Posttraumatic Budd-Chiari syndrome treated with thrombolytic therapy and angioplasty

Transient Budd-Chiari syndrome as an unpredictable complication of supradiaphragmatic inferior vena cava reconstruction after blunt thoracic trauma: A case report

RATIONALE

Supradiaphragmatic inferior vena cava (IVC) injury due to blunt thoracic trauma is extremely rare. Budd-Chiari syndrome (BCS) is also rare and presents with ascites, abdominal pain, hepatomegaly, leg swelling, and jaundice. Its etiology is diverse, and it is rarely caused by trauma.

PATIENT CONCERNS

A 36-year-old man with blunt trauma from a traffic accident presented with chest pain. Chest computed (CT) and emergency surgery with CPB revealed completely transected supradiaphragmatic inferior vena cava (IVC), which reconstruction was essential.

DIAGNOSES

BCS caused by impaired hepatic venous drainage through a reconstructed neo-IVC after severe blunt trauma injury to the supradiaphragmatic IVC was diagnosed.

INTERVENTION

Hepatic failure, ascites, leg swelling, and jaundice were resolved post-insertion of a veno-venous extracorporeal membrane oxygenator (V-V ECMO) for hepatic venous drainage, but these clinical symptoms reappeared after ECMO removal.

OUTCOME

The patient died from rapidly progressing sepsis, pneumonia, and acute renal failure during repeated insertion of ECMO and weaning off ECMO.

LESSONS

Reconstructing and improving the patency of the supradiaphragmatic IVC is essential for successful hepatic venous drainage. Additionally, a surgical strategy focused on graft selection can prevent kinking stenosis, and possibly BCS, especially in emergency surgeries. A ring-supported synthetic graft should be considered an alternative to improve long-term patency and survival rate.

Management of inferior vena cava thrombosis after blunt liver injury

Inferior vena cava (IVC) thrombosis after traumatic liver injury is an extremely rare condition, and only 12 cases have been reported in the English literature since 1911. We report a case of a 26-year-old man who presented with IVC thrombosis after blunt liver injury. IVC thrombosis was incidentally detected by computed tomography 15 days after conservative management of blunt liver injury. The patient denied any symptoms of thrombophlebitis and did not have any evidence of hypercoagulable state. We placed an IVC filter via the right jugular vein and started the anticoagulation treatment. The patient recovered successfully without operative treatment and IVC thrombosis disappeared completely two months later. We suggest that that the possibility of IVC thrombosis should be considered in patients with a large hematoma of the liver, which may cause compression of the IVC.

Thrombectomy under Cardiopulmonary Bypass for Inferior Vena Cava Thrombosis Induced by Liver Injury

Inferior vena cava thrombosis (IVCT) caused by liver injury is a rare and challenging condition. A 32-year-old man sustained a severe liver injury in a traffic accident. Emergent thromboembolic procedure for the affected hepatic arteries was performed for hemostasis, resulting in hemodynamic stabilization of the patient. One month later, however, computed tomography (CT) showed liver congestion caused by IVCT from the suprahepatic IVC to the bilateral common iliac veins. As liver function deteriorated quickly despite heparin administration, surgical thrombectomy was performed under hypothermic circulatory arrest through sternotomy and laparotomy. After this operation, the liver was decongested and its function improved rapidly.

Agitation thrombolysis for fresh iatrogenic IVC thrombosis in patients with Budd-Chiari syndrome

Three patients with Budd-Chiari syndrome (BCS) and fresh inferior vena cava (IVC) thrombosis were treated by agitation thrombolysis as a mechanical thrombectomy procedure and followed up by duplex ultrasonography. Agitation thrombolysis was technically and clinically successful in all patients. Inferior vena cavagrams after the procedure showed complete resolution of the iatrogenic, fresh IVC thrombi without occurrence of pulmonary embolism. Duplex ultrasonography follow-ups after 12, 24, and 28 months, respectively, confirmed complete patency of the IVC without rethrombosis and reobstruction. The results indicate that agitation thrombolysis may be a safe and feasible approach for BCS patients with iatrogenic, fresh IVC thrombosis.

Retrohepatic hematoma causing caval compression after blunt abdominal trauma

Blunt injury to the inferior vena cava (IVC) is a rare event, which occurs in 1% to 10% of blunt-trauma patients. Injuries usually result from deceleration, which causes atriocaval rupture or tearing of the hepatic veins, and are sometimes complicated by uncontrollable hemorrhage. An unusual case of focal extrinsic compression of the vessel caused by retrohepatic hemorrhage is reported, which ultimately has required no operative intervention and seems to have had no long-term ill effects. The literature on blunt injury to the IVC is reviewed, which includes a review of posttraumatic Budd-Chiari syndrome.

Successful surgical treatment of chronic inferior vena caval thrombosis following blunt trauma

Posttraumatic inferior vena cava (IVC) thrombosis is extremely rare. We report a case of surgical treatment for chronic inferior vena caval thrombosis 4 years after blunt trauma. A 22-year-old man was referred to our hospital for investigation of an inferior vena caval thrombosis. He had a history of blunt abdominal trauma at age 18 while dismantling a medium truck and had undergone pancreaticojejunostomy for a pancreatic laceration. Computed tomography (CT) scans revealed an inferior vena caval thrombosis extending into the right atrium. Lung perfusion scintigraphy was unremarkable. We performed thrombectomy through a median sternotomy under deep hypothermic circulatory arrest, which gave adequate visualization in a bloodless field. A fiberscope was used intraoperatively for detailed IVC inspection. Postoperative recovery was uneventful, and he was discharged on the 14th postoperative day. Postoperative CT and echocardiography showed no recurrence of the thrombosis.

Open heart surgery for posttraumatic inferior vena caval thrombosis

A 40-year-old woman was diagnosed as intrahepatic hematoma after blunt abdominal trauma. One month later computed tomography (CT) revealed the inferior vena caval thrombus extending into the right atrium. Emergency thrombectomy was performed under cardiopulmonary bypass. We believe that the thrombus, which was derived from laceration of the hepatic vein, extended through the inferior vena cava into the right atrium, and was the eve of pulmonary embolization. CT study should be repeated, once the intrahepatic hematoma was recognized. We emphasize that we should recognize the existence of such complication to prevent the catastrophic result.

Post-traumatic membranous obstruction of the inferior vena cava associated with a hypercoagulable state

It has been hypothesized that abdominal trauma may be one of the factors involved in membranous obstruction of the inferior vena cava. We present two cases of membranous obstruction of the inferior vena cava associated with trauma. One asymptomatic case, associated with an occult myeloproliferative disorder, developed within 3 years of a violent abdominal trauma. The other case, associated with familial plasminogen deficiency, was discovered at surgery 3 days after a road accident with obvious abdominal trauma, since superimposed extensive thrombosis of the inferior vena cava caused acute Budd-Chiari syndrome. We conclude that underlying prothrombotic conditions are probably necessary for the development of membranous obstruction of the inferior vena cava and that minor trauma may contribute to the development of thrombosis through indirect mechanisms.