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.
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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.{{cite journal |vauthors=Clark JJ, Steinemann S, Lau JM |title=Use of an Atriocaval Stunt in a Trauma Patient: First Reported Case in Hawai'i |journal=Hawai'i Medical Journal | pmid=20358727 | pmc=3104635 |volume=69 |issue=2 |year=2010 |pages=47–8}}{{cite journal |vauthors=Burch JM, Feliciano DV, Mattox KL | title= The atriocaval shunt. Facts and fiction. |journal=Ann. Surg. |pmid=3377566 |volume=207 |issue=5 |date=May 1988 |pages=555–68 |doi=10.1097/00000658-198805000-00010 |pmc=1493506}} 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.{{cite journal |author1=Schrock T |author2=Blaisdell FW |author3=Mathewson C., Jr |title= Management of blunt trauma to the liver and hepatic veins. |journal= Arch. Surg. |pmid=5647544 |volume=96 |issue=5 |date=May 1968 |pages=698–704 |doi=10.1001/archsurg.1968.01330230006002}} 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.
A 1988 review by Burch et al. analyzed their experience with the ACS looking at 31 patients. 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.{{cite journal |vauthors=Pachter HL, Spencer FC, Hofstetter SL, etal |title=The management of juxtahepatic venous injuries without an atriocaval shunt. |journal=Surgery | pmid=3518106 | volume=99 | issue=5 | date=May 1986 | pages=569–75}} Another approach may be the placement of a balloon-caval shunt introduced from the femoral vein in the groin.{{cite journal |vauthors=Pilcher DB, Harman PK, Moore EE, etal | title=Retrohepatic vena cava balloon shunt introduced via the sapheno-femoral junction |journal=J Trauma |pmid=335079 | volume=17 | issue=11 | date=Nov 1977 | pages=837–41 | doi=10.1097/00005373-197711000-00003}}
Buckmann et al. indicate that injury to the juxtahepatic veins may not necessarily require surgery if the hematoma is contained.{{cite journal|vauthors=Buckman RF, Pathak AS, Badellino MM, Bradley KM |title=Injuries of the inferior vena cava |journal=Surg Clin North Am. |pmid=11766184 |volume=81 |issue=6 |date=Dec 2001 |pages=1431–47 |doi=10.1016/s0039-6109(01)80016-5}}
References
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