An iliac vein or worse an IVC (inferior vena cava) tear can be a nightmare. The patient may bleed heavily, and quickly the patient’s situation may become non-reconstructible. So, what can you do to fix it?
The vein repair depends on the area of damage. Is the area visible or not?
The visible hole
Ok. There are two options: get control before the repair or repair without control.
- To get control of the bleeding, you have to press the vein below and above the area of damage. Use whatever is possible. A small gauze on a stick is a good option. Use your assistant to press these sticks and start repairing. Another good option is to try to put a clamp across the area of tearing. The best clamp is a baby-Scatinsky clamp. Get one and make a good bite across the tear. The vein is ready to be repaired. What suture? Definitely, a Prolene one. What size? Not a small one, depending on the vein either a 4/0 or 3/0. What needle? You’d better use a big one (20 mm or 24 mm or 31 mm). If you have good control (i.e. with a baby-Scatinsky clamp) you may have the time to make a formal repair using a fine suture, with a relatively small needle. And what technique for suturing? A continuous one either over-and-over or two-way running, first at a horizontal mattress and then as an over-and-over. In case of a smaller tear, use a figure-of-eight stitch.
- If you want to repair without having controlled the bleeding, you must be prepared to lose blood. Inform the anesthetist and have your assistant grab the suction. Put the section by the hole and let it suck the blood as long as you will try to stitch it. In this situation, use a suture with the biggest needle available. What is the secret in this case? Everybody must be calm: the anesthetist must give fluids, the first assistant must hold still the suction in the proper position so as the vein hole is visible, and the surgeon must put the stitches across as quickly as possible.
- I have found it useful not to pull up the stitch after I have done the first passage through the bleeding vein. I let it as it is (loose) and pass a second stitch across the bleeder. Then I pull the two ends of the suture upwards. Usually, this will show that the bleeding has been controlled. If you try pulling up the suture after the first passage, this may tear the vein and increase the hole. On the other hand, bleeding control with the first passage is very rarely enough to control bleeding.
- Another tip that sometimes works is to cross-clamp the relevant arteries. For example, if the bleeding is from an iliac vein, cross-clamp the relevant artery (i.e. common or external) first, after you have asked the anesthetist to give 5000 IU of heparin first. Similarly, if the bleeding comes from the inferior vena cava, cross-clamp the abdominal aorta. This sometimes reduces the amount of venous bleeding.
After the bleeding has at least roughly stopped, put a fluffy gauze in the wound, press with a swab above and drain the area with loads of warm (almost hot) normal saline. Stay there and press for at least 5 minutes and then gently remove the swabs.