DISCUSSION
The spontaneous hepatic rupture is a tragic condition and is mostly
encountered in cases of benign and malignant liver diseases [1].
During pregnancy, HELLP syndrome and preeclampsia are a major risk
factor of hepatic rupture, associated with about 40% of mortality. The
risk persists even after delivery.
Delayed diagnosis is probably the major contributing factor for high
perinatal (44%) and maternal mortality rate ranging from 7.5% (2) to
39% [3].
If there is a strong clinical suspicion of liver rupture, laparotomy
should be practiced immediately to reduce mortality. The surgical
procedures that can be performed range from hepatic artery ligation or
embolization to liver packing, omentum patches or, intra-abdominal
perihepatic vacuum assisted closure (VAC) therapy. In addition, if
extensive hemorrhagic necroses lead to progressive hepatic failure, a
liver transplant should be considered. It is worth mentioning that
despite surgical efforts, about one-third of the patients with liver
rupture die in hemorrhagic shock.
In this described case, the challenge was not only the management of the
hepatic rupture but also the unexpected complication of ilio-caval
thrombosis.
A multidisciplinary approach was employed to minimize the risks and
ensure the best result for the patient. In this context, a new and
extremely versatile tool available for the cardiovascular surgery team
at our hospital was used to avoid otherwise invasive intervention. The
AngioVac (AngioDynamics,Lathan, New York) aspiration system consists of
a 22F suction cannula, an extracorporeal circuit with a filter, and a
reinfusion catheter for returning blood to the patient (Figure 3). This
device can drain a large volume of blood (>3 L/min)
allowing to remove clots, vegetation, or other debris. It is a safe and
easy-to-use tool and the results reported in literature are very
encouraging [4].
In this case, AngioVac was considered the first line strategy to carry
out, avoiding open surgery, general anesthesia, and all related risks.
More than 3 years since the event, the patient is in excellent health
condition, the caval filter has been removed and the last CTscan control
shows a marked reduction in liver mass to > 50% of the
initial size.
Our case highlights that liver rupture and subsequent massive thrombosis
of inferior vena cava could be dangerous and difficult to manage for
several reasons. Firstly, the high risk related to massive pulmonary
embolism. Secondly, the risk of reduced venous drainage in splanchnic
organs. Thirdly, for the high bleeding risk due to thrombolysis
treatment. Lastly, technical challenge in inferior vena cava filter
implantation.
For these reasons, we believe that technical and technological evolution
made it possible to manage a potentially fatal complication by avoiding
open surgery and major organ manipulation by using a multidisciplinary
approach and the best devices available in each medical specialty
[5].
This strategy allowed, to avoid laparotomy, general anesthesia, and to
reduce the risk of infection.
To the best of our knowledge, this is the first reported case of liver
rupture complicated by massive ilio-caval thrombosis that was
successfully managed with a minimally invasive approach, without
complications.