Inferior vena cava rupture

Clinical History

A 54-year-old male motorcyclist was hit by a car. In the emergency department he complained of pain in the left side of thorax, the left hip, and in the lumbar spine. He was awake and haemo-dynamically stable.

Imaging Findings

Trauma CT scan was performed, including contrast-enhanced scans of the thorax and abdomen. There was no sign of intracranial bleeding, and the cervical spine was normal. In the thorax a small (<1 cm) left-sided pneumothorax was seen (Fig. 1a), as well as bilateral haemothorax (Fig. 1b), and multiple rib fractures (Figs. 1c, d).
In the abdomen a large retroperitoneal haematoma was present (Fig. 2a, b). The vertebral body of L4 was fractured with a small triangular fragment penetrating the inferior vena cava (IVC) leading to traumatic rupture of the infra-hepatic IVC (Fig. 2a). There were irregular margins of the infra-hepatic IVC. The abdominal aorta was intact.
Emergency surgery was performed confirming the diagnosis of infra-hepatic IVC rupture. Unfortunately, bleeding became uncontrollable when trying to suture the ruptured IVC. The patient died from hypovolemic shock.

Discussion

Injuries to the IVC are rare but are associated with high mortality rate [1, 2]. Factors related to high mortality are:

1. Supra-renal and retro-hepatic injuries [2]
2. Injuries larger than 5 cm [2]
3. Other injuries present [3]
4. Shock [3]

Contrast-enhanced CT scan is the method of choice for assessment of haemodynamically stable trauma patients. It can define the anatomical location and severity of IVC injury. Furthermore, it can detect associated injuries and be helpful in preoperative planning [4].
CT findings of IVC injuries depends on the location. With infra-hepatic IVC injury common findings are retroperitoneal haematoma, irregular IVC margins and extravasation of contrast material [5]. CT findings of retro-hepatic IVC injury are liver laceration or irregular retro-hepatic IVC contours [6]. A collapsed IVC at multiple levels indicates hypovolaemia [7].
CT is however not a perfect modality to detect IVC injuries. Lesions can be overlooked or underestimated, for instance due to lack of contrast extravasation or normal IVC contours [3].
A late phase (e.g. 5 min p.i.) CT acquisition can be added, when venous injury is suspected, since this might show the extravasation.
Clinical diagnosis is unreliable. Diagnostic peritoneal lavage does not detect retroperitoneal injuries, and do not provide information about the site of bleeding [8].

In our case some common CT findings of infrahepatic IVC rupture (large retroperitoneal haematoma and irregular IVC contours) were present. Initially the patient was haemodynamically stable, probably because the haematoma was contained within the retroperitoneum. Due to the fatal outcome the case underlines the importance of IVC injuries.

Differential Diagnosis List

Final Diagnosis

IVC rupture

URL:	https://www.eurorad.org/case/11250
DOI:	10.1594/EURORAD/CASE.11250
ISSN:	1563-4086