INTRODUCTION

Injury to the inferior vena cava (IVC) is a rare occurrence resulting from penetrating or blunt trauma to the thoracoabdominal region. The outcome depends on factors such as injury location, hemodynamic stability, availability of blood products, local healthcare infrastructure, and timely intervention [1]. Despite advances, IVC injuries remain extremely lethal, with mortality rates ranging from 65% to 90% [1,2]. Strict adherence to Advanced Trauma Life Support (ATLS) protocols, timely intervention and resuscitation, and a multidisciplinary approach are critical to patient survival. This report presents a series of six cases of IVC injury that underwent comprehensive management.

CASE REPORTS

Six patients presented at the trauma center over 30 months, from July 2022 to December 2024. All cases were managed according to ATLS protocols, with trauma team leaders certified by the American College of Surgeons. The operating teams included three consultant surgeons, two consultant trauma anesthetists, and five senior residents, participating as per the departmental duty roster. Patients underwent primary surveys to identify and correct life-threatening conditions and were transferred to the operating room within 10 to 15 minutes upon identifying nonresponsiveness to fluid resuscitation. Massive transfusion protocols (MTPs) were activated by trauma team leaders, and the transfer of blood products was supervised by trauma nurse coordinators. MTP activation occurred in five cases due to persistent shock, anticipated significant blood loss, and the requirement of transfusing more than 50% of the patient's blood volume within 3 hours.

During laparotomy, four-quadrant packing was performed, and surgical evacuation of fluid or blood from the abdominal cavity was conducted. IVC access typically involved a Cattell-Brasch maneuver, with an additional Mattox maneuver if necessary for better exposure. Repairs or ligation of the IVC were conducted using polypropylene 4-0 or 3-0 sutures, the retroperitoneum was closed, and an abdominal drain was placed in stable patients. Damage control surgery, emphasizing minimal operative time, was performed in unstable patients, who were subsequently transferred to the intensive care unit (ICU) for further stabilization and mop retrieval planning. Four of the six patients underwent damage control surgery, of whom only one survived.

Three patients were referrals from primary or peripheral district centers, while the remaining three were direct presentations. Five patients presented in shock unresponsive to fluid resuscitation, and one patient responded positively. All patients underwent exploratory laparotomy via midline incision, with indications including peritonitis (one patient) and hemodynamic shock (five patients). Three patients had blunt trauma and three penetrating trauma, all involving high-energy mechanisms. Three patients died—two from hemodynamic shock and one from severe sepsis and multiorgan dysfunction syndrome. A summary of the cases and their management is presented in Table 1, with detailed descriptions provided subsequently.

Case 1

A 37-year-old man presented with an alleged shotgun injury from approximately 6 m, arriving 12 hours after injury. Upon presentation, he was conscious and alert, with vital signs indicating mild tachycardia and hypotension (blood pressure, 90/60 mmHg). He responded positively to an initial resuscitation with 1 L of fluids. Focused assessment with sonography in trauma (FAST) was positive in the hepatorenal, splenorenal, and pelvic regions. Examination revealed a small entry wound measuring 2×2 mm in the right epigastrium. Laboratory evaluation showed decreased hemoglobin and hematocrit levels. The patient received blood product resuscitation (2 units of packed red blood cells [pRBCs]). Contrast-enhanced computed tomography (CECT) of the abdomen indicated pneumoperitoneum with air foci suggestive of hollow viscus perforation and a retroperitoneal collection with a metallic artifact in situ at the level of the third part of the duodenum (Fig. 1).

An emergency laparotomy via midline incision revealed a mixed bilious and sanguineous collection of approximately 1 L. A zone 1 hematoma was noted in the supracolic compartment, along with a perforation of the third part of the duodenum. The retroperitoneum was accessed, and proximal and distal controls of the suprarenal IVC were established using Satinsky clamps. A 2×2-mm tear in the anterior wall of the IVC was repaired. Both anterior and posterior duodenal perforations (approximately 5×5 mm each) were repaired following mobilization of the duodenum using Kocher maneuver, and an omental patch was applied. A small metallic pellet lateral to the third part of the duodenum was removed. Following lavage, the retroperitoneum and abdomen were closed in layers. The patient was extubated on postoperative day 1, oral feeds were initiated on day 4, which he tolerated well, and he was discharged after 12 days of hospitalization. The patient remained stable during subsequent outpatient follow-ups.

Case 2

A 53-year-old man presented within 1 hour after a fall from a height of 15 m. On arrival, he exhibited compromised airway integrity, prompting immediate intubation. Clinical assessment revealed possible class IV hemorrhagic shock and abdominal distension. FAST examination was positive in the hepatorenal and pelvic regions. The patient did not respond to an initial fluid challenge of 1 L and was immediately transferred for emergency laparotomy via midline incision, with activation of the MTP.

Intraoperatively, approximately 3 L of hemoperitoneum were noted, alongside an expanding zone 1 and right zone 2 hematoma with an open retroperitoneum. A substantial tear measuring approximately 3×1 cm on the lateral wall of the suprarenal IVC with avulsion of the renal vein at its origin was identified. Satinsky clamps were applied proximal and distal to the injured segment, and the renal hilum was clamped. The IVC tear was repaired, and an emergency right nephrectomy was performed. Due to intraoperative parameters indicating severe physiological compromise (pH, 6.92; lactate, 18.2 mmol/L; bicarbonate, 6.70), damage control surgery was completed, and the patient was transferred to the ICU. Despite continued resuscitation efforts, the patient remained in irreversible shock and died approximately 1 hour postoperatively.

Case 3

A 41-year-old man presented approximately 2 hours after sustaining a gunshot wound to the abdomen. He was in hemodynamic shock with a positive FAST examination in all quadrants. Despite administration of 1 L of crystalloid resuscitation, arterial blood gas (ABG) analysis indicated metabolic acidosis with elevated lactate levels, and he remained tachycardic and hypotensive. Declared a nonresponder, he was urgently transferred for surgical intervention with activation of the MTP.

A midline laparotomy revealed approximately 1.5 L of hemoperitoneum and an expanding retroperitoneal hematoma in zone 1, with the bullet track penetrating through the parietal peritoneum at the level of the hepatic flexure. Upon opening the retroperitoneum and evacuating the hematoma, a lateral wall injury to the suprarenal IVC measuring 2×2 mm was discovered. Proximal and distal controls were established with Satinsky clamps, and the injury was repaired (Fig. 2). Intraoperative resuscitation with blood products improved vital signs and ABG parameters. The bullet, embedded in the retroperitoneum lateral to the IVC, was retrieved. The retroperitoneum and abdomen were closed in layers. The patient was extubated the following day, initiated on oral feeds by postoperative day 2, and drains were removed on day 4. The patient remained stable, was discharged on postoperative day 10, and remained well at subsequent follow-ups.

Case 4

A 23-year-old man presented following a road traffic incident involving a two-wheeler head-on collision with another vehicle. He was a helmeted rider and was referred from a primary health center approximately 2 hours after injury. Upon presentation, the patient was in hemodynamic shock with abdominal distension and bruising over the anterior abdominal wall. He did not respond to 1 L of Ringer's lactate administered through wide-bore cannulas. FAST was negative, and there were no visible external wounds or active bleeding. Given the abdominal distension, he was immediately taken for emergency laparotomy with activation of the MTP.

Intraoperatively, herniation of abdominal contents through the wound was observed, but no intraperitoneal blood was noted. Examination revealed an expanding zone 1 retroperitoneal hematoma. A Cattell-Brasch maneuver was performed, and the hematoma was evacuated, revealing a linear tear approximately 3 cm in length on the anterior wall of the infrarenal IVC, located about 2 cm proximal to its bifurcation. The IVC was ligated proximally and distally after obtaining proximal control. Due to persistent hypotension, ongoing transfusion requirements, and intraoperative metabolic acidosis, damage control surgery with mesh laparostomy was performed (Fig. 3) for abdominal compartment syndrome management. The patient was transferred to ICU, where he received blood product resuscitation. After improvement in vital parameters and ABG, the patient underwent mop retrieval on postoperative day 2. The retroperitoneum was closed, pelvic drains placed, and abdominal sheath closure achieved without tension. He was extubated the next day, underwent delayed primary skin closure on postoperative day 3, and tolerated oral feeds initiated after the fourth day of the second surgery. Following gradual ICU step-down, chest physiotherapy, and incentive spirometry, drains were removed on postoperative day 6 after the second surgery. He was discharged after 14 days, remaining stable on outpatient follow-up.

Case 5

A 36-year-old man was referred from a primary health center approximately 80 km away after sustaining a road traffic injury with thoracic impalement by an iron rod, subsequently removed by bystanders. On arrival, he was receiving oxygen support, had a right intercostal drain (ICD) with 100 mL of blood output, and a laceration at the ninth intercostal space managed with a three-way dressing. He was in shock with FAST positivity in all four quadrants, and he did not respond to initial fluid resuscitation. He was urgently taken for midline laparotomy with MTP activation.

On opening the abdomen, a grade V liver laceration involving segments VIII and V was identified. Attempts at liver packing failed to control the bleeding initially. Bleeding was successfully controlled using a Pringle maneuver with atraumatic bulldog clamps, and perihepatic packing was performed. The patient was then transferred to ICU and stabilized with blood products, leading to improvement in vital and ABG parameters. Before planned mop retrieval surgery, the patient suddenly drained 1.2 L of blood via the ICD, accompanied by significant hypotension (Fig. 4A). He was rapidly returned to the operating room for a right anterolateral thoracotomy, which revealed bleeding from a 5×5-mm diaphragmatic defect. The midline incision was reopened, and the liver was mobilized by dividing the falciform and coronary ligaments, revealing active bleeding from a 1×2-cm rent in the anterior wall of the retrohepatic IVC (Fig. 4B). The rent was repaired, the avulsed liver segment resected (Fig. 4C), and damage control surgery was again performed.

After returning to ICU, the patient received additional resuscitation with 6 units each of pRBCs, fresh frozen plasma, and platelets, resulting in improved vital signs and ABG parameters within 24 hours of the second laparotomy. Mop retrieval was performed the following day; however, postoperatively, the patient developed persistent oozing from the midline wound and ICD output of approximately 100 mL/hr. Laboratory tests indicated a decline in hemoglobin and platelet counts, elevated international normalized ratio (INR; 2.4), prolonged activated partial thromboplastin time (APTT; 56 seconds), reduced fibrinogen (134 mg/dL), and impaired liver function (total bilirubin, 3.9 mg/dL; indirect bilirubin, 2.7 mg/dL; serum glutamic oxaloacetic transaminase and serum glutamate pyruvate transaminase exceeding 1,000 IU). Blood products were transfused, and intravenous tranexamic acid was administered at a dose of 1 g three times daily, improving INR to 1.2 and APTT to 45 seconds. Despite this management, the patient developed sepsis with multiorgan dysfunction syndrome, accompanied by tachycardia (132 beats per minute), hypotension (80/50 mmHg), and declining liver and renal function. Despite extensive supportive care, including inotropic support and empirical antibiotics guided by hospital antibiograms, the patient ultimately suffered cardiac arrest and died on hospital day 8.

Case 6

A 52-year-old man presented to the emergency department approximately 1 hour after a high-velocity car collision with a concrete slab, in which he was the driver. Upon presentation, he had a compromised airway and required immediate intubation with a 7F endotracheal tube. His vital signs indicated hemodynamic shock, accompanied by abdominal distension and positive FAST findings in all quadrants. Initial ABG analysis showed respiratory acidosis, and there was no improvement after administration of a 1-L bolus of Ringer's lactate solution. The MTP was initiated, and he was urgently moved to the operating room.

During midline laparotomy, approximately 2 L of hemoperitoneum were encountered, and four-quadrant packing was performed. An expanding zone 1 retroperitoneal hematoma was noted. Following combined Cattell-Brasch and Mattox maneuvers, injuries identified included a 1×1-cm injury to the anterior wall of the suprarenal IVC, avulsion of the pancreatic body, and transection of the portal vein. Bleeding from the IVC and portal vein was controlled using Satinsky clamps, after which the portal vein was ligated, and the IVC injury was repaired. The avulsed distal pancreatic segment was excised, and hemostasis was secured by suturing the proximal pancreatic remnant. Given ongoing instability and severely deranged ABG values, damage control surgery was conducted, and the patient was transferred to ICU. Despite aggressive resuscitation and extensive transfusion of blood products, the patient remained in irreversible shock and died approximately 4 hours postoperatively.

Ethics statement

The study adhered to the principles outlined in the Declaration of Helsinki. Informed consent for publication of the research details and clinical images was obtained from the patients or their relatives. The details of cases presenting with IVC injury at a single trauma center in Eastern India between July 2022 and December 2024 were collected following informed consent from patients or their relatives.

DISCUSSION

The IVC is formed by the confluence of bilateral common iliac veins, typically at the level of the L5 vertebra, draining blood from the pelvis and lower limbs. It ascends retroperitoneally to the right of the abdominal aorta and vertebral column, remaining posterior to the peritoneum, duodenum, portal vein, and liver. The IVC then enters the thorax through the diaphragmatic tendon at the T8 vertebral level, ultimately draining into the heart [3].

Anatomically, the IVC can be categorized into infrarenal, juxtarenal/renal, suprarenal, retrohepatic, and suprahepatic/thoracic segments [2,3]. The infrarenal segment is reported as the most frequently injured segment [4]. Injuries to the suprarenal segment are the second most common, followed by juxtarenal/renal, retrohepatic, and the least common being suprahepatic injuries [2,5]. More superior injuries generally pose greater surgical and management challenges. Therefore, when feasible, nonoperative or interventional radiology approaches are often favored [4].

In our case series, we encountered six cases of IVC injuries over a 30-month period. Three injuries resulted from penetrating trauma to the thoracoabdominal region (two firearm injuries, one impalement), and three were due to blunt abdominal trauma. While literature commonly cites infrarenal injuries as most frequent [4,5], we predominantly featured suprarenal and pararenal injuries (Fig. 5). This discrepancy could be attributed to the unique nature and mechanisms of injuries presenting at our center.

Mortality factors in IVC injuries typically include the injury level, involvement of tributaries causing exsanguination, concurrent solid organ injuries (such as the liver or kidneys), extensive blood product requirements, and technical constraints [6]. Patients who remain hemodynamically stable without peritonitis may benefit from interventional radiology techniques such as stenting [7]. This approach is particularly advantageous for retrohepatic IVC injuries, given their difficult surgical access, which involves hepatic ligament division, IVC mobilization, and cross-clamping. Injuries situated higher along the IVC may necessitate a median sternotomy or anterolateral thoracotomy for adequate surgical control [2].

All patients in our series required emergency laparotomy, as they either presented with peritonitis or were nonresponsive to initial fluid resuscitation. Only one patient had their IVC injury preoperatively identified through an abdominal CECT scan after stabilization. The remaining cases presented with uncontrolled hemorrhage unresponsive to fluid challenges. Notably, only one patient undergoing damage control surgery survived, emphasizing that massive blood loss, significant blood product demand, and complex injuries substantially contributed to mortality outcomes.

Retrohepatic IVC injuries represent a notably challenging subset, historically associated with mortality rates nearing 100%, though recent studies indicate improved rates closer to 52% [8]. These injuries often coincide with high-grade liver trauma, complicating surgical management and exacerbating hemorrhage and physiological derangement [9]. Management of hemodynamically unstable patients typically includes a Pringle maneuver and hepatic packing or resection, followed by mobilization via division of falciform and triangular ligaments. Advanced techniques, such as veno-venous bypass, can reduce bleeding by diverting blood flow away from the damaged region but require specialized equipment and expertise [8]. Hemodynamically stable patients with contained injuries or pseudoaneurysms may successfully undergo nonoperative management via interventional radiology [7].

In our case series, one retrohepatic IVC injury (case 5) initially remained undetected. The patient initially appeared to have a liver laceration and open pneumothorax, managed with perihepatic packing and damage control, with further management planned post-mop retrieval. However, following initial stabilization and improvement in mean arterial pressure, sudden, substantial bleeding occurred through the chest tube. Whether the retrohepatic IVC injury identified during the second procedure was due to an undetected secondary hemorrhage initially controlled by tamponade and Pringle maneuver or potentially an iatrogenic injury remains uncertain. However, given that the initial surgery did not involve mobilization or hepatic resection, it is less likely that the injury detected during the second operation was iatrogenic.

Even in the presence of hemodynamic stability, IVC injuries require careful monitoring and management. The high volume of blood flow and pressure within the vessel may lead to the development of pseudoaneurysms, posing a risk of delayed rupture and mortality. Historically, surgical intervention was commonly employed; however, advancements in medical technology now enable less invasive management methods. Endovascular interventions, including stenting, balloon occlusion, and arterial stent graft placement, can effectively manage pseudoaneurysms and mitigate the risk of rupture [2]. Furthermore, endovascular approaches are beneficial in managing posttraumatic thrombi within the portal vein or IVC, which carry an inherent risk of pulmonary thromboembolism [10].

Blunt abdominal trauma resulting in IVC injury constitutes less than 1% of all blunt trauma cases; however, the significant kinetic energy involved can cause devastating shear injuries to the IVC [2]. Despite ongoing advancements in trauma care systems and management protocols, the mortality rate associated with IVC injuries remains high, ranging from 65% to 90% [2,11]. Our case series documented three survivors and three deaths, resulting in a mortality rate of 50%. The availability of comprehensive resources such as an adequate blood bank, round-the-clock trauma and critical care services, and strict adherence to ATLS protocols contributed to the relatively improved survival rate observed. Nevertheless, further improvements in survival could be achieved through the availability of hybrid operating rooms, 24-hour interventional radiology services, viscoelastic hemostatic assays to better guide resuscitation efforts, and enhanced prehospital care. Technical challenges related to accessing and controlling hemorrhage significantly prolonged operative times, even when rapid damage control was indicated, thus contributing to patient mortality.

Conclusions

IVC injuries represent rare yet highly lethal trauma presentations arising from both high-velocity blunt and penetrating injuries. Due to the retroperitoneal and thoracic anatomical course of the IVC, management typically demands advanced surgical technical skills for effective bleeding control. In cases of hemodynamic instability, rigorous adherence to ATLS protocols and prompt access to blood products are critical, as active hemorrhage necessitates immediate intervention. Injuries involving the superior portions of the IVC further escalate the technical complexity required for management. Concurrent injuries must be managed effectively using established damage control surgery principles. For hemodynamically stable patients, CECT scans of the thorax and abdomen and interventional radiology techniques offer valuable management alternatives. Additionally, multidisciplinary support from transfusion and critical care medicine significantly enhances patient resuscitation efforts and overall surgical outcomes.

ARTICLE INFORMATION

Author contributions

Conceptualization: RS; Investigation: AVK, HK, AH, DK, MA; Methodology: RS; Supervision: MA; Validation: HK; Writing–original draft: RS; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Acknowledgments

The authors are profoundly grateful to Dr. Anil Kumar (Department of Trauma Surgery and Critical Care, All India Institute of Medical Sciences, Patna [AIIMS Patna], Patna, India) for his mentorship and guidance. His invaluable recommendations, emotional sustenance, and meticulous oversight have greatly enriched this study. The authors also thank Drs. Rekha Kumari and Sanjay Kumar (Department of Trauma Surgery and Critical Care, AIIMS Patna) who have been invaluable parts of the team without whom the research would have been impossible. They also send deepest appreciation to the residents, Drs. Abhishek Kumar, Shashikant, Jeeshan, Mayank, Anupam, Shaman, Karthik, Ankit, Shivangi, Aadil, Sayani, and Bhavya, for their assistance.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Radiographic image and intraoperative photographs from case 1. (A) Contrast-enhanced computed tomography of the abdomen and thorax shows a metallic artifact with associated air foci at the level of the third part of the duodenum (blue arrow). (B) The intraoperative photograph demonstrates the repaired inferior vena cava (green arrow).

Fig. 2.

Intraoperative photograph from case 3 showing the repaired lateral wall of the suprarenal inferior vena cava (arrow).

Fig. 3.

Intraoperative photographs from case 4 illustrating (A) the ligated infrarenal inferior vena cava (arrow) and (B) mesh laparostomy performed for intra-abdominal hypertension using polypropylene mesh.

Fig. 4.

Images from case 5. (A) Intercostal drain tube showing frank blood. (B) Intraoperative images demonstrating the repaired retrohepatic inferior vena cava (arrow). (C) Resected liver specimen.

Fig. 5.

Original schematic diagram illustrating the anatomical course of the intra-abdominal inferior vena cava (IVC), highlighting the locations of IVC injuries encountered in this case series.

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