Endovascular Treatment of Late Aortic Erosive Lesion by Pedicle Screw without Screw Removal: Case Report and Literature Review

Staged complex reconstruction of infected thoracic aortic endograft and adjacent spinal hardware using latissimus wrapped lateral aortic graft

Thoracic endovascular aortic repair (TEVAR) enables rapid and effective treatment of life-threatening aortic injuries. The occurrence of long-term complications from TEVAR and their management is ill-defined in young patients. This report describes a complex case of a 38-year-old male patient who underwent staged interventions for different acute pathologies instigated by blunt thoracic spinal trauma. The patient was initially treated with a TEVAR for aortic pseudoaneurysm in the setting of infected spinal hardware, which later resulted in an aortobronchial fistula and eroded spinal hardware. This report illustrates a successful multidisciplinary approach for definitive treatment with graft explant and aortic reconstruction.

Rating the incidence of iatrogenic vascular injuries in thoracic and lumbar spine surgery as regards the approach: A PRISMA-based literature review

PURPOSE

To assess the rate, timing of diagnosis, and repairing strategies of vascular injuries in thoracic and lumbar spine surgery as their relationship to the approach.

METHODS

PubMed, Medline, and Embase databases were utilized for a comprehensive literature search based on keywords and mesh terms to find articles reporting iatrogenic vascular injury during thoracic and lumbar spine surgery. English articles published in the last ten years were selected. The search was refined based on best match and relevance.

RESULTS

Fifty-six articles were eligible, for a cumulative volume of 261 lesions. Vascular injuries occurred in 82% of instrumented procedures and in 59% during anterior approaches. The common iliac vein (CIV) was the most involved vessel, injured in 49% of anterior lumbar approaches. Common iliac artery, CIV, and aorta were affected in 40%, 28%, and 28% of posterior approaches, respectively. Segmental arteries were injured in 68% of lateral approaches. Direct vessel laceration occurred in 81% of cases and recognized intraoperatively in 39% of cases.

CONCLUSIONS

Incidence of iatrogenic vascular injuries during thoracic and lumbar spine surgery is low but associated with an overall mortality rate up to 65%, of which less than 1% for anterior approaches and more than 50% for posterior ones. Anterior approaches for instrumented procedures are at risk of direct avulsion of CIV. Posterior instrumented fusions are at risk for injuries of iliac vessels and aorta. Lateral routes are frequently associated with lesions of segmental vessels. Suture repair and endovascular techniques are useful in the management of these severe complications.

Delayed Penetration of the Thoracic Aorta by Pedicle Screws: A Case Report of Screws Left As-Is

STUDY DESIGN

A case report.

OBJECTIVE

Presentation of a patient diagnosed with perforation of the aorta by pedicle screws at levels T6 and T9 2 years after spinal fusion, who was advised no intervention. Review of other reported cases that did not undergo excision of the penetrating screws.

SUMMARY OF BACKGROUND DATA

More than 30 cases of aortic penetration by pedicle screws were described. Gradual penetration of the screws into the aorta rarely causes symptoms other than backache. However, only two cases were treated conservatively.

METHODS

A 65-year-old female patient underwent spinal decompression and T5-T10 posterior fusion following a spinal abscess. Two years and 8 months postoperatively, she underwent a computed tomography scan for suspicion of spinal hardware infection, which showed T6 and T10 screws penetrating the thoracic aorta.

RESULTS

Due to high morbidity, the patient was not offered an operation for screw excision.

CONCLUSION

This case report adds to the only two previous reports of patients who did not undergo revision of pedicle screws penetrating thoracic aorta.

LEVEL OF EVIDENCE

5.

A Study of the Sagittal Angle of Lumbar Bicortical Pedicle Screws from the Anatomic Perspective of the Lumbar Artery

OBJECTIVE

To observe anatomic relationships between lumbar bicortical pedicle screws (BPSs) at 2 sagittal section angles (SSAs) and lumbar artery (LA).

METHODS

We observed 2 SSAs, vertical angle and cephalic angle, of the BPS. The positions at which the BPS breaks through the anterior vertebral cortex were defined as point A and point B. Distances from point A and point B to LAs were measured. The percentage of risk of injury to LAs was calculated according to these distances.

RESULTS

At the same transverse section angle on the left and right side in L1 and L2, distance from point A to LA was significantly greater than distance from point B to LA (P < 0.001) except at a transverse section angle of 0° on the right side in L2 (P > 0.05). At the same transverse section angle on the left in L3 and L4, distance from point B to LA was significantly greater than distance from point A to LA (P < 0.001). The percentages of high risk of injury to the LA resulting from BPSs at the vertical angle in L1 and L2 were 0%-6.2%. The percentages of high risk of injury to the LA resulting from BPSs at the cephalic angle on the left side in L3 and L4 were 0%-18.5%.

CONCLUSIONS

Lumbar BPSs present a risk of injury to the LA. The vertical angle is the recommended SSA for BPSs in L1 and L2, and the cephalic angle is the recommended SSA in L3 and L4.