Outcome of ligation of the inferior vena cava in the modern era

Abstract 

Background

Ligation of the significantly injured infrarenal inferior vena cava (IVC) is an accepted practice in the setting of damage control surgery. This is a report of inpatient management, outcomes, and long-term follow-up in 25 patients after IVC ligation.

Methods

The records of patients with injuries to the IVC treated in an urban level I trauma center from 1995 to 2008 were reviewed. Demographics, injury severity, and outcome data were recorded. In addition, outpatient records were reviewed and telephone interviews were conducted to assess for the presence and severity of long-term sequelae.

Results

One hundred patients had IVC injuries, and 25 (25%) underwent ligation. Location of injury was infrarenal in 54 patients, suprarenal in 21, retrohepatic in 15, and suprahepatic in 10. Twenty-two of 54 (41%) injuries to the infrarenal IVC and 3 of 21 (14%) injuries to the suprarenal IVC were ligated. Patients who underwent ligation had a significantly higher Injury Severity Score (ISS) (22 vs 15, P < .001), a higher transfusion requirement (26 U vs 12 U, P < .001), a longer hospital length of stay (78 days vs 26 days, P = .02), a longer intensive care unit length of stay (24 days vs 9 days, P < .001), and a higher mortality (59% vs 21%, P < .001). Ten of 13 early survivors of infrarenal IVC ligation received early below knee fasciotomy. Three other patients with normal compartment pressures were treated expectantly without development of a compartment syndrome. The 1 survivor of suprarenal ligation had below knee fasciotomies and had normal renal function by 1 month post injury, despite an initial creatinine elevation from .7 mg/dL to 3.2 mg/dL. Ten (40%) patients with IVC ligation survived to hospital discharge (9 infrarenal, 1 suprarenal), and long-term follow-up data are available in 8 patients (7 infrarenal, 1 suprarenal). At an average of 42 months (11–117 months), no patient has significant lower extremity edema or dysfunction.

Conclusions

(1) Ligation of the infrarenal IVC is an acceptable damage control technique, although it remains associated with a high mortality. Ligation of the suprarenal IVC may be done, if necessary, although few survivors of this technique exist. (2) Early fasciotomy is generally required, but occasional patients may be treated expectantly, based on measurements of compartment pressures. (3) Long-term sequelae in survivors of IVC ligation for trauma are rare.

Keywords: Damage control, Ligation, Abdominal vascular injury, Inferior vena cava