Objective: Highlight perioperative planning and multidisciplinary management of a traumatic IVC injury complicated by intracardiac graft migration.
Retrohepatic inferior vena cava (IVC) injuries are among the most lethal vascular traumas, with reported mortality rates exceeding 50–80% due to massive hemorrhage and difficult surgical exposure.1,2 Endovascular stent-grafts allow rapid control of bleeding when open repair is not feasible, providing speed, minimal invasiveness, and reduced physiologic stress.3-5
However, their off-label use in the IVC introduces important limitations: risk of thrombus formation, hepatic vein occlusion, and anatomic variability that may predispose to device migration or malposition.6,7 From an anesthetic standpoint, retrohepatic IVC management requires aggressive massive transfusion protocols (MTPs), anticipation of coagulopathy and air embolism, and readiness for rapid conversion between open and hybrid approaches.⁸
Successful outcomes depend on constant communication among trauma, vascular, cardiothoracic, and anesthesia teams throughout all procedural stages.
Management of retrohepatic IVC trauma requires real-time coordination among anesthesia, vascular, and cardiothoracic teams to navigate rapid hemodynamic shifts and complex bleeding control.⁸ Anesthesiologists play a central role at every stage—stabilizing physiology during exploratory laparotomy, supporting endovascular deployment, and guiding definitive cardiac repair through intraoperative TEE imaging.
Intraoperatively, anesthesia management centers on vigilant hemodynamic monitoring, activation of the massive transfusion protocol (MTP), and readiness for abrupt preload and pressure changes caused by IVC manipulation or balloon inflation. Continuous communication with the surgical team is essential to anticipate and prevent arrhythmias, cardiac obstruction, or air embolism near the heart and diaphragm.⁸˒¹¹
Postoperatively, anesthesiology remains integral to ICU surveillance, anticoagulation management, and prevention of thrombotic or pulmonary complications. Additional vigilance is required for hepatic dysfunction from hepatic vein occlusion and renal injury from altered venous outflow.
This case also highlights the limitations of using aortic-designed endografts in the venous system, as differences in radial force, vessel compliance, and venous hemodynamics can lead to device migration into the right atrium or pulmonary artery.⁶˒⁹˒¹⁰ Such outcomes underscore the importance of device selection tailored to venous physiology and the critical, longitudinal role of anesthesiology in managing hemodynamic, thrombotic, and coagulopathic risks through resuscitation, procedural guidance, and postoperative care.
This case illustrates how anesthesiologists extend beyond airway and anesthetic delivery to function as perioperative physicians in complex endovascular trauma.
Through vigilant physiologic management and team coordination, anesthesiologists play a pivotal role in optimizing outcomes and procedural success in high-risk endovascular trauma.
BACKGROUND
Conventional open repair is often unsuccessful in unstable patients due to limited exposure and massive bleeding. Endovascular stent-grafting has therefore emerged as a damage-control alternative that can achieve rapid venous hemostasis when time and access are constrained.3-5
This case highlights the successful outcome achieved through close interdisciplinary coordination and underscores the pivotal role of anesthesiologists in complex trauma settings—providing continuous perioperative management across evolving surgical stages and guiding definitive management.
Management required close intradisciplinary coordination between trauma, vascular, and cardiothoracic teams, while also considering patient-specific factors such as age, physiology, and lifestyle.
The endovascular stent could not be removed without risking disruption of the fresh retrohepatic IVC injury or precipitating massive hemorrhage and bile leak. Because the stent was not fully secured, there was a persistent risk of thrombus formation and potential migration into the right atrium. Management therefore focused on hemodynamic stabilization, prevention of further stent migration, and anticoagulation balance.
First Operation: An 18-year-old male with no prior medical history sustained a gunshot wound to the upper abdomen, arriving in hemorrhagic shock (SBP ≈ 60 mm Hg). Massive transfusion protocol was activated, and exploratory laparotomy revealed a Grade IV liver injury (segments 2–4b) with uncontrolled retrohepatic venous bleeding. Hemostasis attempts with compression, packing, Argon beam coagulation, and Pringle maneuver were unsuccessful. The patient received 10u PRBCs, 6u FFP, 1u platelets, and 3 L crystalloid, requiring intermittent phenylephrine boluses (700 μg total). The abdomen was temporarily packed and closed with a Bogota bag, and CT angiography confirmed a retrohepatic IVC disruption (T11–T12). Patient was then returned to OR for second surgery.
Second operation: In the hybrid OR, REBOA-PLUS was inflated for aortic control. Venography localized the injury, and a 21 × 21 × 100 mm GORE cTAG endograft was deployed with immediate hemostasis (EBL ≈ 3.5 L). During access, a right-sided chest tube released >3 L of blood from a retained hemothorax and 4u PRBCs was given. The patient stabilized post-deployment and was transferred to the SICU.
Third operation: Within 24 h, CT demonstrated cephalad migration (~1.5 cm) into the right atrium. TEE confirmed a 3-cm portion of the graft projecting into the right atrium, parallel to the interatrial septum and approximately 2–3 mm from the tricuspid valve, without obstruction or valvular dysfunction. During re-exploration, the Bogota bag and eight lap pads were removed; the liver was hemostatic. A 28 × 28 × 100 mm cTAG was overlapped 60 mm to anchor the migrated stent, restoring laminar caval flow. Right-sided VATS evacuated organized clot, and a new 32 Fr chest tube was placed.
Interim ICU course: The patient remained stable on low-dose heparin, later transitioned to enoxaparin and aspirin 325 mg daily. Transaminases peaked (AST 963 U/L, ALT 1433 U/L) then normalized. Complications included a bile leak treated with ERCP and intrahepatic stent placement and a transient GI bleed managed endoscopically.
Fourth operation: After stabilization, multidisciplinary discussion with cardiothoracic surgery, cardiology, vascular surgery, and anesthesia led to open heart surgery along with stent trimming and fixation. Under general anesthesia with balanced volatile technique and TEE guidance, a median sternotomy and bicaval cannulation were performed. The stent was trimmed with wire-cutting and Metzenbaum scissors and anchored with 4-0 polypropylene sutures in four quadrants. Because complete IVC occlusion was not possible, field flooding made use of TEE valuable. The TEE enabled imaging of the stabilization position of stent with regards to vital structures, like coronary sinus, valves and interatrial septum .The patient was weaned from CPB without inotropes; post-CPB TEE showed patent IVC, mild TR, and preserved function.
Postoperative course: The patient was extubated within hours, transitioned to room air, and advanced to full activity. Anticoagulation was resumed per multidisciplinary protocol. He was discharged home on postoperative day 7, and four-month follow-up imaging confirmed a patent retrohepatic IVC with stable graft position and return to baseline activity without hepatic or cardiac sequelae.