Nonoperative Management of Contained Retrohepatic Caval Injury Imtiaz R. Khan, Alireza Hamidian Jahromi, Faiza M. Khan, and Asser M. Youssef, Shreveport, Louisiana Traumatic inferior vena cava (IVC) injuries are associated with high mortality rates, despite all improvements in the technical skills and prehospital and hospital care. Selective conservative management of the penetrating abdominal injuries involving IVC has not been widely discussed before. Here, we report a case of a young female with a single gunshot wound to her abdomen, who presented to our level 1 trauma center 10 minutes after injury and was hemodynamically stable. A computed tomographic scan revealed a large liver laceration with a trajectory through the liver and the IVC. The IVC was surrounded by a moderate amount of fluid, consistent with a contained retroperitoneal hematoma. We discuss the outcome of nonoperative management of this patient along with a review of the literature. Patients with penetrating abdominal trauma (PAT) are at risk of having life-threatening injuries. The most common injuries caused by PAT are of the small bowel (60%), colon (41.6%), liver (29.3%), vascular structures (24.6%), stomach (17.3%), and kidneys (17.0%). 1 Although controversy exists concerning the management of PAT, there has been a recent trend toward selective conservative management of these injuries in the absence of peri- tonitis, evisceration, and hemodynamic instability, despite continuous fluid and blood resuscitation. 2,3 Traumatic inferior vena cava (IVC) injuries, although uncommon, are associated with high mortality rates, despite all improvements in the technical skills and prehospital and hospital care. 4 Reported mortalities are as high as 56% even in the recent reports. 5 More than half of IVC injuries spontaneously contain the site of injury with cessa- tion of bleeding, and as many as 40% of these patients die of exsanguination on surgical decom- pression of the tamponade. 6,7 Selective conservative management of the penetrating abdominal injuries involving IVC has not been widely discussed before. In this report, we present the successful nonopera- tive management of a patient with contained retro- hepatic IVC injury. CASE REPORT A 19-year-old female was brought in to our level 1 trauma center at Louisiana State University Health Sciences Center in Shreveport by emergency medical personnel 10 minutes after she was shot in her upper abdomen with a handgun. On physical examination, the patient was not in distress and had normal vital signs. She had a single wound in her upper epigastrium and had tender- ness to palpation at the wound site but had an otherwise normal abdominal examination, with positive bowel sounds and no peritoneal signs or guarding. Strong distal pulses were palpable in both upper and lower extremities. Focused Assessment with Sonography for Trauma exami- nation in the emergency room did not show fluid in her abdomen or in the pericardial cavity. Plain X-ray film (posteroanterior and lateral view) of the patient showed the location of the ballistic fragment in the posterior aspect of right upper abdomen (Fig. 1). A computed tomographic (CT) scan with intravenous contrast of the chest and abdomen revealed a large laceration following bullet trajectory through the right hepatic lobe and the retrohe- patic IVC. The IVC had an irregular contour and was Department of Surgery, Louisiana State University Health Sciences Center, Shreveport, LA. Correspondence to: Asser M. Youssef, MD, Division of Trauma and Critical Care Surgery, Department of Surgery, Louisiana State Univer- sity Health Sciences Center, 1501 Kings Highway, Shreveport, LA 71103-4228, USA; E-mail: AYouss@lsuhsc.edu Ann Vasc Surg 2012; 26: 420.e9e420.e12 DOI: 10.1016/j.avsg.2011.05.042 Ó Annals of Vascular Surgery Inc. Published online: February 9, 2012 420.e9