Penetrating injury to the superior vena cava, to the thoracic course of the inferior vena cava (IVC), and the right atrium has the potential to seriously compromise hemodynamic stability both by exsanguinations and by drastic reduction of the right atrium venous return. If the patient reaches the hospital alive, a median sternotomy reveals a defect that can be temporarily controlled by digital pressure, skin stapler (27–29), satinsky vascular clamp, row of Allis clamps, Foley balloon catheter (30) and crossed mattress sutures for bigger defects. In case of uncontrollable bleeding, caval inflow occlusion can help the surgeon achieve hemostasis for a minute or two due to induced severe hypotension and bradycardia. Before employment of cardiopulmonary bypass (CPB) circuitry, bolus 3 mg adenosine-induced short asystole (31, 32) has been used to achieve a quick suture repair. When control is impossible, the patient will need to be placed on CPB with the inferior cannula placed in the abdominal IVC via the femoral vein and a balloon catheter occluding the IVC beyond the injury. Air embolism is something to watch for just prior to major thoracic vein repair completion but can also take place after blunt trauma (33).

Crossover left innominate vein injury is managed by a median sternotomy and should be repaired if the patient is stable. If necessary, it can be ligated though and the left upper limb put in stockingette and monitored for superficial volar compartment pressure rise [>35 mm requires fasciotomies (34)]. Endovascular repair has been reported with encouraging results (35). Subclavian vein traumatic injury can lead to devastating exsanguination due to communication with the pleural cavity and should be promptly controlled by a high anterolateral thoracotomy at the third or fourth intercostal space and adequate packing of the pleural space together with supraclavicular fossa pressure. If repair is dangerously cumbersome, it is better ligated and the arm monitored for signs of venous hypertension. Axillary, azygos (36), and pulmonary vein injuries are highly lethal and even less frequent targets of injury that recent imaging advances has provided insight into their underestimated incidence (37).

Trauma injury to the IVC, portal (PV), and mesenteric venous (SMV) systems is not common and is accompanied by high mortality. Despite advances in care, the mortality associated with these venous injuries has not changed in the last 30 years and literature reports death rates of 50–70% for injuries to the SMV, the PV, and IVC (38–40). With IVC injuries alone, 30–50% of patients will fail to reach hospital alive (41). High mortality has been attributed to difficulty in operatively accessing the structures as well as hemorrhage from a high-flow, low-pressure system (39, 42).

Neighboring anatomy protects these vessels and, according to Asensio et al. (39), there coexist 2–4 associated organ injuries for every visceral vessel damaged. Penetrating trauma is the dominant (95%) type of injury to these structures (39, 43). The IVC is the most frequently damaged and requires complex decision-making. Therapy for this triad of injuries is mainly operative and prompt identification and surgical competence are prerequisites for a good outcome.

The overall incidence of IVC injury ranges from 0.5 to 5% of penetrating injuries and 0.6–1% of blunt trauma (44). Approximately 30–50% of patients will die before reaching the hospital (41, 44). Of the patients who survive to the hospital, 20–57% will not survive to discharge (41). As the IVC is a low-pressure retroperitoneal structure, bleeding is initially contained. Patients presenting stable with contained hematomas are candidates for non-operative management (45). Vigorous intravenous fluid resuscitation—especially through lower extremity access sites—must be avoided to reduce chances of tamponade release. Importantly, obvious signs of deterioration indicate failure of the current course of management and the need for surgical exploration.

Injuries to the infrarenal IVC have the best survival due to the ease of access and tolerance to ligation. The suprarenal IVC is relatively accessible but is more closely associated with sensitive neighboring structures while suprarenal ligation is poorly tolerated (43). Injury to the retrohepatic IVC almost and always includes damage to the liver parenchyma, and this allows free bleeding into the peritoneal cavity. Exposure is difficult and survival is low (46). Finally, mortality from injuries in the suprahepatic IVC approaches 100% due to difficulty gaining control in this region. When the injury is identified preoperatively, endovascular techniques will likely provide better salvage than open approaches. The use of endografts has been reported for treating retrohepatic IVC in conjunction with laparotomy (47, 48), with adjunctive Pringle maneuver/packing and as a primary intervention alone (49) or combined with fenestrations for hepatic vein drainage (50). Such a strategy could be beneficial in cases of iatrogenic caval avulsions are anticipated in “hostile” abdomen elective surgery or in cases of suspected caval invasion by malignancy. Still, controversy exists regarding anticoagulation to prevent thromboembolic events (50, 51).

In the presence of a retroperitoneal hematoma, the IVC is approached from the right. Specifically, left visceral rotation followed by an extensive Kocher maneuver is performed. Proximal and distal control of the IVC is advisable but is not always possible. If active hemorrhage is encountered, direct pressure on the area of injury should be applied. Then control is achieved by starting proximal and distal to this region and moving toward the defect. Control of the retrohepatic and suprahepatic portions of the IVC is particularly difficult to achieve (52) but retraction of the liver upward will allow access to the most proximal portion of the infrahepatic IVC. Complete mobilization of the liver by division of the suspensory ligaments will provide some mobility to access the retrohepatic portion of the cava but removes the possibility of tamponade by the organ. Access to the suprahepatic IVC will always require division of the diaphragm for adequate exposure and a sternotomy may be due for proximal control of such injuries (53). Percutaneous approaches that involve use of compliant endovascular balloons for inflow and outflow occlusion may be sought to address injuries to this portion of the IVC.

For penetrating injury, the common approach is to apply sponge sticks above and below the wound for proximal and distal control (41, 43), but this may widen the injury or create a new one. Direct pressure on the injury is better starting with one’s fingers. In the case of linear injuries, the vein edges may be grasped with Judd-Allis clamps and closed either with a Satinsky clamp or sutures. A simple stitch placed at the proximal and distal extent of the laceration, with gentle upward traction, will elevate and collapse the laceration and allow control and exposure for primary suture closure (54). Another consideration in repair of the IVC is the use of a larger non-cutting needle that can be visualized in the presence of considerable amounts of blood. The combination of an anterior and posterior caval laceration can be managed easier in the infrarenal cava by slight rotation. However, proximal IVC cannot rotate due to tributaries so that the posterior defect must be repaired through an extension of the anterior one. Finally, in cases of large defects, interposition grafting should be considered taking into account the considerable time needed for this cumbersome reconstruction.

Hemorrhage control presents unique challenges in the case of blunt retrohepatic and suprahepatic IVC injuries. Direct pressure on the liver parenchyma to reapproximate tissues and direct pressure posteriorly along with a Pringle maneuver should be utilized if the parenchyma is bleeding. When hematoma is identified behind the hepatic ligaments, division of the ligaments should be avoided (55). In such cases, endovascular single balloon control, caval isolation using two balloons (56), or caval stent-grafting (57) can solve the problem while atriocaval shunts are likely to become obsolete in the endovascular era (58–60). Open liver total isolation requires sternotomy or a right thoracoabdominal incision plus a Pringle maneuver and is rarely tolerated by the patient while the ultimate step involves supraceliac aortic clamping (58, 59). The use of circulatory arrest (52, 53, 61), veno-venous bypass, hypothermia, and liver autotransplantation (62) require demanding equipment, surgical team experience, and are time consuming, thus only marginally improving outcomes.

Ligation of the infrarenal IVC, iliac veins, and left renal vein are tolerated fairly well. Conversely, ligation of the PV and the SMV are poorly tolerated and while ligation of the right renal vein often results in kidney loss (63). Sullivan et al. reported that over a 13-year time period, 43% of patients underwent ligation and had a 59% overall mortality rate—compared to 21% of the repair group. The major morbidity of infrarenal IVC ligation is lower extremities swelling that is potentially severe enough to cause acute compartment syndrome. However, fasciotomy is not recommended as a routine prophylactic measure following IVC ligation (54, 64).