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.