CHALLENGES

IN

ACUTE CARE SURGERY

A severe traumatic juxtahepatic blunt venous injury Carlos Alberto Ordon˜ez, MD, Juan Pablo Herrera-Escobar, MD, Michael William Parra, MD, Paola Andrea Rodriguez-Ossa, MD, and Juan Carlos Puyana, MD, With expert commentary by Megan Brenner, MD

Figure 1. A, Angiogram with active extravasation of contrast from the RHA. B, Angiogram after coil embolization of the RHA.

A

16-year-old male involved in a highspeed motorcycle collision was initially managed at a Level II trauma center where he was found to have significant abdominal pain, abdominal distension, and the following vital signs: systolic blood pressure (SBP) of 100, a heart rate (HR) of 110, and a shock index (SI) of 1.1. A Focused Assessment with Sonography in Trauma and a whole-body computed tomographic scan were performed demonstrating free abdominal fluid and a 10-cm liver laceration involving Segments IV through VIII with active extravasation of contrast from the right hepatic artery

(RHA). Patient became hemodynamically unstable, and damage-control resuscitation (DCR), endotracheal intubation for airway control, and interfacility transfer to our Level I trauma center were performed. On arrival to our facility, the patient remained hemodynamically unstable (SBP, 80; HR, 120; and SI, 1.5) and with marked abdominal distention. Lactic acid was 8.97 mmol/L, and an arterial blood gas revealed a blood pH of 7.23 and a base deficit of j11 mmol/L. Two units of packed red blood cells and 2 U of fresh frozen plasma were transfused at the Level II trauma center before transfer.

What Would You Do? A. Selective endovascular embolization of the RHA and transfer after intervention to the intensive care unit for further DCR. B. Immediate exploratory laparotomy. C. Selective endovascular embolization of the RHA followed by an exploratory laparotomy. D. Selective endovascular embolization of the RHA combined with a resuscitative endovascular balloon occlusion of the aorta (REBOA) and the vena cava (REBOC) followed by an exploratory laparotomy.

From the Centro de Investigaciones Clı´nicas (C.A.O., J.P.H.-E.), and Division of Trauma and Acute Care Surgery (C.A.O., P.A.R.-O.), Department of Surgery, Fundacio´n Valle del Lili; Division of Trauma and Acute Care Surgery (C.A.O.), Department of Surgery, Universidad del Valle; and Division of Trauma and Acute Care Surgery (C.A.O.), Department of Surgery, Hospital Universitario del Valle, Cali, Colombia; Division of Trauma Critical Care (M.W.P.), Broward General Medical Center, Fort Lauderdale, Florida; and Division of Trauma and Acute Care Surgery (J.C.P.), Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania. Address for reprints: Carlos Alberto Ordon˜ez, MD, Department of Surgery, Fundacio´n Valle del Lili, Avenida Simo´n Bolivar, Carrera 98 # 18Y49, Cali, Colombia; email: [email protected]. DOI: 10.1097/TA.0000000000000979

J Trauma Acute Care Surg Volume 80, Number 4

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J Trauma Acute Care Surg Volume 80, Number 4

Ordon˜ez et al.

Seventy-two hours later, the patient underwent packing removal, drain placement, and definitive abdominal wall closure. On postoperative Day 10, the patient was discharged home. Drains were removed on postoperative Day 17. No further complications were noted during the patient’s 60-day follow-up. (C.A.O., J.P.H-E., M.W.P, P.A.R-O., J.C.P.).

Expert Opinion

Figure 2. A, Fluoroscopic image of REBOA and REBOC in place. B, REBOA and REBOC catheter placement via the right groin.

What We Did and Why D. Selective endovascular embolization of the RHA combined with a REBOA and the vena cava (REBOC) followed by an exploratory laparotomy. Because of the computed tomographic evidence of an RHA injury, a hepatic angiography was indicated, and a selective endovascular embolization was performed (Fig. 1). Patient remained hemodynamically unstable (SBP, 72; HR, 126; and SI, 1.75) despite presumptive source control after embolization. This increased our suspicion of a possible associated major hepatic venous injury. A REBOA was performed percutaneously via the femoral artery and inflated in the descending thoracic aorta between the origin of the left subclavian and celiac arteries (Zone 1) to aid in the hemodynamic stabilization of the patient. A REBOC was also placed percutaneously via the femoral vein and inflated in the retrohepatic inferior vena cava to achieve proximal control of any possible juxtahepatic venous bleeding before laparotomy. Each balloon positioning was confirmed by fluoroscopy, and both were inflated simultaneously achieving instantaneously an SBP of 100 mm Hg (Fig. 2A and B). The patient was then taken immediately to the operating room where an exploratory laparotomy and a Pringle maneuver were performed. The intraoperative findings included a 4,000-mL hemoperitoneum and a Grade V liver laceration of approximately 10 cm involving Segments IV through VIII with

an associated juxtahepatic venous injury, which was oversewn (Fig. 3). The REBOA provided adequate coronary and cerebral perfusion, and the REBOC facilitated the intraoperative visualization and subsequent ligation of the juxtahepatic venous injury. By combining the REBOA, the REBOC, and the Pringle maneuvers, we were able to achieve adequate liver isolation in a new hybrid fashion (endovascular and operative) as part of our damage-control approach. Both balloons were deflated after 30 minutes of inflation followed by perihepatic packing. There was no evidence of active bleeding, and temporary abdominal closure was performed. Balloon catheters were removed, and the patient was transferred to the intensive care unit for rewarming and continued DCR management.

The answer to this question really depends on institutional resources. The ideal situation is to admit the patient directly to a hybrid operating room. Because the diagnosis of active extravasation from the RHA has been made, it is implicit that, at the very least, angiography will be required. The patient had significant abdominal pain and free fluid upon arrival at the initial facility. This, with additional significant hypotension, would mandate an immediate exploration for hemorrhage control (and less urgent hollow viscous injury) in most institutions. At our institution, a Zone 1 REBOA (at the level of the diaphragm) would be placed on admission as a bridge to angiography. With continued hypotension after embolization (or in the presence of abdominal compartment syndrome), abdominal exploration should be performed to identify and repair any further hemorrhage and possible hollow viscous injury. A REBOC could be placed after isolating the level of venous hemorrhage if control of bleeding could not be achieved. Confirmation of REBOC positioning could be performed manually or under fluoroscopy.

Figure 3. Exploratory laparotomy.

* 2016 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

675

J Trauma Acute Care Surg Volume 80, Number 4

Ordon˜ez et al.

Given that the patient was unstable on arrival, transfer to an angiography suite without temporizing with abdominal packing or a REBOA is potentially disastrous. An experienced traumatologist once said ‘‘Interventional radiology is where patients go to die.’’ Again, awareness of institutional resources is key. The geographic distance between the bleeding patient and the trauma surgeon is exponentially related to mortality. In this case, placing a retrohepatic caval balloon before exploration was fortuitousVhad there been a major superior mesenteric vein or portal vein

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injury, the outcome may have differed (although to what degree with the presence of aortic occlusion is unknown). In addition, care must be taken when using a Coda balloon in the venous system where vascular integrity and compliance are significantly less in the arterial system. Currently, an endovascular technology company is developing a long compliant venous occlusion balloon, which could be available in 2016 pending Food and Drug Administration approval. Answer A would neither address the persistent hypotension after embolization nor would it rule out a hollow

viscous injury. B is wise especially in locations without immediate angiographic capability or REBOA. C and D advocate for immediate angiography, which in most locations is not immediate and, depending on hemodynamic status, could be unsafe. Again, institutional resources play a large role in the treatment of these complex combined arterial and venous hepatic injuries, and constant reappraisal of resources and the patient’s clinical status will drive the treatment algorithm. The authors should be congratulated on their successful outcome and their use of endovascular damagecontrol procedures (M.B.).

* 2016 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

A severe traumatic juxtahepatic blunt venous injury.

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