endovascular management of ivc injuries - ucsf cme · endovascular management of ivc injuries...

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Endovascular Management of IVC Injuries

4/7/2017

Adam Oskowitz M.D., Ph.D.Assistant Professor of SurgeryDivision of Vascular & Endovascular Surgery

Disclosures

None

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Overview• Challenges associated with IVC injuries

• Approach to treatment

• Endovascular options

• Cases


Traumatic IVC Injuries�Mortality rate of patients that reach the hospital between 20% and

57%1

� Injuries often made worse with surgical dissection

�The two most important factors for postoperative survival 3

• Hemodynamic condition on arrival

• Anatomic location of the injury


1: Buckman RF et al. Injuries of the inferior vena cava. Surg Clin North Am. 2001;81:1431-1447.2: Huerta S et al. Predictors of mortality and management of patients with traumatic inferior vena cava injuries. Am Surg. 2006;72:290-296.


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Anatomic Considerations

� (1) Infrarenal: 23% Mortality

� (2) Suprarenal: 75% Mortality

� (3) Retrohepatic: 66% Mortality


Iatrogenic IVC Injuries

�Rare Events

�Study looking at 231 attempts at filter retrieval over 10 years1

• Only 2 IVC injuries resulting in bleeding

‒ Both were treated with venoplasty alone

‒ Both occurred with advanced retrieval techniques


Endovascular Treatment�Management goals of patients with IVC injuries1

• Minimize duration of shock

• Rapid control of active hemorrhage

�The main advantages of the endovascular approach 2

• Speed

• Remote access

• Minimal additional trauma


1: Huerta S, Bui TD, Nguyen TH, et al. Predictors of mortality and management of patients with traumatic inferior vena cava injuries. Am Surg. 2006;72:290-296.2: Piffaretti G et al. Traumatic IVC Injury and Repair: The Endovascular Alternative. Endovascular Today. Nov 2013

Diagnosis�CT

• Active extravasation

• Hematoma

• Defined contrast gradient in IVC can signify an AVF

�Venography

• Often difficult to visualize actually defect

� IVUS

• Often more useful than venography



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Question

A. Injury at the level of the renal veinsB. Injury at the level of the hepatic veins

C. Hemodynamic instabilityD. IVC filter in place that can NOT be removedE. All of the aboveF. None of the above


Which of the following represents an absolute contraindication to endovascular repair of an IVC Injury

3%

16%

28%

19%

9%

25%

Minimally Invasive Treatment Options�Medical Therapy

�Venoplasty

• Restoring favorable pressure dynamics can result in injury resolution

�Placement of a Covered Stent

• Thoracic endograft

• Aortic cuff

• NO off the shelf venous specific devices available

�Fenestrated Grafts

• Case report for retro-hepatic injuries


Case One

� 28 year old man presenting after a motorcycle collision

• Arrived with stable vital signs

• Mild abdominal and flank pain

• CT scan identified IVC injury

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Two week follow-up


Case 2� 19 year old female pedestrian vs auto

�Multiple traumatic injuries including grade 4 liver laceration

�Head trauma

�Fluid responsive hemodynamic changes

�Suprahepatic IVC dissection and pseudoaneurysm identified on CT



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2 weeks later



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Case 3 Endovascular Management

� IVC filter retrieval

�Advanced methods employed




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Endovascular Management

�After filter manipulated BP suddenly dropped to 54/30


Endovascular Management

�Cava was not in continuity

�Transfemoral and transjugular balloon control achieved

�Wire from above snared from below

�Attempted Aortic cuff x 2

�Ultimately repaired with 10cm thoracic endograft



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Available device options

�No large diameter covered stents FDA approved for venous use

�Aortic Cuffs

• Available in 3.3 cm length and longer

�Thoracic Devices

• Three major manufacturers make endografts that are ~10cm in length



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Case 4� 52 y/o with multiple prior abdominal surgeries undergoing routine

lap cholecystecomy.

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Case 4�Massive Intra-op bleeding

� IVC repaired

�Nephrectomy

�Significant bloody output from intrabdominal drain on POD 2



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Fenestrated Repair� 62 y/o man identified to have retro-hepatic caval injury after traffic

accident

�Hemodynamically Unstable on Hospital Day 2

�Fenestrated Repair attempted

• Graft modified on back table

• Deployed from below

• Hepatic veins marked with wires from above

• Completed in 2002!




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Question

A. Injury at the level of the renal veins

B. Injury at the level of the hepatic veins

C. Hemodynamic instability

D. IVC filter in place that can NOT be removed

E. All of the above

F. None of the above

Which of the following is an absolute contraindication to endovascular repair of an IVC Injury


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