Hepatic Trauma and Inferior Vena Cava Thrombosis; A Review of Current Literature

Patient characteristics and presentation

There were 16 patients meeting the inclusion criteria, 62.5 % were males (10 / 16) with a mean age of 31.5 ± 3.3 (14-58) years. Clinically, 62.5 % presented to the ER hemodynamically stable with either right quadrants’ pain or diffuse abdominal pain, and 12.5% had right chest pain. Moreover, risk factors of thrombotic sequelae were reported, one patient had protein C deficiency [7], one patient was on regular OCP use [3], and one patient had prior iliac vein thrombosis [6]. The most common mechanisms of injury were RTA’s (56.3%), Motorcycle accident (31.2%) and lastly are fall (12.5%). There was a noted delayed from presentation until IVC-Th diagnosis with 37.5% being diagnosed one the same day of presentation, and a mean duration of 11 ± 3 days with one outlier being diagnosed of acute on top of chronic IVC-Th 10 years post-RTA [9].

Diagnostics

The American Association for the Surgery of Trauma (AAST) liver trauma grading scale was noted to be used through using an Abdominal CT with IV contrast due to the set protocols of its utility according to the American trauma life support guidelines (ATLS) [17]. The majority of diagnosed IVC-Th were through CT with IV contrast, in either focused abdominal CT or Pan-CT (81.2%), however only 37.5% reported it accordingly (two grade I, one grade III, three grade V). Anatomically, the most commonly reported injured segments were VI (31.2 %) and VII (12.5%), presenting with either a small hematoma of a contusion (43.7%), a hepatic laceration (18.7%) or a complex multi-segment injury in 25%. In addition, the detected IVC-Th location was either Supra-hepatic reaching the atrio-caval junction (25%), Retro-hepatic (31.2%) or most commonly infra-hepatic (43.7%) with possible extensions (e.g., iliac vein thrombosis, renal vein thrombosis, pulmonary emboli). The length of the detectable IVC-Th through CT had a mean of 5.1 ± 1.4 (0.6-9.7) cm, and one patient had a complete obstruction secondary to IVC-Th [9]. Rarely, US-guided diagnosis (12.5 %), or venography-based assessment of IVC-Th (18.7%) were performed.

Management and Outcomes

The multifactorial nature of polytrauma patients (e.g., hemodynamic status, other injuries, comorbidities), led to a constant discussion between conservative, interventional radiology (e.g., hepatic artery embolization) and surgical (e.g., IVC-Th thrombo-embolectomy and reconstruction). There were 56.2 % initially treated conservatively, however multiple interventional radiology techniques were reported, 25% had IVC filters, two patients underwent left hepatic artery embolization [5,11], two patients underwent direct thrombolysis [8,15], and one patient underwent Echo-guided hematoma drainage [13]. Surgically, an initial hemodynamic support (e.g., massive transfusion protocol activation) and laparotomy was done in 18.7% [2,11,15], IVC-Th surgical thrombo-embolectomy (± reconstruction) was done in 31.2% through a laparotomy, median sternotomy or a sterno-laparotomy [2,11,12,14,15]. The Anticoagulation initiation and duration differed depending upon various factors (e.g., other injuries, time of diagnosis), accordingly it was rarely initiated on same day of presentation or within a week post-RTA (25%), unless the patient’s clinical picture showcases a probability of a non-operative course. The commonly used protocol of anticoagulant initiation is an initial unfractionated heparin infusion that is bridged with an oral anticoagulant (vitamin K antagonist or direct-oral anticoagulants) for at least 3 months (43.7%), despite prior interventions (e.g., IVC filter placement). In addition, two patients were initiated and continued on LMWH only [10,16], while one was initiated and then bridged to an oral anticoagulant [8]. The majority of patients survived IVC-Th, with one patient dead secondary to the severity of concomitant injuries [15], a follow up radiological study (i.e., Abdominal CT with IV contrast or and ultrasound) was done in 5 patients (one week post-injury in 2 and 2-3 months in 3 patients) and a mean follow up period of 4 (± 1) months and only 2 patients were followed for 1 week [5].

Discussion

IVC-Th is a rare diagnosis that can possibly occur in conjunction with blunt hepatic trauma secondary to several factors which may be anatomical (e.g., a compressive hematoma) or trauma-related (e.g., trauma induced coagulopathy). The fifteen studies we have reviewed showed that most of the patients were young males with the most common mechanism of injury being RTAs and diagnoses of IVC-Th were often made within two weeks following the injury through contrast-enhanced Abdominal CT or trauma protocol’s Pan-CT. A wide variation in management strategies was noticed, ranging from conservative anticoagulation to surgical interventions which could be a result of the probable lack of standardized treatment protocols. The repeated pattern of delayed diagnosis probably implies the need for close monitoring of patients during the subacute recovery phase was reported in several cases of traumatic IVC-Th [18-20].

Patients’ Presentation and Risk Factors

The majority of reported cases consisted of males (62.5%), a male to female ratio of 2:1 with a mean age of 31.5 ± 3.3 years, unlike the reported cases of non-traumatic IVC-Th with the majority being females (60%) with a relatively comparable age (35.5-36.5 years) [21,22]. The mechanism of injury was mainly road traffic accidents and motorcycle accidents encompassing 87.5% of the included patients which is usually reported in a similar demographic niche in trauma. The clinical presentation is often nonspecific (i.e., lower limb edema or persistent abdominal pain could be attributed to the primary trauma itself), therefore emphasis on the importance of maintaining high clinical suspicion in patients who exhibit signs of unexplained venous congestion, prolonged immobility, or persistent inflammatory markers especially following hepatic trauma, regardless of grade [19,21,23]. Initially, 62.5% of patients presented hemodynamically stable, with a report of either right upper quadrant or diffuse abdominal pain, which can be reflected direct injuries (e.g., steering wheel trauma), hence deeming IVC-Th difficult to predict [2,10,11]. In addition, the risk factors for venous thromboembolic events (VTE) were reported in 18.75%, with one patient having protein C deficiency [7], regular OCP use [5], and prior iliac vein thrombosis [6]. Therefore, proving the necessity of performing the Advanced trauma life support (ATLS), AMPLE history format (mainly medications and past medical history).

Diagnostic and therapeutic challenges

The diagnosis of IVC-Th in hepatic trauma poses a considerable challenge as there is a noted gap in the studies and reports regarding the diagnosis and management. The non-specificity of polytrauma cases and risk of missing such a diagnosis reiterate the importance of Trauma Pan-CT (Contrast-enhanced CT) with it being the primary diagnostic modality observed in 81.2%, allowing concurrent assessment of hepatic injury and vascular patency. The US-guided diagnosis was less in frequency (12.5 %), as its utility is showcased in the focused assessment of sonography in trauma (FAST) exam (i.e., assessing for abdominal free fluids, rather than solid organs’ injury). In addition, venography-based assessment (18.7%) was done by IR to intervene (e.g., IVC filter), hence it was rarely utilized. Consequently, prompt and timely utilization of computed tomography or magnetic resonance imaging is crucial to reach a diagnosis [18,23,24]. The timeliness of diagnosis is unclear as shown by a trended latency in the mean interval between presentation to diagnosis (11 ± 3 days post-injury), suggesting that the development of IVC-Th occurs possibly from fulfilling Virchow’s triad of VTE and systemic inflammatory response (Figure 1), hence it occurs during the post-traumatic, subacute phase of conservative IVC-Th. Accordingly, dealing with posed trauma-related (e.g., polytrauma), patient-related (e.g., multiple comorbidities, extremes of ages), post-traumatic care (e.g., hepatic trauma non-operative care and rehab) challenges on when and for how long do we initiate anticoagulation, the role of IR and whether a surgical intervention is indicated? [18-20].

Anticoagulation Considerations and Use

The utility of anticoagulation was reported in hemodynamically stable patient, with non-major secondary injuries (e.g., radial fracture), underwent non-operative hepatic trauma management and was followed daily by examination and laboratory markers (56.2%) (Table 1). However, initiating therapeutic anticoagulation may present a therapeutic dilemma, considering the risk of thrombus progression against potential haemorrhagic complications, yet no major anticoagulation-related haemorrhages reported in follow up visits [20]. Therefore, Patients with no active, post-traumatic bleeding or progressing hepatic hematomas could benefit from prophylactic anti-coagulation [18]. Though, in the analysed cohort only 25% received chemical anticoagulants within a week post-trauma, which is possibly secondary to a low Caprini score (i.e., the majority were young, non-comorbid males). The most frequently used regimen noted was Low-molecular-weight heparin or unfractionated heparin, commonly transitioned to oral anticoagulants (vitamin K antagonist or direct-oral anticoagulants) or continued therapeutically for at least 3 months in 56.2% of patients [3-6,8-11]. The selected patients should undergo screening appropriately through taking a detailed history, examination, and blood tests for conditions that can raise the risk for thrombus formation [18] (Figure 3).

Figure 3: Suggested approach to hepatic injuries with concurrent IVC-Th.

OR: operative room (surgical intervention), IR: interventional radiology (e.g., hepatic artery embolization), Echo (transthoracic or transoesophageal), CTPA: CT pulmonary angiography, US: Liver ultrasound.

Technically, the use of anticoagulants lowers the chance of thrombus propagation, it does not cause clot lysis, which puts patients at risk for developing Post-thrombotic syndrome (i.e., localized pain, possible distal extremities skin changes and chronic venous ulcerations), a condition that despite appropriate treatment, is identified in up to 40% of patients with traumatic IVC-Th, and only 6% of patients treated with anticoagulation alone achieve lysis of the clot within 10 days of treatment, while none were reported in our cohort [23].

Surgical and Interventional Techniques’ Indications and Utility

There was a total of 5 patients who underwent surgery (31.25%) aged 16 to 40 with a mean age of 31.2 ± 8.09 years, in which 2 were via laparotomy while 3 had either median sternotomy or sterno-laparotomy, 2 required Cardiopulmonary Bypass (CBP) and 2 required Extra-Corporeal Membrane Oxygenation (ECMO) with one mortality [2,11-13,15]. The surgical approach depended upon the patients’ hemodynamics and extent of IVC-Th, in which if the right atrium was involved, a median sternotomy was done to facilitate CPB and Atrio-Cavatomy with thrombo-embolectomy with or without Cavo-plasty (with a bovine patch) and a temporary IVC-filter placement [11-13]. 

The common traumatic feature is a high-grade liver injury with a compressive (anteroposterior) hematoma formation and right hepatic lobe lacerations.In terms of prognostication, as all patients presented initially unstable with major sequelae a mortality rate of 1 out of 5 patients was expected. On the other hand, IR techniques (e.g., hepatic artery embolization) was utilized in 8 patients, with a mean age 38.7 ± 4.4 years, with 5 IVC-filters placement, 1 hepatic artery aneurysmal coiling, 1 left and 1 right hepatic arteries angioembolization [3,5,6,8,9,11,16]. Notably, 2 patients’ IVC-Th were incidentally diagnosed during a trial of IVC-filter placement in which in one patient the trial was aborted, and the patient was started on anticoagulants directly [8,9]. A follow-up period of 2-3 months with a form of radiological assessment (e.g., CT or US) was done before the IVC-filter retrieval with no associated major complications or mortality. Therefore, depending upon the patient’s hemodynamic status, type of injury, anatomical location and available expertise a decision of IR techniques or surgical techniques is utilizated, with similar reported outcomes in traumatic IVC-Th [18-20].

 Prognosis, Follow-up and Outcomes

The survival rate post-diagnosis was 93.75%, with one mortality case which is attributed to severe respiratory distress rather than the thrombotic event itself [15]. The follow-up imaging was done in 5 patients (31.25%) with two being one week (12.5%) and three 2-3 months (18.75%) post-diagnosis, all of which had improved conditions (e.g., absence or decrease in IVC-Th size). Moreover, favourable outcomes with early anticoagulation and/or IVC filter placement, with no major long-term thrombotic complications were reported [3,5]. On the other hand, delayed diagnosis or missed thrombus detection could lead to VTE-related complications (e.g., pulmonary embolism) which may lead to possible life-threatening complications (e.g., obstructive shock), a reported a case of pulmonary embolism after complex management of the IVC thrombus, complicating the recovery and requiring long-term monitoring in ICU [4]. In addition, Boggi et al. 2006, presented a fatal case where the prognosis was extremely poor due to the severity of the trauma and the need for total hepatectomy and allotransplantation, followed by respiratory distress [15]. Conclusively, there were no noted significant differences in outcome between conservatively treated and surgically treated patients in terms of hepatic injury to IVC-Th related complications, with mortality being associated with trauma severity rather than IVC-Th. Moreover, regardless of location of IVC-Th and degree of hepatic injury reported, there were no associated differences in acute VTE-related outcomes (e.g., sequelae of chronic hepatic congestion).

Conclusion

Rarely, IVC-Th can happen in any degree of post-traumatic hepatic injury, possibly in the infra-hepatic IVC with the most common form of injury being a contusion of hematoma involving segment VI and VII, in hemodynamically stable, young males’ post-RTA. Despite the rarity of IVC-Th post-hepatic trauma close observation might be required with a suggested duration of 1-2 weeks, with considerations regarding anticoagulants initiation and duration, IR utility and surgical interventions with follow-up radiologic studies (e.g., Ultrasound). Therefore, urging future research to investigate IVC-Th in a larger sample, due to the possibility of our results’ difficult generalizability.

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