Atriocaval shunt

An atriocaval shunt (ACS) is an intraoperative surgical shunt between the atrium of the heart and the inferior vena cava. It is used during the repair of larger juxtahepatic (next to the liver) vascular injuries such as an injury to the local vena cava. Injuries to the inferior vena cava are challenging, those behind the liver being the most difficult to repair.

Procedure and results

Injury to the vena cava adjacent to the liver and/or connected hepatic veins leads to often fatal bleeding. Patients may be admitted already in hemorrhagic shock with death occurring even before the bleeding area is localized.[1][2] Surgically, the area is difficult to access as it is largely covered by the liver. In 1968 Schrock et al. reported on the first use of the ACS.[3] They devised this approach after observing that above the renal veins only the right adrenal vein, the hepatic veins, and the inferior phrenic veins enter the inferior vena cava.[2] The placement of the shunt allowed venous return to the heart and, along with the Pringle manoeuvre, controlled local bleeding. While their patient did not survive, other investigators followed their lead with some success.

A 1988 review by Burch et al. analyzed their experience with the ACS looking at 31 patients.[2] They indicated that “few technical maneuvers in surgery (are) as dramatic or desperate as the use of the atriocaval shunt ...” Ninety percent of the patients were admitted in shock. In 74% the vena cava was directly involved. In addition to the laparotomy to access the retrohepatic space, a thoracotomy is necessary to find the atrium so that the stent—usually a 36 French chest tube—can be inserted. The stent is secured with tourniquets. Problems during surgery involve uncontrollable bleeding and technical problems in placing the shunt in a timely fashion. Six patients survived (about 20%).

Alternatives

Pachter et al. devised a transhepatic approach to access the inferior vena cava.[4] Another approach may be the placement of a balloon-caval shunt introduced from the femoral vein in the groin.[5]

Buckmann et al. indicate that injury to the juxtahepatic veins may not necessarily require surgery if the hematoma is contained.[6]

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References
  1. Clark JJ, Steinemann S, Lau JM (2010). "Use of an Atriocaval Stunt in a Trauma Patient: First Reported Case in Hawai'i". Hawai'i Medical Journal. 69 (2): 47–8. PMC 3104635. PMID 20358727.
  2. Burch JM, Feliciano DV, Mattox KL (May 1988). "The atriocaval shunt. Facts and fiction". Ann. Surg. 207 (5): 555–68. doi:10.1097/00000658-198805000-00010. PMC 1493506. PMID 3377566.
  3. Schrock T; Blaisdell FW; Mathewson C., Jr (May 1968). "Management of blunt trauma to the liver and hepatic veins". Arch. Surg. 96 (5): 698–704. doi:10.1001/archsurg.1968.01330230006002. PMID 5647544.
  4. Pachter HL, Spencer FC, Hofstetter SL, et al. (May 1986). "The management of juxtahepatic venous injuries without an atriocaval shunt". Surgery. 99 (5): 569–75. PMID 3518106.
  5. Pilcher DB, Harman PK, Moore EE, et al. (Nov 1977). "Retrohepatic vena cava balloon shunt introduced via the sapheno-femoral junction". J Trauma. 17 (11): 837–41. doi:10.1097/00005373-197711000-00003. PMID 335079.
  6. Buckman RF, Pathak AS, Badellino MM, Bradley KM (Dec 2001). "Injuries of the inferior vena cava". Surg Clin North Am. 81 (6): 1431–47. doi:10.1016/s0039-6109(01)80016-5. PMID 11766184.
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