Iatrogenic injuries are common, can be diagnosed preoperatively and the proper surgical approach chosen accordingly. In contrast, penetrating SVC injuries are rare but highly lethal. They are rarer following blunt chest trauma such as crushing and deceleration injuries [1]. The true incidence of penetrating wounds of the SVC as well as other great vessels is not known since many of these patients succumb shortly after injury and autopsy examination is not done in all patients dying after trauma [3]. Little has been written about cervicomediastinal venous injury [4]. We searched the English medical literature on the net; we obtained sporadic case reports of penetrating SVC injuries caused by stab wounds or gunshots but no case of SVC shrapnel injury was found.

In the study of Nair et al., 49 patients had cervico-mediastinal venous injuries. Eight patients (26.7%) died. All of them were shocked on admission. Four of the 9 patients who were admitted in profound shock died on the operating table from exsanguinating haemorrhage. In the same study, there were 3 patients with SVC injuries. Two patients with stab wounds of SVC died on the operating table (66% mortality) whilst the third patient survived an extensive laceration of SVC at the confluence of the brachiocephalic veins. He was subjected to venorrhaphy, narrowing the lumen of the SVC to 25% of its normal caliber. Postoperatively, he developed massive oedema of the arms, head and neck [4].

Symbas et al. reported on 36 patients with penetrating wounds of the great vessels treated at Grady Memorial Hospital during a 7-year period (1965-1972). One patient had 2 stab wounds of the SVC. Tangential partial occlusion of the SVC was used [3].

SVC injuries, resulting from blunt or penetrating trauma will result in death before admission to the hospital in 45% of cases [1]. One third to one half of the remaining patients will die despite aggressive resuscitation and early surgical intervention [1]. The high mortality is due to difficulty in diagnosis and technical problems with repair [1]. Despite optimal care, thoracic venous injuries have a high mortality [1]. Exsanguinations may result without aggressive resuscitation and rapid surgical intervention.

SVC injuries should be considered in any patient with a massive haemothorax. Unfortunately, there are no pathognomonic signs of azygos or SVC injuries [1]. Pulmonary, hilar and intercostal vessel injuries present with haemothorax as well. Subclavian, brachiocephalic and aortic injuries must also be considered [1]. Thoracic venous injuries usually present with signs of shock [1]. The blood pressure in these vessels is normally below systemic pressures, but the flow is high; therefore bleeding is usually massive [1]. Depending upon its exact site; SVC injury may result in bleeding into the pleural cavity, mediastinum or into the pericardium producing pericardial tamponade (when the entrance of SVC into the pericardium is injured) [1].

Aggressive fluid resuscitation and blood transfusion are important to prevent haemodynamic collapse prior to transporting these patients to operating room where better lighting and equipment are available [1]. Auto-transfusion is helpful when blood loss is massive as it uses blood drained from the pleural cavity to restore circulating blood volume [1].

The approach is usually dictated by the clinical presentation [5]. A massive haemothorax mandates a right thoracotomy [5] as in our case. However, there is no incision which will satisfy all needs in emergency exploration of SVC injuries [3]. The trap door incision (antero-lateral thoracotomy, upper mid-sternotomy and lower neck incision) has the advantage that it can be extended to gain access to almost all great vessel wounds but is associated with greater morbidity to the patient and is more time-consuming for the surgeon [3]. Wide prepping and draping of the thorax and neck so that thoracotomy incision can be extended if needed, good exposure, adequate assistance, effective suction, sufficient blood for transfusion (or the use of intra-operative auto-transfusion) is essential for successful repair of great vessel injury [3].

Partial caval clamping or clamping a chronically obstructed SVC is generally well tolerated; on the other hand, occlusion of a patent SVC may produce intracranial bleeding, brain oedema and damage, and a potentially lethal reduction of cardiac output [5].

Repair should be undertaken in stable patients [4] whereas in haemodynamic unstable patient or when complex repair is needed, ligation is the preferred option [4]. However, ligation of the SVC is not the best management option particularly if there were no collateral veins to provide significant drainage of the upper body [5]. Successful ligation of the juxta-atrial portion of the SVC has been reported and attributed to the collateral effect of superior intercostals, azygos and hemiazygos veins [5].

Auto-transfusion greatly contributed to successful outcome in patients with massive intra-thoracic bleeding by promptly procuring sufficient quantities of blood [3]. This procedure has been proved to be safe and frequently life-saving for such patients [3].

The majority of caval injuries can be repaired without the need of cardiopulmonary bypass (CPB). However, median sternotomy and CPB may be required for injuries close to the heart where distal control is not tolerated and can be helpful in decompressing the venous system and allowing improved exposure [5].

Our patient unfortunately died despite surgical exploration and different measures used to control the haemorrhage such as balloon catheter and clamping of the SVC. Ligation was not used as it would not control back flow. Probably he could be saved if facilities of auto-transfusion and CPB were available.