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

Hybrid surgery for the treatment of lumbar spine surgery complicated with iliac artery pseudoaneurysm, arteriovenous fistula, and lower limb artery embolism: A rare case report

INTRODUCTION AND IMPORTANCE

Vascular injuries during lumbar surgery are rare, but complications such as false aneurysm of the iliac artery, arteriovenous fistula, and lower limb artery embolism are even rarer. These complications can easily be misdiagnosed and result in the inability to choose an appropriate surgical approach, leading to serious consequences.

CASE PRESENTATION

A 36-year-old male patient experienced swelling in both lower limbs, along with numbness, coldness, and dysfunction in his right lower limb, after undergoing a "posterior lumbar discectomy" surgery. On the 20th day post-surgery, a clear diagnosis was established through CTV: 1) Right common iliac artery injury with pseudoaneurysm formation; 2) Right iliac arteriovenous fistula; 3) Right popliteal artery embolism. The patient underwent hybrid surgery to address multiple complications simultaneously and made a good recovery after the procedure.

CLINICAL DISCUSSION

Rarely, lumbar spine surgery can concurrently lead to conditions such as pseudoaneurysm, arteriovenous fistula, and lower limb artery embolism. Due to atypical symptoms and signs, it is often misdiagnosed. Hybrid surgery involves incising the femoral artery, using a thrombectomy catheter to remove clots from the iliac artery above and the popliteal artery below, and then re-implanting a covered stent to treat pseudoaneurysm and arteriovenous fistula.

CONCLUSION

With a solid clinical knowledge, one can make a timely diagnosis and choose an appropriate surgical method to intervene, thereby improving the prognosis. Hybrid surgery combines the minimally invasive and safe effects of endovascular techniques with the precise effects of open surgery, and it also allows for the simultaneous treatment of multiple comorbidities.

Iatrogenic arteriovenous fistula after lumbar discectomy surgery: a case report

Iatrogenic arteriovenous fistula (IAVF) is an unusual and potentially fatal complication of lumbar spinal surgery. A 62-year-old patient presented with a history of dyspnea, left lower limb edema and coughing. A physical exam showed bilateral basal rales in the lungs, abdominal bruit and bilateral lower limb pitting edema. A computed tomography angiograph revealed an arteriovenous communication between the right internal iliac artery and the left common iliac vein. The patient was diagnosed with an IAVF, which developed post-lumbar disc surgery. The patient underwent a successful endovascular treatment by using covered stent at the common iliac artery with embolism of lumbar artery. The patient's symptoms were relieved 2 months after surgery.

Morphometric analysis of the lumbar vertebrae and intervertebral discs in relation to abdominal aorta: CT-based study

Purpose

Although lumbar discectomy is the most common procedure in spine surgery, reports about anatomical relations between discs and prevertebral vessels are limited. Aim of this research was to investigate morphometric of the lumbar region and the relations between intervertebral discs (IVDs) and abdominal aorta.

Methods

557 abdominal computed tomography scans were assessed. For each spinal column level from Th12/L1 down to L4/L5, we investigated: intervertebral disc’s and vertebra’s height, width, length, and distance from aorta or common iliac artery (CIA). Those arteries were also measured in two dimensions and classified based on location.

Results

54.58% of patients were male. There was a significant difference in arterial-disc distances (ADDs) between genders at the levels: L1/L2 (1.32 ± 1.97 vs. 0.96 ± 1.78 mm; p = 0.0194), L2/L3 (1.97 ± 2.16 vs. 1.15 ± 2.01 mm; p < 0.0001), L3/L4 (2.54 ± 2.78 vs. 1.71 ± 2.61 mm; p = 0.0012), also for both CIAs (left CIA 3.64 ± 3.63 vs. 2.6 ± 3.06 mm; p = 0.0004 and right CIA: 7.96 ± 5.06 vs. 5.8 ± 4.57 mm; p < 0.001)—those ADDs were higher in men at all levels. The length and width of IVD increased alongside with disc level with the maximum at L4/L5.

Conclusion

Bifurcations of the aorta in most cases occurred at the L4 level. Collected data suggest that at the highest lumbar levels, there is a greater possibility to cause injury of the aorta due to its close anatomical relationship with discs. Females have limited, in comparison to males, ADD at L1/L2, L2/L3, and L3/L4 levels what should be taken into consideration during preoperative planning of surgical intervention.

Abdominal Vascular Injury During Posterior Lumbar Discectomy, Experience from Three Cases and Review of Literature

STUDY DESIGN

Case series and review of literature.

OBJECTIVE

To report three cases of vascular injury during posterior lumbar disc surgery, two of these occurred during open discectomy, and one during an endoscopic surgery. Aim is to highlight importance of early diagnosis and prompt steps taken to prevent morbidity and mortality.

SUMMARY OF BACKGROUND DATA

Vascular injury during lumbar discectomy is rare injury. Also no case has been reported so far occurring during an endoscopic discectomy.

METHODS

Three patients were treated for lumbar intervertebral disc prolapse, two had undergone open posterior discectomy while the third patient underwent endoscopic discectomy and all of them were diagnosed to have suffered an abdominal vascular injury.

RESULTS

In two cases pseudo-aneurysm was found while third case was diagnosed as an arterio-venous fistula. All the three cases were managed with endovascular stenting and followed for a minimum period of 2 years. No further complications were detected.

CONCLUSION

Vascular injury during a disc surgery is difficult to diagnose due to the rarity of occurrence and subtle signs which need to be recognized to start early management.

LEVEL OF EVIDENCE

5.

The summary of experience of abdominal vascular injury related to posterior lumbar surgery

PURPOSE

To study the clinical and pathophysiologic characteristics and summarize the experience of treatment of abdominal vascular injury related to lumbar surgery.

METHODS

We analyzed patients who suffered abdominal vascular injury during lumbar surgery in our hospital retrospectively and reviewed related literature in the PUBMED database from 2002 to 2017. Combined with the existing treatment options and outcomes, we investigated further and summarized our findings.

RESULTS

With the data from our hospital, four cases of injuries were included, i.e., left common iliac artery and vein (CIA and CIV), left internal iliac artery, and inferior vena cava. Almost all of the patients (one exception) manifesting unstable haemodynamics were primarily treated by traditional vessel suture. After treatment, two patients died eventually, while the others recovered well at follow-up. With the reported data, 77 patients with the most frequently type of laceration (58.4%) were included. For vascular laceration, unstable haemodynamics was diagnosed in most of the patients (88.9%); CIA and CIV accounted for the all the most common patients (78.7%). Extracted from these data, traditional surgical method was selected to repair laceration prevalently (86.7%), while arteriovenous fistula and pseudoaneurysm were treated with an interventional procedure. Negative outcomes included two deaths, two suffered lower limb deep vein thrombosis, and two suffered graft infection.

CONCLUSIONS

Different treatment choices should be conducted depending on different injury characteristics and patients' condition. Moreover, early recognition and prompt treatment are critical components to successful rescue. When a vascular injury is suspected, ultrasonography and positive abdominal exploration are recommended together with unified leadership in the rescue team.

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.

Intravertebral pseudomeningocele: an unusual complication after disc surgery

BACKGROUND CONTEXT

Pseudomeningoceles are most commonly the result of dural tear during spine surgery. They may sometimes slowly enlarge but they generally develop inside the spinal canal, toward the foramina or toward the surgical incision.

PURPOSE

To describe a late and exceptional complication of a surgical discectomy.

STUDY DESIGN

A case report.

METHODS

We report a unique case of a large asymptomatic pseudomeningocele strictly developed in the L5 vertebra, discovered incidentally in a 38-year-old woman. Computed tomography and magnetic resonance imaging showed a large cystic lesion involving the vertebral body and the left pedicle of L5 without contrast enhancement. There was neither extension of the cyst toward the vertebral lamina nor toward the spinal canal. Consent to publish the data was obtained from our patient.

RESULTS

Diagnosis was performed during transpedicular image-guided puncture, when opacification of the cyst revealed dural communication. Biochemical analysis and cytology confirmed the presence of cerebrospinal fluid and absence of tumoral cells.

CONCLUSIONS

Dural tear was considered as a neglected complication after surgical discectomy at the same level performed 18 years ago. Differential diagnoses of cystic spinal lesions are discussed.