Staged Reconstruction of the Inferior Vena Cava After Gunshot Injury

Penetrating injuries with transection of the inferior vena cava carry a high mortality. In a hemodynamically unstable patient, ligation of the vena cava often becomes necessary. The aim of this case report is to describe a delayed reconstruction after stabilization of the patient. A 23-year-old man arrived in the trauma bay with severe hypotension after a gunshot injury to the abdomen. During acute resuscitation, the patient arrested, requiring emergency thoracotomy and aortic cross-clamping. On abdominal exploration, the distal inferior vena cava and the origins of both common iliac veins were transected. The inferior vena cava and both iliac veins were ligated, and an emergency transfusion protocol was initiated. A segment of the small bowel was also resected, leaving the bowel in discontinuity; the patient’s abdomen was packed, and he was transferred to the surgical intensive care unit for resuscitation. The next morning, vascular surgery was consulted for early leg congestion and a second look at the vena cava injury. There was too much loss of venous tissue for direct reconstruction. Because of the presence of bowel contamination in the abdomen, we harvested the right femoral vein and created a bifurcated bypass. The bowel was reanastomosed and the midline fascia was closed. The patient required a second laparotomy because of fever and abdominal pain with a finding of a retained laparotomy sponge. His venous reconstruction was verified patent by duplex ultrasound. This case demonstrates the value of working with the trauma team to delay vena cava reconstruction, when the initial hemorrhagic shock and abdominal contamination are under better control. The patient’s femoral vein provided an excellent size match for his venous reconstruction