title: Comparison of atriocaval shunting with perihepatic packing versus perihepatic packing alone for retrohepatic vena cava injuries in a swine model.
abstract: BACKGROUND
  Retrohepatic vena cava (RVC) injuries are technically challenging and often lethal. Atriocaval shunting has been promoted as a modality to control haemorrhage from these injuries, but evidence from controlled studies supporting its benefit is lacking. We hypothesised that addition of an atriocaval shunt to perihepatic packing would improve outcomes in our penetrating RVC injury swine model.
  
  
  METHODS
  After a survivable atriocaval shunting model was refined in 4 swine without an injury, 13 additional female Yorkshire swine were randomised into either perihepatic packing and atriocaval shunt (PPAS, n=7) or perihepatic packing alone (PP, n=6) treatment arms prior to creating a standardised, 1.5 cm stab wound to the RVC. Haemodynamic parameters, intravenous fluid, and blood loss were recorded until mortality or euthanisation after 4h. Statistical tests used to test differences include the Wilcoxon rank sums test, Fisher exact test and analysis of covariance. A p-value ≤0.05 was considered statistically significant.
  
  
  RESULTS
  Immediately before and after RVC injury, no difference in temperature, cardiac output, heart rate, mean arterial pressure or mean pulmonary artery pressure was detected (all p>0.05) between the two groups. While the RVC injury did affect measures parameters in PPAS swine over time, haemodynamic compromise and blood loss were not significantly greater in PPAS than PP swine. Survival time was significantly different with all PPAS swine dying within 2h (mean survival duration 39 (SD 58)min) while all 6 PP swine survived the entire 4h study period.
  
  
  CONCLUSIONS
  While perihepatic packing alone slowed haemorrhage to survivable rates during the 4h study period, atriocaval shunt placement led to rapid physiologic decline and death in our standardised, penetrating RVC model.
authors.affiliation: Division of Trauma, Cooper University Hospital, Camden, NJ, United States. Electronic address: hazelton-joshua@cooperhealth.edu.
authors.forename: Joshua P
authors.initials: JP
authors.lastname: Hazelton
authors.affiliation: Department of Surgery, Cooper University Hospital, Camden, NJ, United States. Electronic address: choron-rachel@cooperhealth.edu.
authors.forename: Rachel L
authors.initials: RL
authors.lastname: Choron
authors.affiliation: Department of Anesthesia, Cooper University Hospital, Camden, NJ, United States. Electronic address: dodson-gregory@cooperhealth.edu.
authors.forename: Gregory M
authors.initials: GM
authors.lastname: Dodson
authors.affiliation: Department of Anesthesia, Cooper University Hospital, Camden, NJ, United States. Electronic address: gerritsen-jeffrey@cooperhealth.edu.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Gerritsen
authors.affiliation: Department of Surgery, Cooper University Hospital, Camden, NJ, United States. Electronic address: khan-sophia@cooperhealth.edu.
authors.forename: Sophia
authors.initials: S
authors.lastname: Khan
authors.affiliation: Department of Surgery, Boston University Medical Center, Boston, MA, United States. Electronic address: kathryn.vanorden@bmc.org.
authors.forename: Kathryn E
authors.initials: KE
authors.lastname: VanOrden
authors.affiliation: Division of Trauma, Cooper University Hospital, Camden, NJ, United States. Electronic address: capano-wehrle-lisa@cooperhealth.edu.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Capano-Wehrle
authors.affiliation: Department of Anesthesia, Cooper University Hospital, Camden, NJ, United States. Electronic address: mitrev-ludmil@cooperhealth.edu.
authors.forename: Ludmil V
authors.initials: LV
authors.lastname: Mitrev
authors.affiliation: Department of Anesthesia, Jefferson University Hospital, Philadelphia, PA, United States. Electronic address: marc.torjman@jefferson.edu.
authors.forename: Marc C
authors.initials: MC
authors.lastname: Torjman
authors.affiliation: Cooper Research Institute, Cooper University Hospital, Camden, NJ, United States. Electronic address: gaughan-john@cooperhealth.edu.
authors.forename: John P
authors.initials: JP
authors.lastname: Gaughan
authors.affiliation: Department of Medicine, Cooper Medical School of Rowan University, Camden, NJ, United States. Electronic address: goldfarb@rowan.edu.
authors.forename: Roy D
authors.initials: RD
authors.lastname: Golfarb
authors.affiliation: Division of Trauma, Cooper University Hospital, Camden, NJ, United States. Electronic address: ross-steven@cooperhealth.edu.
authors.forename: Steven E
authors.initials: SE
authors.lastname: Ross
authors.affiliation: Division of Traumatology, Surgical Critical Care and Emergency Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, United States. Electronic address: mark.seamon@uphs.upenn.edu.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Seamon
mesh_terms: D000818:Animals; D004195:Disease Models, Animal; D004621:Embolization, Therapeutic; D005260:Female; D006488:Hemostasis, Surgical / Q000379:methods; D006503:Hepatic Veins / Q000293:injuries* / Q000473:pathology; D008099:Liver / Q000293:injuries* / Q000473:pathology; D011897:Random Allocation; D013552:Swine; D057772:Vascular System Injuries / Q000473:pathology* / Q000628:therapy*; D014684:Venae Cavae / Q000293:injuries* / Q000473:pathology
keywords: Abdominal injury, Schrock shunt; Atriocaval shunt; Damage control; Juxtahepatic venous injury; Liver injury; Major vascular injury; Perihepatic packing; Retrohepatic vena cava; Vena cava injury