Injury to the vena cava adjacent to the liver and/or connected hepatic veins leads to often fatal bleeding. Patients may be admitted already in hemorrhagic shock with death occurring even before the bleeding area is localized.[1][2] Surgically, the area is difficult to access as it is largely covered by the liver. In 1968 Schrock et al. reported on the first use of the ACS.[3] They devised this approach after observing that above the renal veins only the right adrenal vein, the hepatic veins, and the inferior phrenic veins enter the inferior vena cava.[2]
A 1988 review by Burch et al. analyzed their experience with the ACS looking at 31 patients.[2] They indicated that “few technical maneuvers in surgery (are) as dramatic or desperate as the use of the atriocaval shunt ...” Ninety percent of the patients were admitted in shock. In 74% the vena cava was directly involved. In addition to the laparotomy to access the retrohepatic space, a thoracotomy is necessary to find the atrium so that the stent—usually a 36 French chest tube—can be inserted. The stent is secured with tourniquets. Problems during surgery involve uncontrollable bleeding and technical problems in placing the shunt in a timely fashion. Six patients survived (about 20%).[2]