CASE REPORT
We describe the case of a 33year-old woman affected by an undiagnosed hepatic hemangioma during pregnancy. She never had health problems but, a few hours after giving birth, she presented a brutal abdominal pain and dyspnea. Her physical examination revealed no fever, normal blood pressure and sinusal tachycardia. She was agitated with cold sweating, respiratory alkalosis, and hepatomegaly. The blood tests and coagulation panel were within normal limits.
The abdominal echo-fast showed the presence of blood in the peritoneal cavity and a total body CT-scan showed a rupture of intra-parenchymal mass with a massive intra-hepatic hematoma (Figure 1) and active spreading of contrast from the right branch of the hepatic artery. Severe hemoperitoneum and some spots of pulmonary embolization were also reported. In particular, the increased abdominal pressure had been so intense to cause compression of the inferior vena cava, leading to an almost total thrombosis affecting the inferior vena cava and iliac arteries (Figure 2).
The patient was then fully monitored and transferred in emergency status to the radiological operating room. Four units of red blood cells were administered to maintain a hemoglobin level >10g/dl, and stable hemodynamic control was assured through low doses of inotropes during perioperative phases.
Under local anesthesia, catheterization and embolization of selective hepatic arteries were performed through the right femoral artery. The post procedural control confirmed a massive thrombotic obstruction that extended from the iliac veins to the whole inferior vena cava.
Considering the hemodynamic stability and satisfactory control of bleeding, we decided to perform an aspiration of the iliocaval thrombus with the use of AngioVac system (Figure 3). After the administration of 5000UI of heparin, the right femoral vein was cannulated in a percutaneous standard fashion and the 22-French AngioVac inflow cannula was advanced through the sheath of a 26-French GORE DrySeal (W.L. Gore & Associates, Inc, Newark, DE) into the inferior vena cava. The reinfusion cannula was inserted through the right jugular vein and the lines were connected to the circuit (Figure 3). Once the veno-venous bypass was established, the complete extraction procedure was performed using suction power (Figure 4). The success of the procedure was defined by the complete aspiration of the thrombus, checked by the return of an antegrade flow into the vena cava, at the angiographic control (Figure 5A). The procedure was then completed with the placement of a caval-filter, to avoid any other small embolism (Figure 5B). No complications were reported, and the CT-scan control showed a good result of both procedures, with satisfactory control of bleeding and venous flow into the inferior vena cava.
Three days later, thanks to the stable condition, we decided to complete the treatment with a peritoneal wash out with laparoscopic approach, without complications. The total ICU and hospitalization time was 9 and 34 days, respectively. No pulmonary embolism or other intra-abdominal bleeding episodes were reported.
Up to now, total follow up time is 3 years and 3 months and no complications occurred.