Disclosures None Endovascular Management of IVC Injuries Adam Oskowitz M.D., Ph.D. Assistant Professor of Surgery Division of Vascular & Endovascular Surgery 4/7/2017 2 Endovascular Management of IVC Injuries 4/7/2017 Overview Traumatic IVC Injuries � Mortality rate of patients that reach the hospital between 20% and • Challenges associated with IVC injuries 57% 1 � Injuries often made worse with surgical dissection • Approach to treatment � The two most important factors for postoperative survival 3 • Endovascular options • Hemodynamic condition on arrival • Cases • 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. 3 Endovascular Management of IVC Injuries 4/7/2017 4 Endovascular Management of IVC Injuries 4/7/2017 1 4/7/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Iatrogenic IVC Injuries Anatomic Considerations � (1) Infrarenal: 23% Mortality � Rare Events � (2) Suprarenal: 75% Mortality � Study looking at 231 attempts at filter retrieval over 10 years 1 � (3) Retrohepatic: 66% Mortality • Only 2 IVC injuries resulting in bleeding ‒ Both were treated with venoplasty alone ‒ Both occurred with advanced retrieval techniques 5 Endovascular Management of IVC Injuries 4/7/2017 6 Endovascular Management of IVC Injuries 4/7/2017 Endovascular Treatment Diagnosis � Management goals of patients with IVC injuries 1 � CT • Minimize duration of shock • Active extravasation • Rapid control of active hemorrhage • Hematoma � The main advantages of the endovascular approach 2 • Defined contrast gradient in IVC can signify an AVF • Speed � Venography • Remote access • Often difficult to visualize actually defect • Minimal additional trauma � IVUS • Often more useful than venography 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 7 Endovascular Management of IVC Injuries 4/7/2017 8 Endovascular Management of IVC Injuries 4/7/2017 2 4/7/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Question Minimally Invasive Treatment Options Which of the following represents an absolute contraindication to � Medical Therapy endovascular repair of an IVC Injury � Venoplasty • Restoring favorable pressure dynamics can result in injury A. Injury at the level of the renal veins 28% resolution B. Injury at the level of the hepatic veins 25% � Placement of a Covered Stent C. Hemodynamic instability 19% D. IVC filter in place that can NOT be removed 16% • Thoracic endograft E. All of the above • Aortic cuff 9% F. None of the above • NO off the shelf venous specific devices available 3% � Fenestrated Grafts • Case report for retro-hepatic injuries 9 Endovascular Management of IVC Injuries 4/7/2017 10 Endovascular Management of IVC Injuries 4/7/2017 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 11 Endovascular Management of IVC Injuries 4/7/2017 12 Endovascular Management of IVC Injuries 4/7/2017 3 4/7/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
13 Endovascular Management of IVC Injuries 4/7/2017 14 Endovascular Management of IVC Injuries 4/7/2017 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 15 Endovascular Management of IVC Injuries 4/7/2017 16 Endovascular Management of IVC Injuries 4/7/2017 4 4/7/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
17 Endovascular Management of IVC Injuries 4/7/2017 18 Endovascular Management of IVC Injuries 4/7/2017 2 weeks later 19 Endovascular Management of IVC Injuries 4/7/2017 20 Endovascular Management of IVC Injuries 4/7/2017 5 4/7/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Case 3 Endovascular Management � IVC filter retrieval � Advanced methods employed 21 Endovascular Management of IVC Injuries 4/7/2017 22 Endovascular Management of IVC Injuries 4/7/2017 23 Endovascular Management of IVC Injuries 4/7/2017 24 Endovascular Management of IVC Injuries 4/7/2017 6 4/7/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Endovascular Management � After filter manipulated BP suddenly dropped to 54/30 25 Endovascular Management of IVC Injuries 4/7/2017 26 Endovascular Management of IVC Injuries 4/7/2017 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 27 Endovascular Management of IVC Injuries 4/7/2017 28 Endovascular Management of IVC Injuries 4/7/2017 7 4/7/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
29 Endovascular Management of IVC Injuries 4/7/2017 30 Presentation Title and/or Sub Brand Name Here 4/7/2017 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 31 Endovascular Management of IVC Injuries 4/7/2017 32 Endovascular Management of IVC Injuries 4/7/2017 8 4/7/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Case 4 � 52 y/o with multiple prior abdominal surgeries undergoing routine lap cholecystecomy. 33 Endovascular Management of IVC Injuries 4/7/2017 34 Presentation Title and/or Sub Brand Name Here 4/7/2017 Case 4 � Massive Intra-op bleeding � IVC repaired � Nephrectomy � Significant bloody output from intrabdominal drain on POD 2 35 Endovascular Management of IVC Injuries 4/7/2017 36 Endovascular Management of IVC Injuries 4/7/2017 9 4/7/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
37 Endovascular Management of IVC Injuries 4/7/2017 38 Endovascular Management of IVC Injuries 4/7/2017 39 Endovascular Management of IVC Injuries 4/7/2017 40 Endovascular Management of IVC Injuries 4/7/2017 10 4/7/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
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! 41 Endovascular Management of IVC Injuries 4/7/2017 42 Endovascular Management of IVC Injuries 4/7/2017 43 Endovascular Management of IVC Injuries 4/7/2017 44 Endovascular Management of IVC Injuries 4/7/2017 11 4/7/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
Question Which of the following is an absolute contraindication to endovascular repair of an IVC Injury 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 45 Endovascular Management of IVC Injuries 4/7/2017 12 4/7/2017 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS]
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