Case Report
Dissection of left iliac artery during anterior lumbar interspace fusion: Report of a case
Vascular 2015, Vol. 23(2) 176–178 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1708538114534235 vas.sagepub.com
Uwe M Fischer1,2, Mark G Davies1 and Hosam El Sayed1
Abstract Vascular injury is an uncommon complication of spine surgery. Among the different approaches, anterior lumbar interbody fusion has increased potential for vascular injuries, since the great vessels and their branches overly the disc spaces to be operated on, and retraction of these vessels is necessary to gain adequate surgical exposure. The reported incidence for anterior lumbar interbody fusion-associated vascular injuries ranges from 0% to 18.1%, with venous laceration as the most common type. We report a case of anterior lumbar interbody fusion-associated left common iliac artery dissection leading to delayed acute limb ischemia developing in early post-operative period.
Keywords Iliac artery dissection, spine surgery
Case report The patient is a 67-year-old woman with an extensive medical history including vasculitis, polymyositis, fibromyalgia, Hashimoto thyroiditis, hypertension, Sjogren’s syndrome, osteoarthrosis, rheumatoid arthritis, hypertension, celiac disease, and diabetes mellitus. She underwent anterior lumbar interbody fusion (ALIF) via a paramedian retroperitoneal approach at L4–L5 and L5–S1 for lumbar spondylosis with spondylolisthesis. Ten hours post surgery, the patient developed acute onset of left lower extremity pain mainly in the calf and foot associated with decrease in sensation and motor function. A computer tomographic angiogram (CTA) showed complete occlusion of the left external iliac artery (Figure 1(a)) with reconstitution of the left common femoral artery (Figure 1(b)). The patient was taken to the operating room. An abdominal aortogram and bilateral iliac angiogram showed a near complete occlusion of the left common iliac artery with thrombus (Figure 2). We decided to perform an open thrombectomy via a left femoral approach. The 4-Fr Fogarty catheter could not be advanced past 15 cm into the left external iliac artery. A large amount of fresh clot was removed, however, without improvement of arterial inflow. We performed a retrograde arteriogram that showed a patent left external iliac and hypogastric arteries but the left
common iliac artery had a flow occlusive dissection (Figure 3). With a soft Glidewire (Terumo, Somerset, NJ) and a Bern catheter (Boston Scientific Corp., Natick, MA), the occlusion of the proximal iliac artery could be crossed and an angiogram confirmed position of the catheter in the true lumen of the abdominal aorta. Next, we placed and deployed a 10 mm 8 cm nitinol type stent in the common iliac artery with the proximal end just at the origin of the common iliac not protruding into the aorta. A completion arteriogram showed patent abdominal aorta and bilateral common external and internal iliac arteries (Figure 4). The patient tolerated the procedure well. She had complete recovery of her left lower extremity motor and sensory function with palpable pulses and could be discharged home in good condition on post-operative day 4.
1 Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA 2 Michael E. DeBakey Institute for Comparative Cardiovascular Science and Biomedical Devices, Texas A&M University, College Station, TX, USA
Corresponding author: Uwe M Fischer, Houston Methodist Hospital, 6550 Fannin Street, Suite 1401, Houston, TX 77030, USA. Email: [email protected]
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Figure 1. Computer tomographic angiogram of the aorto-iliac system with complete occlusion of the left external iliac artery (a, arrow) and with reconstitution of the left common femoral artery (b, arrow).
Figure 2. Abdominal aortogram and bilateral iliac angiogram showing near complete occlusion of the left common iliac artery with thrombus (arrow).
Figure 3. Retrograde arteriogram with patent left external iliac and hypogastric arteries and the common iliac artery nearly occluded with a large dissection (arrow).
Figure 4. Completion arteriogram with patent abdominal aorta and bilateral common external and internal iliac arteries.
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Vascular 23(2) References
Conclusions Vascular injury during spinal surgery is an uncommon complication.1 An ALIF can result in major vascular injuries mostly caused during retraction of the iliac vessels with venous injuries being more common than arterial injuries.2–4 In our case, retraction resulted in left common iliac artery dissection with acute limb ischemia presenting 10 h after surgery. Awareness of potential vascular injuries despite initial normal vascular examination is important as dissection of the artery can lead to delayed potential limb-threatening complications.
1. Inamasu J and Guiot BH. Vascular injury and complication in neurosurgical spine surgery. Acta Neurochir (Wien) 2006; 148: 375–387. 2. Harmon PH. A simplified surgical technic for anterior lumbar diskectomy and fusion; avoidance of complications; anatomy of the retroperitoneal veins. Clin Orthop Relat Res 1964; 37: 130–144. 3. Watkins R. Anterior lumbar interbody fusion surgical complications. Clin Orthop Relat Res 1992; 284: 47–53. 4. Weiner BK, Walker M and Fraser RD. Vascular anatomy anterior to lumbosacral transitional vertebrae and implications for anterior lumbar interbody fusion. Spine J 2001; 1: 442–444.
Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Downloaded from vas.sagepub.com at University of British Columbia Library on November 18, 2015
Dissection of left iliac artery during anterior lumbar interspace fusion: Report of a case
Vascular 2015, Vol. 23(2) 176–178 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1708538114534235 vas.sagepub.com
Uwe M Fischer1,2, Mark G Davies1 and Hosam El Sayed1
Abstract Vascular injury is an uncommon complication of spine surgery. Among the different approaches, anterior lumbar interbody fusion has increased potential for vascular injuries, since the great vessels and their branches overly the disc spaces to be operated on, and retraction of these vessels is necessary to gain adequate surgical exposure. The reported incidence for anterior lumbar interbody fusion-associated vascular injuries ranges from 0% to 18.1%, with venous laceration as the most common type. We report a case of anterior lumbar interbody fusion-associated left common iliac artery dissection leading to delayed acute limb ischemia developing in early post-operative period.
Keywords Iliac artery dissection, spine surgery
Case report The patient is a 67-year-old woman with an extensive medical history including vasculitis, polymyositis, fibromyalgia, Hashimoto thyroiditis, hypertension, Sjogren’s syndrome, osteoarthrosis, rheumatoid arthritis, hypertension, celiac disease, and diabetes mellitus. She underwent anterior lumbar interbody fusion (ALIF) via a paramedian retroperitoneal approach at L4–L5 and L5–S1 for lumbar spondylosis with spondylolisthesis. Ten hours post surgery, the patient developed acute onset of left lower extremity pain mainly in the calf and foot associated with decrease in sensation and motor function. A computer tomographic angiogram (CTA) showed complete occlusion of the left external iliac artery (Figure 1(a)) with reconstitution of the left common femoral artery (Figure 1(b)). The patient was taken to the operating room. An abdominal aortogram and bilateral iliac angiogram showed a near complete occlusion of the left common iliac artery with thrombus (Figure 2). We decided to perform an open thrombectomy via a left femoral approach. The 4-Fr Fogarty catheter could not be advanced past 15 cm into the left external iliac artery. A large amount of fresh clot was removed, however, without improvement of arterial inflow. We performed a retrograde arteriogram that showed a patent left external iliac and hypogastric arteries but the left
common iliac artery had a flow occlusive dissection (Figure 3). With a soft Glidewire (Terumo, Somerset, NJ) and a Bern catheter (Boston Scientific Corp., Natick, MA), the occlusion of the proximal iliac artery could be crossed and an angiogram confirmed position of the catheter in the true lumen of the abdominal aorta. Next, we placed and deployed a 10 mm 8 cm nitinol type stent in the common iliac artery with the proximal end just at the origin of the common iliac not protruding into the aorta. A completion arteriogram showed patent abdominal aorta and bilateral common external and internal iliac arteries (Figure 4). The patient tolerated the procedure well. She had complete recovery of her left lower extremity motor and sensory function with palpable pulses and could be discharged home in good condition on post-operative day 4.
1 Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, TX, USA 2 Michael E. DeBakey Institute for Comparative Cardiovascular Science and Biomedical Devices, Texas A&M University, College Station, TX, USA
Corresponding author: Uwe M Fischer, Houston Methodist Hospital, 6550 Fannin Street, Suite 1401, Houston, TX 77030, USA. Email: [email protected]
Downloaded from vas.sagepub.com at University of British Columbia Library on November 18, 2015
Fischer et al.
177
Figure 1. Computer tomographic angiogram of the aorto-iliac system with complete occlusion of the left external iliac artery (a, arrow) and with reconstitution of the left common femoral artery (b, arrow).
Figure 2. Abdominal aortogram and bilateral iliac angiogram showing near complete occlusion of the left common iliac artery with thrombus (arrow).
Figure 3. Retrograde arteriogram with patent left external iliac and hypogastric arteries and the common iliac artery nearly occluded with a large dissection (arrow).
Figure 4. Completion arteriogram with patent abdominal aorta and bilateral common external and internal iliac arteries.
Downloaded from vas.sagepub.com at University of British Columbia Library on November 18, 2015
178
Vascular 23(2) References
Conclusions Vascular injury during spinal surgery is an uncommon complication.1 An ALIF can result in major vascular injuries mostly caused during retraction of the iliac vessels with venous injuries being more common than arterial injuries.2–4 In our case, retraction resulted in left common iliac artery dissection with acute limb ischemia presenting 10 h after surgery. Awareness of potential vascular injuries despite initial normal vascular examination is important as dissection of the artery can lead to delayed potential limb-threatening complications.
1. Inamasu J and Guiot BH. Vascular injury and complication in neurosurgical spine surgery. Acta Neurochir (Wien) 2006; 148: 375–387. 2. Harmon PH. A simplified surgical technic for anterior lumbar diskectomy and fusion; avoidance of complications; anatomy of the retroperitoneal veins. Clin Orthop Relat Res 1964; 37: 130–144. 3. Watkins R. Anterior lumbar interbody fusion surgical complications. Clin Orthop Relat Res 1992; 284: 47–53. 4. Weiner BK, Walker M and Fraser RD. Vascular anatomy anterior to lumbosacral transitional vertebrae and implications for anterior lumbar interbody fusion. Spine J 2001; 1: 442–444.
Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Downloaded from vas.sagepub.com at University of British Columbia Library on November 18, 2015
