Endovascular solutions to arterial injury due to posterior spine surgery

Abstract

Iatrogenic arterial injury is an uncommon but recognized complication of posterior spinal surgery. The spectrum of injuries includes vessel perforation leading to hemorrhage, delayed pseudoaneurysm formation, and threatened perforation by screw impingement on arterial vessels. Repair of these injuries traditionally involved open direct vessel repair or graft placement, which can be associated with significant morbidity. We identified five patients with iatrogenic arterial injury during or after posterior spinal surgery between July 2004 and August 2009 and describe their endovascular treatment. Intraoperative arterial bleeding was encountered in two patients during posterior spinal surgery. The posterior wounds were packed, temporarily closed, and the patient was placed supine. In both patients, angiography demonstrated arterial injury necessitating repair. Covered stent grafts were deployed through femoral cutdowns to exclude the areas of injury. In three additional patients, postoperative computed tomography imaging demonstrated pedicle screws abutting/penetrating the thoracic or abdominal aorta. Angiography or intravascular ultrasound imaging, or both, confirmed indention/perforation of the aorta by the screw. Aortic stent graft cuffs were deployed through femoral cutdowns to cover the area of aortic contact before hardware removal. All five patients did well and were discharged home in good condition. Endovascular repair of arterial injuries occurring during posterior spinal procedures is feasible and can offer a safe and less invasive alternative to open repair.

Combined Thoracic Endovascular Aortic Repair and Neurosurgical Intervention for Injury Due to Posterior Spine Surgery

“…Close coordination with the neurosurgical team allowed endografting repair with a prosthesis deployed immediately after screw retraction. In agreement with Jim and Loh, we performed no balloon remodeling with the consideration that graft oversize warranted a good sealing to the aortic wall …”

“…This is probably due to the usually normal anatomical features of the injured aorta above and below the perforation, unlike degenerative aneurysmatic disease . However, open surgery with primary aortic repair or patch repair remains the treatment for particular occasions that preclude endografting, such as injury of the posterior wall of the aorta at the level of the origin of the superior mesenteric artery or the celiac trunk …”

“…Loh et al in 2011 reported their experience and mentioned that an AneuRx cuff (Medtronic) was chosen because of the nitinol exoskeleton covering the graft fabric. They concluded that “this might help to prevent perforation of the graft fabric by the screw tip before screw removal.” They also underlined the need of minimal oversizing since the endograft will be deployed in a healthy aorta without aneurismal degeneration, as postulated by Jim who proposes the need for endograft ballooning only in cases of identified endoleaks . Aggressive dilation can, in fact, be dangerous in iatrogenic or traumatic aortic injuries.…”

Anatomical Location of the Common Iliac Veins at the Level of the Sacrum: Relationship between Perforation Risk and the Trajectory Angle of the Screw

“…Such complications occur during posterior instrumentation of the spine in <1 of every 2000 operations [18, 19]. Injury to the aorta and iliac vessels can carry a mortality rate as high as 61% [19, 20]. …”

Delayed Presentation of Aortic Injury by a Thoracic Pedicle Screw

“…The incidence of late presentation is much lower. So far, 38 cases of delayed (≥30 days) presentation of aortic injury by pedicle screws have been reported in the English literature . Table summarizes the presentations and clinical characteristics of these patients.…”