Thoracic Aortic Stent-Graft Placement for Safe Removal of a Malpositioned Pedicle Screw

Thoracic aortic stent graft placement and simultaneous screw removal for a screw hitting the aorta

Vascular injury caused by spinal screw displacement is a rare complication of spinal fusion surgery. Here, we report a case with no perforation of the aortic wall, which we treated by means of simultaneous thoracic endovascular aorta repair (TEVAR) and screw removal. An 82-year-old female underwent corrective spinal fixation. Postoperatively, a screw became displaced from the vertebrae and contacted the outer membrane of the descending aorta. To prevent rupture of the aorta, we performed stent graft placement from the right common femoral aorta. We left a flexion-resistant catheter in the left arm and moved the patient into an abdominal position with the left arm extended upward to enable immediate insertion of a guidewire and occlusion balloon if necessary. Then we removed the displaced screw with a drill. This safe and effective method can prevent possible aortic injuries secondary to displaced spinal screws. The key to our method is the simultaneous performance of TEVAR and screw removal, made possible through patient repositioning.

Delayed Presentation of Thoracic Aortic Pseudoaneurysm Following Pedicle Screw Implantation: A Case Report

Background

Pedicle screw insertion has been known to have several complications even in the most skilled surgical hands. However, injury to the thoracic aorta during pedicle screw insertion is rare, delayed presentation secondary to pseudoaneurysm is even rarer, the pseudoaneurysm formation caused by a series of malpositioned pedicle screws has perhaps not been reported so far.

Case presentation

In this paper, we report here a case in which inadvertent injury to the thoracic aorta resulted in pseudoaneurysm, its manifestation was initially vague, resulting in a delayed diagnosis. Delayed aortic pseudoaneurysm or injury can be asymptomatic for a long time. Patients with renewed or continued back pain should alert orthopaedic surgeons regarding the possibility of pseudoaneurysms, regardless of the period that has elapsed after pedicle screw implantation.

Malpositioned pedicle screw in spine deformity surgery endangering the aorta: report of two cases, review of literature, and proposed management algorithm

STUDY DESIGN

Case reports and review of the literature with a proposed management algorithm.

OBJECTIVES

To report two cases of a potential vascular complication due to an incorrectly placed pedicle screw (PS) during spine deformity surgery. Relevant literature regarding the management of vascular complications is reviewed, and an evidence-based management algorithm is proposed. Aortic lesions represent a rare but potentially life-threatening complications with spine deformity and revision surgery, significantly increasing the risk. A management algorithm for an aortic lesion in the case of a malpositioned PS has not yet been published.

METHODS

Case 1: An 18-year-old female with proximal thoracic spinal non-instrumented fusion underwent a revision corrective procedure due to a progressive right-sided thoracolumbar compensatory curve. However, postoperative computed tomography (CT) performed to evaluate the position of the PS revealed malposition of the left T9 PS, which was abutting the descending aorta with CT angiography excluding the perforation of the aorta. Case 2: A 17-year-old male was scheduled for correction of Lenke 3-C-N adolescent idiopathic scoliosis. Postoperative routine evaluation with low-dose CT revealed a left T9 PS paravertebral malposition, and subsequent CTA demonstrated that the thread of the PS was in contact with the descending thoracic aorta and an unlikely hemodynamically significant vessel injury.

RESULTS

Successful removal of both malpositioned PS was performed. In the first case, a cardiovascular surgeon attended the operation if an urgent thoracotomy was needed, and in the second case, additional video-assisted thoracoscopic control of the aorta was performed during PS removal.

CONCLUSIONS

Preoperative imaging in spinal surgery is essential to avoid major vascular and other complications when placing PS, especially in thoracic deformities. When a potential major vessel complication emerges, an interdisciplinary approach and an appropriate management algorithm are mandatory to make the best clinical decisions.

LEVEL OF EVIDENCE

4.

Aortic Injury by Thoracic Pedicle Screw. When Is Aortic Repair Required? Literature Review and Three New Cases

PURPOSE

Aortic injury by pedicle screw is rare but can cause serious complications. It has not been clearly determined when aortic repair is necessary in cases of screw impingement without perforation of the aortic wall. In this article, we review the treatment and clinical course of pedicle screw aortic impingement and attempt to clarify this issue.

METHODS

Cases of aortic injury during thoracic screw procedures were found using a MEDLINE search and analyzed together with 3 new cases that we present.

RESULTS

Nineteen cases collected from the literature and 3 new cases were included in the study. In 7 of the cases, aortic impingement by the pedicle screw was detected during postoperative follow-up (day 1) radiologic examinations. In the other cases, time to presentation of aortic impingement ranged between 2 weeks and 60 months after fixation. The main indications for thoracic spinal fixation were post-traumatic vertebral fracture and kyphoscoliosis/scoliosis. Repair of the aortic damage ranged from primary repair to stent and tube graft placement by the thoracic endovascular aortic repair method.

CONCLUSIONS

In cases in which the screw impinges less than 5 mm into the aortic wall, hardware revision without aortic repair may be sufficient if recognized early and there are no sign of aortic leakage in vascular imaging. However, cases with more than 5 mm of screw impingement should undergo aortic repair first, even in the absence of aortic leakage, following by screw revision.

Delayed Presentation of Aortic Injury by a Thoracic Pedicle Screw

Delayed presentation of a thoracic aortic injury is an extremely rare complication after spine surgery. We report a case of delayed presentation of a thoracic aortic injury with a vertebral pedicle screw after posterior spinal surgery without periaortic hematoma, hemorrhage or pseudoaneurysm formation and review the relevant literature.

Endovascular repair of thoracic aortic injury after spinal instrumentation

Aortic injury after thoracic spinal instrumentation is a rare complication that carries significant potential morbidity and mortality if it is not appropriately managed. We report a patient successfully treated in an endovascular manner, thereby applying minimally invasive techniques to avoid the morbidity of open thoracotomy. Decreased short-term morbidity with the endovascular approach offers significant advantage over open repair, thereby omitting aortic cross-clamping, thoracotomy, and increased risk from the patient's comorbidities. An endovascular approach to this potentially devastating complication of thoracic spinal instrumentation can be both safe and effective in selected patients and not exclusively performed in cases of hemorrhage, hematoma, or pseudoaneurysm.

Thoracic Aortic Injury: Embolization of the Tenth Intercostal Artery and Endovascular Treatment in a Young Woman after Posterior Spinal Instrumentation

Iatrogenic aortic injuries are rare and well-recognized complications of a variety of procedures, including spinal surgery. The placement of pedicle screws is sometimes associated with devastating consequences. Aortic perforation with rapid hematoma formation and delayed aortic trauma leading to pseudoaneurysm formation have been described in the literature. A case describing a significant time interval between iatrogenic aortic injury and diagnosis in the absence of pseudoaneurysm formation is described in this paper and, according to our knowledge, is unique in the literature. The aortic injury was successfully treated, selecting the appropriate graft and, as a consequence, normal spinal cord blood flow was achieved.

Aortic dissection associated with penetration of a spinal pedicle screw: a case report and review of the literature

A 30-year-old male underwent a corrective posterior instrumented spinal fusion for scoliosis. Six years later, he was found to have an aortic dissection after aortic penetration of a spinal pedicle screw. We review the literature, including diagnostic modalities, and treatment decision-making for this unusual complication.

An endovascular treatment of a thoracic aortic injury caused by a misplaced pedicle screw: Case report and review of the literature

Aortic injuries are devastating complications after spinal surgery. We here would like to share our experience with a successful endovascular treatment of an iatrogenic thoracic aortic injury caused by misplaced pedicle screw after spinal surgery. A patient underwent posterior spinal surgery for L1 burst fracture was transferred to our department for instrumentation removal. An iatrogenic thoracic aortic injury at T11 level caused by a pedicle screw was recognized after routine CT scans. Complete screw extraction and instrumentation removal were performed after the placement of a thoracic aortic stent graft covering the injured region. The patient had an uneventful postoperative period and no complications were observed in the 1 and 12-month follow-up by contrast-enhanced CT scans. For the delayed thoracic aortic injuries which usually were usually shown on CT scans as pseudoaneurysm or penetration of the aorta, stent graft implantation would provide a preferred solution with high-effectiveness, low-invasiveness and fewer complications compared with conventional open surgery.

Screw in the aorta: minimally invasive graft replacement for chronic aortic erosion by spinal instrument

Intra-and early post-operative aortic injury by pedicle screw is not a rare complication in orthopedic surgery, but aortic penetration by a screw head over a long time period is considered as an uncommon case. There are various surgical management options for thoracic aortic injury caused by malpositioned spinal instruments. We report a case of a patient who underwent minimally invasive graft replacement of the descending thoracic artery for pedicle screw penetration.

Late diagnosis of pedicle screw malplacement with perforation of the thoracic aorta after posterior stabilization in a patient with multiple myeloma: case report

STUDY DESIGN

A case report.

OBJECTIVE

To demonstrate delayed diagnosis of screw malpositioning with perforation of the thoracic aorta after posterior stabilization of a Th7-vertebral collapse due to multiple myeloma. Relevant diagnostic and therapeutic strategies are outlined in the context of a rather unfortunate series of interventional events.

SUMMARY OF BACKGROUND DATA

Pedicle screw instrumentation has become a well-established standard in the surgical treatment of various disorders of the spinal column. Particularly at the upper-thoracic level, the close anatomic relationship of the spine to the aorta places it and other major structures at high risk. Although iatrogenic vascular injuries are rare, a few cases have been described.

METHODS

A 64-year-old female patient remarked progressive back pain after 2 years of uneventful recovery from a multilevel posterior stabilization by pedicle screw and rod instrumentation because of an osteolytic collapse of the Th7 vertebra. The subsequent computed tomographic scan demonstrated kyphotic deformity of the thoracic spine with transspinal and periaortic screw malplacement.

RESULTS

The revision strategy was an interdisciplinary single session two-phase operation. The primary phase included a left-sided thoracotomy, mobilization of the thoracic aorta, and posterior implant removal under vascular monitoring in right lateral position. The initially planned corporectomy of Th7 and subsequent vertebral body replacement by cage implantation via the anterior approach was dismissed because of critical tissue adhesions of the thoracic aorta to the anterior vertebral column. Finally, the thoracotomy was closed, the patient transferred into prone position and stabilized by a multilevel posterior reinstrumentation under fluoroscopy guidance.

CONCLUSION

Although the clinical course in malpositioned pedicle screw instrumentation may stay unremarkable, this case illustrates that in a proven injury to the thoracic aorta revision is mandatory to prevent further vascular damage. The appropriate strategy demands exact and provident planning using a preferably interdisciplinary approach.