|Year : 2022 | Volume
| Issue : 1 | Page : 48-53
Traumatic visceral venous pseudoaneurysm: A review of reported cases over last 25 years
Vignesh Kumar1, Anand Katiyar2, Niladri Banerjee3, Sunny Aggarwal4, Suyash Singh5, Harshit Agarwal4
1 Department of Trauma Surgery, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of General Surgery, Command Hospital, Udhampur, Jammu and Kashmir, India
3 Department of General Surgery, AIIMS, Jodphur, Rajasthan, India
4 Department of Trauma and Emergency, AIIMS, Raebareli, Uttar Pradesh, India
5 Department of Neurosurgery, AIIMS, Raebareli, Uttar Pradesh, India
|Date of Submission||07-Sep-2021|
|Date of Acceptance||28-Sep-2021|
|Date of Web Publication||23-Mar-2022|
Department of Trauma and Emergency, AIIMS, Raebareli, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
The natural history of traumatic visceral venous pseudoaneurysm (VVP) is largely unknown, and hence, there is a lack of consensus for their management. This review aims to determine the management and outcomes of these injuries. A review of the reported cases over the last 25 years was performed. Only 32 cases were found, 24 abdominal, and 8 thoracic. Traumatic abdominal VVPs were largely managed nonoperatively, while majority of traumatic thoracic VVPs underwent intervention. Hemodynamic instability was the most common cause for intervention. No uniformity was noted for follow-up imaging of these injuries.
Keywords: Embolization, pseudoaneurysm, venous
|How to cite this article:|
Kumar V, Katiyar A, Banerjee N, Aggarwal S, Singh S, Agarwal H. Traumatic visceral venous pseudoaneurysm: A review of reported cases over last 25 years. Indian J Vasc Endovasc Surg 2022;9:48-53
|How to cite this URL:|
Kumar V, Katiyar A, Banerjee N, Aggarwal S, Singh S, Agarwal H. Traumatic visceral venous pseudoaneurysm: A review of reported cases over last 25 years. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Jul 4];9:48-53. Available from: https://www.indjvascsurg.org/text.asp?2022/9/1/48/340516
| Introduction|| |
Traumatic visceral venous pseudoaneurysm (VVP) is an extremely rare entity and their natural history is unclear. The rarity of the disease is because most of the time, they are asymptomatic and/or have spontaneous resolution over a course of time. Hence, there is a lack of consensus regarding the management of VVPs. The recent guidelines published by the American Association for the Surgery of Trauma–World Society of Emergency Surgery on abdominal vascular injuries have given a Grade 2C recommendation for nonoperative management of selected visceral venous injuries. However, management of these injuries is not discussed separately. The treatment options range from clinical observation to endovascular therapy to open surgical repair. The indications for intervention for these VVPs and the choice for intervention remain unclear. The challenges in a trauma patient become even more interesting, first because they have an acute presentation and second because the treating clinician has to keep in mind the management of several associated injuries. To decide on the appropriate management of traumatic VVPs, we conducted a literature search over the last few years. To the best of our knowledge, this is the first review on noniatrogenic VVPs, and is an effort to summarize traumatic VVPs over the last 25 years. This review could help in formulating guidelines or consensus statements regarding the management of visceral venous injuries in the future.
| Materials and Methods|| |
A parallel search as conducted by two individual authors. We searched the PubMed and the Google scholar databases with the keywords- “VVP,” “Venous pseudoaneurysm (PSA),” and named visceral vessel PSA over the last 25 years (1996–2020). We excluded any peripheral PSA and/or fistulous communication of the vein with the artery. We also excluded cases with nontraumatic cause of VVP as they are mostly iatrogenic in nature. We studied the mechanism of injury, presenting features, management, and outcomes of the cases.
| Results|| |
The largest series on this topic consisted of six cases, while the rest all were case reports. We found only 24 reported cases of traumatic abdominal VVPs and only 8 traumatic thoracic VVPs reported cases. The mean age was 33.4+/‒16.8 years [Table 1]. Male:female ratio was 19:13. The most common mode of injury was blunt in nature with the most common mechanism of injury being road traffic injury (21/31 cases), followed by fall from height (4/30).
Traumatic abdominal visceral venous pseudoaneurysms
All patients but one presented within 24 h of injury. The most common vein was the renal vein (9/24), which was followed by portal venous PSA (7/24) and inferior vena caval (IVC) PSA (5/24) [Table 2]. They were primarily managed conservatively (14/24), out of the rest, six cases underwent endovascular procedures and three patients underwent surgery. One patient was managed with a combination of endovascular and surgical procedures. Out of the ten patients who required some sort of intervention, the reason was hemorrhagic shock in 7, abdominal pain with computed tomography (CT) findings in 2, and compression of common bile duct in 1. The resolution of the PSA was confirmed by CT in 14 cases, duplex imaging in 4 cases, and in 4 cases, no follow-up imaging was done. There were two mortalities, of which one died due to bleeding, while the other patient died due to traumatic brain injury.
|Table 2: Reported cases of traumatic abdominal visceral venous pseudoaneurysms over last 25 years|
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Traumatic thoracic visceral venous pseudoaneurysms
Thoracic VVPs seem to be highly under-reported, with only 8 cases documented in literature so far [Table 3]. The most common injured vessel was a branch of the pulmonary vein in 4 cases, the azygos vein in 2 cases, and the subclavian vein and brachiocephalic vein in 1 case each. Majority of the patients underwent intervention (7/8). Five cases were managed surgically, one patient by endovascular means and one patient by percutaneous embolization. One patient died due to bleeding.
|Table 3: Reported cases of traumatic thoracic visceral venous pseudoaneurysms over last 25 years|
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| Discussion|| |
VVPs are usually caused by blunt injury. It may occur as a result of sudden deceleration injury or a crush injury. There are no specific signs or symptoms of VVPs, nonspecific signs being abdominal pain, compression symptoms, and/or hemodynamic instability. In the majority of cases, the diagnosis is made by contrast-enhanced CT (CECT). Imaging modalities such as ultrasonography are not helpful for the diagnosis of VVPs, as they are difficult to diagnose owing to deep-seated location and lack of technical expertise. On CECT scan, venous injury can be of five types: an intimal flap, thrombosis, PSA, active contrast extravasation, and AV fistula., VVP appears like a globular-shaped contrast-filled structure arising from a major vein in the venous phase of the scan. It is important to differentiate it from an arterial PSA which enhances during the arterial phase. While reading the CECT, it is important to look for evidence of contrast leaking freely into the peritoneal or pleural cavity from the PSA.
There are several options for the treatment of VVPs. They may be managed nonoperatively, or may require intervention either through endovascular intervention or through surgical exploration. However, the decision to choose the right treatment modality depends on the following key aspects: site, size, hemodynamic status, symptoms, duration, contrast leak, and variability in the size of the PSA over time. As per the literature, we did not find any uniformity in the management of such cases. Asymptomatic and nonenlarging PSAs were generally managed expectantly.,,, However, there are also reports of cases where large PSAs have been managed surgically or by endovascular means. According to available literature, there is no absolute cutoff value for the size of PSA that would mandate an intervention. The primary factor for deciding the management is the hemodynamic status of the patient. Thus, we divided this review on the basis of the management.
Nonoperative management is often the preferred line of treatment in abdominal VVPs, as they arise in a low-pressure system and are often contained by the surrounding structures. They often undergo a spontaneous resolution over time. However, we find that only one patient with thoracic VVPs was managed nonoperatively. This may be because of lack of sufficient tamponade in the pleural cavity and also because lungs are in continuous motion with pressure changes. Hence, the chances of resolution would be less. In the reported traumatic VVPs, we found that 15 patients were managed nonoperatively, of which 7 had renal vein injuries, 4 had IVC injuries, 2 had portal vein injuries, 1 had common iliac vein injury, and 1 had right superior pulmonary vein injury. All of them survived to discharge, except for one who died due to traumatic brain injury. There was no uniformity in re-imaging protocols for the evaluation of spontaneous resolution. Resolution of VVPs was noted as early as the 4th day Furthermore, the imaging modality utilized varied between centers.
The second option for managing VVPs is the endovascular approach. However, there is a technical difference in approaching the systemic and portal venous systems. Systemic venous circulation is approached by femoral or jugular routes, while the portovenous system is approached by the transjugular, transhepatic, or transsplenic routes. The management options by the endovascular approach involve gelfoam or coil embolization, stenting, and/or thrombin injection. Of the eight cases managed by endovascular techniques over the last 25 years, five were managed by stenting, while three were managed by coiling. In six cases, hypotension was the cause for intervention, while in two cases, it was based on abdominal pain and CT findings. One patient required an exploratory laparotomy for a delayed bowel perforation, when during surgery, the stent in the superior mesenteric vein was dislodged, eventually requiring ligation of the vein. All eight patients survived. Other options such as thrombin instillation in VVPs may require multiple attempts and hence is preferred only for peripheral PSAs only. In the current study, we found that three cases were managed with coiling, while four cases underwent stenting. At most of the centers, arterial stents are deployed in the veins also. However, the stents in the veins are subject to different forces as compared to arteries. It has been shown that the thrombosis rate of these stents is higher in veins owing to the low pressure in the venous system. It has also been noted that the rate of stent migration is higher in the venous system, the constant change in the vessel caliber, adapting to the preload may be a reason for such a high migration rate. The diameter of the vena cava is known to double during the respiratory cycle. Hence, the flexibility of venous stents should be higher than that of arterial stents. However, it is still under research.,
The surgical management of a visceral vein injury is a matter of debate. They are different from arterial PSAs as they are in a low-pressure system, and hence in a majority of the cases, nonoperative management is preferred. Furthermore, there is a limited expertise both in surgical and endovascular domains for their management. These VVPs are often noted when surgery is performed for hemodynamic instability arising due to blood loss from either these VVPs or due to associated injuries. We found that only 8/25 cases (4 abdominal and 4 thoracic) required surgical intervention. Primary repair or interposition graft placement is preferred. However, they can be challenging in a hemodynamically unstable patient. Hence, a trauma surgeon may have to ligate the visceral vein in dire situations. On review, we noted that in only one case, a visceral vein (Superior mesenteric vein) was ligated. Ligation of visceral venous injuries may always not be life-threatening. However there remains the possibility of back pressure changes such as acute renal failure, lower limb edema, and bowel edema leading to bowel necrosis. Hence, there is a need to continuously monitor the patient to watch for these changes. Management of PSA of the portal venous system remains a huge challenge, as the surgical approach is difficult and they are often associated with other organ injuries. In a hemodynamically unstable patient, one may have to divide the pancreatic neck by staples so as to quickly approach the confluence of the SMV and splenic vein, forming the portal vein.
The outcome of surgical repair of a venous injury is poor as compared to arterial injury because of high risk of thrombosis owing to the low-pressure system. The surgical repair of veins is also challenging as they are thin walled. The management of traumatic VVPs poses a challenge to trauma surgeons, and is best decided by a multidisciplinary approach, with the involvement of vascular surgeons, interventional radiologists, and critical care intensivists. It should be individualized based on the hemodynamic status of the patient, CECT findings, and the management of the associated injuries.
| Conclusion|| |
Traumatic VVPs can be managed nonoperatively. Intervention should be planned if VVP is symptomatic or if the patient is hemodynamic unstable. Endovascular approaches can be attempted if adequate expertise is available.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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