Surgical approach to major vascular injury after severe blunt trauma: Traumatic superior vena cava pseudoaneurysm with unstable pelvis fracture

Abstract text (incl. references and figure legends)

An 80 year old woman was taken to the emergency department after a run over, with severe thoracoabdominal blunt trauma. She was haemodynamically unstable, with systolic blood pressure of 60mmHg, heart rate 130bpm, oximetry 88%, Glasgow coma scale 8/15, at arrival.

Orotracheal intubation was performed, fluid resuscitation, and vasoactive drugs were provided, and external compression device was set to pelvic fixation. Massive transfusion protocol was triggered. Chest and pelvic X-ray showed a mediastinal widening and an unstable pelvic fracture.

Transient response to resuscitation allowed to perform a CT scan, showing: pseudo-aneurysm of superior vena cava (SVC) with no active bleeding, mediastinal hematoma, bilateral haemopneumothorax and pulmonary contusion, pneumopericardium and pelvic fracture with venous bleeding.

Emergency surgery was decided. External pelvic fixation over the iliac crest and extraperitoneal pelvic packing was performed, followed by a median sternotomy for SVC repair. A pseudoaneurysm of the SVC with profuse bleeding was identified and emergent cardiopulmonary bypass was stablished. After vessel control, SVC burst ruptured was identified, making impossible primary repair. Azygos vein was ligated and a 10mm Dacron graft was sewn for SVC substitution. A temporary closure was carried out.

A second-look surgery was scheduled 72 hours later, and in the absence of bleeding, chest and abdomen were both definitely closed. After a prolongated ICU stay with several complications, the patient was finally discharged to a rehabilitation hospital.

Major vascular injuries are associated to a high mortality rate. There is not much evidence of traumatic pseudoaneurysm SVC management, but achieving an early vessel control is imperative to prevent exsanguination, and may require complex cardio-thoracic surgery.

Fig1. CT scan showing a SVC pseudo-aneurysm.

Fig2. SVC ruptured.

Naidoo S, et al. Traumatic injury to the great vessels of the chest. Doi: 10.21037/med-21-15.

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