Percutaneous endovascular stent-graft for iliac pseudoaneurysm following lumbar discectomy

Successful Endovascular Surgery for Iatrogenic Common Iliac Artery Injury during Lumbar Spine Surgery: A Case Report

An 80-year-old man was admitted with an L5 compression fracture, L4/5 spondylolisthesis, and L5 radiculopathy and underwent a TLIF procedure. Refractory hypotension occurred, though it indicated a possible great vessel injury with vasopressor and fluid infusion. Emergent intraoperative angiography was performed, which showed extravasation at the right common iliac artery. Resuscitative endovascular balloon occlusion of the aorta followed by right common iliac artery stenting was successfully performed to arrest the bleeding. The iatrogenic right common iliac artery laceration was complicated with abdomen compartment syndrome and acute kidney injury. The patient received supportive care, including continuous venovenous hemofiltration (CVVH) for a week, after which the patient’s condition improved. The patient did not have any residual complications at the one-month follow-up. Great vessel injury during the TLIF procedure is rare but fatal. Refractory hypotension is indicative of a great vessel injury. Endovascular intervention is a fast and promising method to diagnose and treat arterial injury.

Vascular injury after lumbar discectomy mimicking appendicitis: Report of a case

Right lower quadrant pain after a lumbar discectomy is a rare condition. We report on a 29-year-old man who developed right lower quadrant pain 12 h after lumbar discectomy due to the formation and rupture of a right iliac artery pseudoaneurysm. The diagnostic laparoscopy was done under the impression of acute appendicitis but showed a retroperitoneal hematoma. An emergency abdominal computed tomography confirmed a right iliac artery pseudoaneurysm rupture. We performed a transarterial embolization with multiple metallic coils in the aneurysm cavity and connected the proximal and distal right internal iliac artery because his hemodynamics became progressively unstable. In this article, in addition to presenting the clinical course of an unusual case, we also wanted to emphasize that patients with right lower quadrant pain could be presenting an early sign of pseudoaneurysm formation and rupture after a lumbar discectomy.

A misdiagnosed iliac pseudoaneurysm complicated lumbar disc surgery performed 13 years ago

STUDY DESIGN

Case report.

OBJECTIVE

To describe a unique case of iliac pseudoaneurysm-complicated lumbar disc surgery performed 13 years ago.

SUMMARY OF BACKGROUND DATA

Major vascular injury is an unusual but life-threatening complication of lumbar disc surgery. If a major vascular injury is unnoticed, the late complications, pseudoaneurysm, may be diagnosed years after primary lumbar disc surgery. Pseudoaneurysm can lead to compression of adjacent neurovascular structures; however, erosion into the adjacent vertebras and presentation with symptoms of nerve root irritation are rare.

METHODS

The patient was a 54-year-old man who presented with pain and numbness in right hip and leg. Examination was normal. A plain radiograph showed destruction of the fourth and fifth lumbar vertebras. Magnetic resonance image showed a retroperitoneal mass eroding into the adjacent vertebras. The mass was primarily misdiagnosed as a neoplasm and a percutaneous needle biopsy was recommended. Before puncture, the computed tomographic angiogram confirmed it to be a pseudoaneurysm of left common iliac artery. Then, implantation of a covered stent was undergone.

RESULTS

After implantation of a covered stent, the symptoms were relieved immediately. At the 12-month follow-up, the patient remained asymptomatic, and a computed tomographic angiogram revealed progressive shrinkage of the mass and significant healing of the eroded vertebras.

CONCLUSION

As an unusual complication of lumbar disc surgery, iliac pseudoaneurysm can present with radiating pain even after 13 years and erode into the adjacent vertebras producing appearances mimicking a tumor. For mass located anterior to vertebras, the percutaneous biopsy must be cautiously performed, and a contrast-enhanced computed tomographic scan is necessary.

Endovascular repair of aorto-iliac artery injuries after lumbar-spine surgery

OBJECTIVE

This study aims to describe the endovascular management of abdominal-aortic- or common-iliac-artery injuries after lumbar-spine surgery.

METHODS

Patients treated for abdominal-aortic- or common-iliac-artery injuries after lumbar-spine surgery during a 13-year period were identified from an endovascular database, providing prospective information on techniques and outcome. The corresponding patient records and radiographic reports were analysed retrospectively.

RESULTS

Seven patients were treated with acute (n = 3) or subacute (n = 4) injuries of the common iliac artery (n = 6) or abdominal aorta (n = 1) after lumbar-spine surgery. Vascular injuries included arterial lacerations (n = 3), arteriovenous fistulas (n = 2) and pseudo-aneurysms (n = 2). The mean age of the patients was 51.7 years (30-60 years), 71.4% were women. These lesions were repaired by transluminal placement of stent grafts: Passager (n = 3), Viabahn (n = 1), Wallgraft (n = 1), Zénith (n = 1) and Advanta V12 (n = 1). Exclusion of the injury was achieved in all cases. Mortality was nil. There were no procedure-related complications. During a median follow-up of 8.7 years (range 0.3-13 years), all stent grafts remained patent.

CONCLUSIONS

Sealing of common iliac artery or abdominal aortic lesions as a complication of lumbar-disc surgery with a stent graft is effective and is suggested as an excellent alternative to open surgery for iatrogenic great-vessel injuries, particularly in critical conditions.

Use of a percutaneous septal occlusion device to exclude a juxta-renal pseudoaneurysm of the abdominal aorta

Abdominal aortic pseudoaneurysm is an uncommon, but challenging condition. The most common etiologies are either trauma or iatrogenic repair via open surgery, endovascular aortic cuff, and exclusion via placement of coils has been described. We describe a case of a juxta-renal aortic pseudoaneurysm following aorto-bi-iliac bypass grafting that was successfully excluded by endovascular placement of a percutaneous septal occlusion device.

High output heart failure due to an iatrogenic arterio-venous fistula after lumbar disc surgery

Vascular injury is a rare but not uncommon complication of spinal surgery and associated with dramatic consequences. Congestive heart failure secondary to a hyperkinetic circulation can occur in systemic diseases and in arterio-venous fistulae. A 57-year-old man was admitted to hospital complaining of dyspnoea and oedema of the left leg. Eight days previously he had undergone a discectomy at L4-L5. On auscultation a systolic-diastolic murmur was noted over the entire abdomen. An echocardiogram demonstrated an enlarged right atrium, severe mitral and tricuspid regurgitation and increased pulmonary artery pressure. An abdominal CT demonstrated irregular dilatation of the left common iliac vein and through a fistula and simultaneous opacification of the right common iliac artery; subsequently, this was also confirmed by angiography. The patient underwent an emergency endovascular stent-graft of the right common iliac artery with normalization of the venous return pressure and quick resolution of the heart failure. It is important for the physician involved in clinical work to keep in mind all the possible post-surgical complications that can occur in symptomatic patients who have recently undergone an intervention.

Les complications vasculaires de la chirurgie discale lombaire

Vascular complications of lumbar disc surgery are rare (about 0,04% of discectomies) but very severe. Great variations of the anatomical lesions and of their clinical aspects may be observed. These lesions are often unrecognised during the operation and they are sometimes identified several years after the injury. The treatment is mainly surgical but percutaneous endovascular treatment has been recently performed successfully in several patients.

Translumbar thrombin embolization of an aortic pseudoaneurysm complicating lumbar disk surgery

We report a case of translumbar embolization of an aortic pseudoaneurysm complicating lumbar disk surgery. The iatrogenic pseudoaneurysm was initially treated by open repair, but due to failure of this treatment, we opted for direct translumbar thrombin injection under computed tomography (CT) guidance. The patient recovered completely, and follow-up CT scans showed progressive shrinkage of the residual retroperitoneal hematoma. This minimally invasive treatment should be considered in selected cases as a valuable treatment option for pseudoaneurysms that arise from the aorta.

Complicaciones intra-abdominales de la cirugía de la hernia discal lumbar

INTRODUCTION

: Removal of a lumbar disc herniation is, at present, the most frequent surgical procedure, related to the spine in Neurosurgical Departments. It carries a very low rates of complications and a short postoperative hospital stay. However, in spite of their rarity, serious adverse intraoperative complications may occur, so we must be aware of its existence in order to make an early diagnosis and treatment to prevent a fatal outcome. It is important to ensure that the patient understand the possible complications and obtaining written consent to avoid later medico-legal problems.

CLINICAL CASES

We report two cases with typical lumbociatic pain secondary to lumbar disc herniation operated at our Department, that resulted in intraoperative complications, due to perforation of intraabdominal structures. Initially, the patients underwent planned flavectomy, followed by simple disc removal. However, symptoms of abdominal pain and systemic hypotension in each case, began some hours later. Early diagnosis was achieved using abdominal-pelvic CT scan, showing an intestinal perforation in one patient and a tear of both iliac artery and vein in the other. In both, an urgent laparotomy was performed by colleagues from the Department of General and Vascular Surgery, with surgical repair. The final outcome was good and both are asymptomatic.

CONCLUSION

Surgical removal of the lumbar disc herniation is a very effective procedure, but is not free from certain severe though rare complications. Intestinal perforation and vascular tears are two possible complications to suspect if abdominal pain or systemic arterial to suspect if abdominal pain or systemic arterial urgent surgical repair of such complications. It is of vital importance that the patient knows the existence of such complications and so obtain a written consent.

Percutaneous stent-graft treatment of superior mesenteric and internal iliac artery pseudoaneurysms

Traumatic pseudoaneurysms can cause compression of adjacent structures and hemorrhage. The mortality rate for bleeding visceral artery pseudoaneurysms is particularly high, and surgical repair is all but impossible in some cases. The authors describe two cases in which traumatic pseudoaneurysms of the internal iliac and superior mesenteric arteries were successfully treated with a low-profile stent-graft (Jostent) designed for coronary use. The technical and regulatory issues pertinent to this device are discussed.

Vascular injury complicating lumbar disc surgery. A systematic review

OBJECTIVES

to review the literature concerning the early and late vascular complications of lumbar disc surgery.

METHODS

using the MEDLINE database, we reviewed all reports of vascular complications associated with surgical excision of a prolapsed disc via a posterior approach reported in the English literature since 1965.

RESULTS

we identified 98 cases of vascular complications for an incidence of 1-5 in 10000 disc operations. Early presentation is shock due to rupture of a large retroperitoneal vessel. Late complications include development of pseudoaneurysms and arteriovenous fistulas. Treatment of a vascular tear consisted mainly of primary suturing of the injured vessel. The preferred method for arteriovenous fistula and pseudoaneurysm repair was suturing from within the arterial lumen along with interposition grafting. Recently, endovascular techniques have been recommended, lowering the high morbidity and mortality related to conventional repair.

CONCLUSION

iatrogenic vascular injury during lumbar disc surgery, although rare, should be suspected if signs of circulatory instability are noted or if lumbar pain, leg oedema or high output cardiac failure develop months to years following such surgical procedures. However, these symptoms may arise during or immediately after surgery, requiring immediate intervention.