An atriocaval shunt (ACS) is an intraoperative

surgical Surgery ''cheirourgikē'' (composed of χείρ, "hand", and ἔργον, "work"), via la, chirurgiae, meaning "hand work". is a medical specialty that uses operative manual and instrumental techniques on a person to investigate or treat a pat ...

shunt between the

atrium Atrium may refer to: Anatomy * Atrium (heart), an anatomical structure of the heart * Atrium, the genital structure next to the genital aperture in the reproductive system of gastropods * Atrium of the ventricular system of the brain * Pulmona ...

of the

heart The heart is a muscular organ in most animals. This organ pumps blood through the blood vessels of the circulatory system. The pumped blood carries oxygen and nutrients to the body, while carrying metabolic waste such as carbon dioxide to t ...

and the

inferior vena cava The inferior vena cava is a large vein that carries the deoxygenated blood from the lower and middle body into the right atrium of the heart. It is formed by the joining of the right and the left common iliac veins, usually at the level of th ...

. It is used during the repair of larger juxtahepatic (next to the

liver The liver is a major organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the synthesis of proteins and biochemicals necessary for digestion and growth. In humans, it ...

) vascular

injuries An injury is any physiological damage to living tissue caused by immediate physical stress. An injury can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, or o ...

such as an injury to the local vena cava. Injuries to the inferior vena cava are challenging, those behind the liver being the most difficult to repair. __TOC__

Procedure and results

Injury to the vena cava adjacent to the liver and/or connected hepatic veins leads to often fatal bleeding. Patients may be admitted already in

hemorrhagic shock Hypovolemic shock is a form of shock caused by severe hypovolemia (insufficient blood volume or extracellular fluid in the body). It could be the result of severe dehydration through a variety of mechanisms or blood loss. Hypovolemic shock is a m ...

with death occurring even before the bleeding area is localized. Surgically, the area is difficult to access as it is largely covered by the liver. In 1968 Schrock et al. reported on the first use of the ACS. They devised this approach after observing that above the renal veins only the right adrenal vein, the hepatic veins, and the inferior phrenic veins enter the inferior vena cava. The placement of the shunt allowed venous return to the heart and, along with the

Pringle manoeuvre The Pringle manoeuvre is a surgical technique used in some abdominal operations and in liver trauma. The hepatoduodenal ligament is clamped either with a surgical tool called a haemostat, an umbilical tape or by hand. This limits blood inflow thr ...

, controlled local bleeding. While their patient did not survive, other investigators followed their lead with some success. A 1988 review by Burch et al. analyzed their experience with the ACS looking at 31 patients. They indicated that “few technical maneuvers in surgery (are) as dramatic or desperate as the use of the atriocaval shunt ...” Ninety percent of the patients were admitted in shock. In 74% the vena cava was directly involved. In addition to the

laparotomy A laparotomy is a surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy. Origins and history The first successful laparotomy was performed without ane ...

to access the retrohepatic space, a

thoracotomy A thoracotomy is a surgical procedure to gain access into the pleural space of the chest. It is performed by surgeons (emergency physicians or paramedics under certain circumstances) to gain access to the thoracic organs, most commonly the hea ...

is necessary to find the atrium so that the stent—usually a 36 French chest tube—can be inserted. The stent is secured with tourniquets. Problems during surgery involve uncontrollable bleeding and technical problems in placing the shunt in a timely fashion. Six patients survived (about 20%).

Alternatives

Pachter et al. devised a transhepatic approach to access the inferior vena cava. Another approach may be the placement of a balloon-caval shunt introduced from the

femoral vein In the human body, the femoral vein is a blood vessel that accompanies the femoral artery in the femoral sheath. It begins at the adductor hiatus (an opening in the adductor magnus muscle) as the continuation of the popliteal vein. It ends a ...

in the groin. Buckmann et al. indicate that injury to the juxtahepatic veins may not necessarily require surgery if the hematoma is contained.

References

{{reflist Emergency medical procedures