into a spinal stroke occurred in 8 (13.3 %) cases. Five-year survival rate was 61 %.CONCLUSION. The use of a temporary bypass during the thoracic and thoracoabdominal aneurysms repair could be used for prevention of the visceral organs, kidneys and spinal cord ischemic complications during operations with need in cross clamping of the descending thoracic aorta.

Abstract 3836: Efficacy And Safety Evaluation Of Endovascular Revascularization Devices In The A Rabbit CCA Occlusive Model

Background: Intra-arterial recanalization strategies targeting acute ischemic stroke (AIS) are a focus of increased interest, since their use results in a faster and a higher grade of recanalization. We evaluated different treatment strategies in a dedicated rabbit CCA model of thromboembolic occlusion. The response to Alteplase in rabbits is similar to humans; making this model ideal for thrombolytic evaluation. Method: New Zealand White rabbits were anesthetized, the CCA was exposed and a luminal stenosis created bilaterally with 3-0 silk suture. Allogenic clot was injected through a 6F catheter, which lodged consistently at the site of the stenosis. Allowing 45 minutes for clot-vessel wall interaction, the stenosis was released. The clot adhered to the vessel wall and did not migrate distally. The occlusion was treated with either intra-arterial Alteplase (n=4), balloon angioplasty (n=3), balloon infusion wire (NIT Therapeutics, PA; n=3) which in its embodiment mechanically disrupts and adjuvantly delivers Alteplase within the clot or partial stent deployment as a temporary bypass with (n=2) and without Alteplase (n=5). The control vessel (n=4) received no treatment. The primary efficacy endpoint was the final thrombolysis in cerebral infarction (TICI) score. The primary safety endpoint was the vascular safety of the device, which was assessed on luminal scanning electron microscopy (SEM) and hematoxylin and eosin staining. Results: Thromboembolic occlusion was created successfully with TICI 0 flow at the CCA in all animals. Partial stent deployment resulted in transient revascularization, however on resheathing, the vessel reoccluded. Use of partial stent deployment with adjuvant Alteplase resulted in revascularization in the high dose (4mg) group, however it failed to recanalize when using a lower (2mg) dose. Use of balloon angioplasty alone or intra-arterial Alteplase alone often failed to revascularize the vessel. The use of the balloon infusion wire resulted in a higher grade of recanalization (TICI 2B) consistently at a lower dose of Alteplase. Histomorphometric and SEM data revealed an acceptable level of disruption for endovascular devices, with endothelial denudation and exposure of the internal elastic lamina. Conclusion: With incorporation of newer endovascular treatment strategies to treat AIS, it is imperative to test their safety and efficacy in valid preclinical models, which simulates the thrombolytic and mechanical device- clot interaction as experienced in humans.

Repair of aortic coarctation using temporary ascending to descending aortic bypass in children with poor collateral circulation

Aortic coarctation can now be repaired surgically with excellent results. Even though rare, injury to the spinal cord resulting in paraplegia remains a major concern. Preoperative evaluation showing the absence of collateral circulation is valuable in order to introduce protective actions. This report describes our experience using a temporary bypass from the ascending to the descending aorta bypass in children undergoing surgical correction of aortic coarctation in the setting of poorly developed collateral circulation.Between 1990 and 2002, we undertook direct surgical repair in 56 patients with isolated aortic coarctation, 20 as neonates, 11 as infants, and 25 during childhood. From 1998 onwards, we introduced preoperative evaluation of the collateral circulation with magnetic resonance imaging. From that time, we placed a temporary bypass from the ascending to the descending aorta, using a polytetrafluoroethylene tube of 4 to 8 mm diameter, whenever distal pressures were shown to be 25 mmHg or less after test clamping, or when magnetic resonance imaging revealed absence of collateral circulation.We found excellent correlations between the direct intra-operative measurements of distal pressure and the findings at magnetic resonance imaging. Following introduction of the temporary bypass, we observed no neurological complications, nor were there any complications related to bypass. Freedom from restenosis was 96%.Preoperative magnetic resonance imaging, therefore, can accurately visualize poor collateral circulation in children with aortic coarctation. The use of a temporary bypass can possibly eliminate the risk of neurological sequels following direct repair of coarctation in children with poorly developed collateral circulation. The temporary bypass is both easy to apply and safe.