Management of Proximal Iliac Artery Injury during Lumbar Discectomy with Stent Graft

Abstract

Iatrogenic vascular injuries during lumbar disc surgery may occur rarely but they are serious complications, which can be fatal without appropriate management. Prompt diagnosis and management of these complications are imperative to prevent a desperate outcome. A 72-year-old female with proximal left common iliac artery iatrogenic injury during lumbar discectomy was successfully treated by percutaneous deployment of a stent graft in an emergency setting. Postprocedural angiogram demonstrated complete exclusion of the iliac artery laceration. The patient became hemodynamically stable. Two weeks later she complained of vascular claudication. Follow-up angiography revealed decreased arterial flow in the opposite common iliac artery. An additional kissing stent was inserted into the right common iliac artery and the symptoms of vascular claudication disappeared. Endovascular stenting offers a safe and effective method for the treatment of an iatrogenic arterial laceration, particularly in a critical condition. But, the contralateral iliac arterial flow should be kept intact in case of proximal iliac artery injury. Otherwise, additional treatments may be needed.

Endovascular Management of Great Vessel Injury Following Lumbar Microdiscectomy

“…The common iliac artery and common iliac vein are located anterior to the L4-L5 lumbar and L1 sacral vertebral bodies, which is where great vessel injury most frequently occurs 1 , 4) . Great vessel injury is the most frequent injury that occurs when operating on the L4-5 lumbar segments 6 , 9) .…”

“…When the vessel injury is recognized intraoperatively and signs of life-threatening hypovolemic shock are observed, vigorous volume replacement and urgent repair of vascular laceration should be considered. In arterial injuries with critical bleeding, the mortality rate increases to 100% when surgery is not immediately performed 4 , 6 , 8) . Although the injury is not confirmed during surgery and the vital signs are stable, insignificant symptoms such as abdominal distension, pain, palpitation, unexplainable anemia, and blurring of the psoas muscle on radiographs are possible predictors of vessel laceration.…”

“…Great vessel injury can result in massive retroperitoneal hemorrhage or present as a delayed pseudoaneurysm or arteriovenous fistula (AVF) 2 , 3 , 6 , 8 , 9 , 11) . Despite a very low incidence (0.016-0.17%), the reported mortality rate ranges from 15% to 100%, and this complication may elicit serious medicolegal problems 2 , 4 , 5 , 7 , 9 , 10 , 12) . In cases of great vessel injury, early detection and management is critical to ensure patient survival 1 , 4 , 7) .…”

“…Despite a very low incidence (0.016-0.17%), the reported mortality rate ranges from 15% to 100%, and this complication may elicit serious medicolegal problems 2 , 4 , 5 , 7 , 9 , 10 , 12) . In cases of great vessel injury, early detection and management is critical to ensure patient survival 1 , 4 , 7) . Major vascular surgery is often required to prevent fatality; however, procedure-related morbidity and mortality must also be considered 4 , 5 , 10) .…”

“…In cases of great vessel injury, early detection and management is critical to ensure patient survival 1 , 4 , 7) . Major vascular surgery is often required to prevent fatality; however, procedure-related morbidity and mortality must also be considered 4 , 5 , 10) .…”