A rare opportunity for conservative treatment in a case of blunt trauma to the supradiaphragmatic inferior vena cava
A 20-year-old female was the restrained driver of a vehicle traveling ∼45 miles per hour when her vehicle crashed into a city bus. She was extricated on scene by emergency responders and brought to the trauma bay alert, oriented and in stable condition complaining of pain on deep inspiration as well as left leg pain. She denied any abdominal pain or light-headedness. Vital signs on arrival were heart rate of 115 bpm, respiratory rate of 20 breaths per minute and blood pressure of 101/76 mmHg; her Glasgow coma scale was 15. The initial chest radiograph showed a small, right-sided pneumothorax and pulmonary contusions. Two radiographic views of the left leg revealed comminuted, mildly displaced tibia and fibula fractures. Computed tomography (CT) scans of the brain and neck were unremarkable. A contrast-enhanced chest CT scan demonstrated non-displaced right lateral second and third rib fractures, right upper lobe pulmonary contusions with laceration and a small pneumothorax, partially visualized grade 5 liver laceration with active contrast extravasation, and an acute, traumatic supradiaphragmatic IVC injury with an associated moderate hematoma and contrast extravasation that appeared to be contained, as seen in Figs and . In view of incompletely imaged critical findings of the upper abdomen and continued hemodynamic stability of the patient, a dedicated abdomen and pelvis CT scan, seen in Figs –, was performed 20 min later, which showed a stable 1.3 cm pseudoaneurysm of the supradiaphragmatic IVC without extension into the pericardium, stable moderate pericaval hematoma surrounding the injury, stable grade 5 liver laceration and a trace amount of fluid in the peritoneal cavity. A liver transplant surgeon and a cardiovascular surgeon were consulted due to the presence of acute traumatic suprahepatic IVC pseudoaneurysm.\nThe patient remained in stable hemodynamic condition over the subsequent 3 h, and the decision was made to obtain an IVC venogram, depicted in Fig. , which showed a small focal contour irregularity of the suprahepatic IVC and slight irregularity of the right middle vein consistent with a pseudoaneurysm and no active contrast extravasation. Conservative management of the hepatic laceration and IVC injury was continued in the intensive care unit with strict bed rest. On post trauma day 3, her tibia and fibula fractures were repaired without complications. The patient was discharged on post trauma day 7.