Annals of Vascular Surgery
Volume 25, Issue 1 , Pages 132.e1-132.e6, January 2011

Endovascular Repair of an Intraoperative Thoracic Aortic Injury During All-Posterior Vertebral Column Resection Surgery

Presented at the 20th Annual Winter Meeting of the Peripheral Vascular Surgery Society, Vail, CO, January 29-31, 2010.

  • Jeffrey Jim
    • ,
  • Luis A. Sanchez
    • ,
  • Patrick J. Geraghty

      Affiliations

    • Corresponding Author InformationCorrespondence to: Patrick J. Geraghty, MD, Associate Professor of Surgery & Radiology, Washington University School of Medicine, Campus Box 8109, 660 South Euclid Ave, St. Louis, MO, 63110, USA

Section of Vascular Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO

published online 27 August 2010.

Article Outline

Iatrogenic aortic injuries that occur during spinal procedures are rare but potentially lethal. When the posterior spinal approach is used, prone positioning and the need to prevent contamination of exposed bone and hardware adds complexity to the management of significant aortic injuries. We present a case of an intraoperative aortic injury that occurred during reoperative all-posterior vertebral column resection surgery that was successfully treated with emergent endograft deployment. The patient recovered without significant clinical sequelae. To our knowledge, this is the first reported case of intraoperative endovascular repair of a thoracic aortic injury incurred during posterior approach spinal surgery.

 

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Introduction 

Iatrogenic vascular injuries are recognized complications of spine surgery. There is a significant variation in the reported rate of injury depending on the type of surgical approach, the extent of spinal intervention, and the definition of vascular injury. Injuries to the aorta are rare but can result in lethal hemorrhage. Open repair is associated with significant morbidity and mortality. We present a case of intraoperative endovascular repair of a thoracic aortic injury incurred during posterior approach spinal surgery.

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Case Reports 

A 53 year old man with adult Scheuermann's kyphosis presented with recurrent pain. He had undergone multiple prior anterior and posterior approach reconstructions. One year before the current hospitalization, he developed an infection that necessitated complete removal of all previously placed hardware. Preoperative imaging demonstrated 130° of kyphosis (Fig. 1). Because of recurrence of symptoms, redo all-posterior approach fusion from C7 to L3 levels was recommended, with concomitant vertebral column resection (VCR) to facilitate kyphotic correction. After induction of general anesthesia, a four-pin halo was placed for traction and the patient was positioned prone on an OSI “Jackson” operative frame (Orthopedic Systems Inc., Union City, CA). He then underwent exposure from the cervical spine to the distal lumbar spine (Fig. 2). Extensive reconstruction was undertaken with facet resections, osteotomies, and laminectomies performed at multiple levels. Segmental pedicle screws and temporary stabilizing rods were placed. Approximately 6 cm of bilateral eighth rib was dissected out for planned resection of the T8 vertebral body. During dissection of the left side of the T8 vertebral body, torrential bleeding was encountered and temporarily controlled by digital occlusion, albeit with difficulty (Fig. 3).

Because of the patient's positioning, kyphotic habitus, and prior thoracotomy, an endovascular approach to repair the suspected aortic injury was believed to be the only safe option. While maintaining digital occlusion, the spine exposure was packed with antibiotic-soaked sponges and sealed with an iodine-impregnated adhesive dressing. The patient was then moved to a radiolucent table (Skytron, Grand Rapids, MI) and placed in the right lateral decubitus position. The left femoral artery was surgically exposed and contrast angiography confirmed the aortic injury at the T8 level (Fig. 4). A 30 × 77 mm TX2 endograft (Cook Medical, Bloomington, IN) was deployed without difficulty and molded with a balloon. The bleeding immediately stopped and the patient stabilized hemodynamically. Postdeployment angiography demonstrated exclusion of the aortic injury, with no evidence of extravasation (Fig. 5). After closure of the groin wound, he was then returned to the prone position for completion of his spinal procedure. The total estimated blood loss for the procedure was 7 L.

The patient's postoperative course included operative drainage of a significant left-sided hemothorax through a limited thoracotomy on postoperative day 1. He displayed transient paraparesis which fully resolved within several weeks. He returned to the operating room for formal spine fusion from C7 to L3 (without vertebral body resection) two weeks later. The remainder of his postoperative course was unremarkable. A follow-up contrast computed tomography scan was obtained at one month after the endovascular repair displaying resolution of the injury (Fig. 6).

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Discussion 

Iatrogenic vascular injuries are the most common intraoperative complications during spine surgery. Injuries occur because of the proximity of the vasculature to the vertebral bodies, and result from retraction or dissection. Iatrogenic injuries of the lower abdominal aorta and iliac vessels were first reported by Linton and White in 1945.1 Since then, numerous series have reported the incidence of vascular injury during spinal procedures. Although a rate as high as 15% has been reported, more recent literature suggests a much lower incidence of <5%.2, 3, 4, 5 Arterial injuries occur much less frequently (<1%) than venous injury and generally present as laceration or thrombosis.3, 5 Injuries to the aorta are exceedingly rare but can result in significant morbidity and can be potentially life-threatening. Intraoperative aortic injury may manifest with bleeding, rapid hematoma formation, or hemodynamic instability. Aortic injury can also present in a delayed manner (with rupture or pseudoaneurysm formation) secondary to erosion into the aorta by implanted hardware.6, 7 Aortic injuries have traditionally been addressed with open surgical repair by oversewing the injury or aortic replacement.

The use of endovascular techniques to treat vascular injury complicating spine surgery was first reported in 2000.8 Lee et al. presented four patients who underwent endovascular treatment of vascular injuries complicating lumbar surgery. Two patients with massive hemorrhage from lumbar artery lacerations were successfully embolized with microcoils. Two other patients with large iliac arteriovenous fistulae were either treated with embolization or placement of a stent graft. Since that time, additional reports have been published which describe the use of stent grafts to exclude acute iliac artery injuries from spinal surgery.9, 10, 11 However, all these cases involved hemodynamically stable patients who had their vascular injuries treated after completion of the spinal procedure. In contrast, Schneider et al. reported a case of immediate intraoperative repair of an acute iliac venous injury with stent-graft deployment.12 The patient was undergoing L4- to L5-level discectomy and spinal fusion from a left retroperitoneal approach when significant bleeding was encountered. As a major venous injury was suspected, the wound was packed and the patient rolled into a supine position. A venogram performed through percutaneous left transfemoral approach revealed a laceration of the left common iliac vein. This was successfully treated with placement of a stent graft. With exclusion of the bleeding site, the patient was returned to the right lateral decubitus position for completion of the spine operation.

The use of stent-grafts to treat thoracic aortic lesions was first described in 1994.13 Endovascular aortic repair is now widely accepted as a viable alternative to open thoracic aortic surgery.14, 15, 16 Elective endovascular thoracic repair is associated with lower rates of postoperative complications and allows treatment of patients at prohibitive risk for open surgery. Although there is widespread use of endografts to treat various thoracic aortic disease processes, there is only one report of the use of a thoracic stent graft to treat an aortic injury complicating spinal surgery.17 Minor et al. reported a case of a misplaced pedicle screw at T5 which had penetrated the aortic wall. This injury was discovered on routine postoperative imaging and the patient was taken for elective endovascular repair. A single thoracic endograft was deployed simultaneously with surgical removal of the screw. The patient recovered without sequelae. We now present the first case of intraoperative endovascular repair of a thoracic aortic injury incurred during spinal surgery.

Our patient had a history of multiple anterior and posterior spinal reconstruction surgeries secondary to severe adult Scheuermann's kyphosis. He was recommended to undergo reoperative all-posterior VCR for more dramatic clinical correction of his spine deformity. The all-posterior approach, first described in 2002, mitigates some of the difficulties encountered during the traditional circumferential approach with anterior releases through discectomies followed by posterior instrumentation and fusion.18, 19, 20 However, the procedure is technically challenging and requires circumferential access to the vertebra(e) to be resected. This involves extensive dissection in much closer proximity to the anterior vasculature (i.e., aorta) than in traditional posterior approach surgery. In this procedure, it was during the difficult dissection of the scar tissue adjacent to the T8 vertebral body that torrential bleeding was encountered.

The surgical options for this patient were limited as traditional open aortic repair was not feasible. The severity of his kyphosis had brought his ribs in fairly close apposition and open left thoracotomy would have required the “shingling” of multiple ribs to provide any degree of aortic exposure. Furthermore, the substantial scarring from his prior anterior spine approach surgery would have made dissection extremely difficult and time consuming. This concern was confirmed during the patient's postoperative period when he required a technically difficult open drainage of a left-sided hemothorax after intrathoracic adhesions negated the use of tube thoracostomy. Furthermore, the patient was hemodynamically unstable and digital occlusion was difficult to sustain. A significant technical challenge of this procedure involved repositioning of the patient while almost his entire spine was surgically exposed. With close coordination between multiple groups (anesthesiologists, spine surgeon, vascular surgeon, nursing staff), the patient was transferred to a different operating table and repositioned from prone to right lateral decubitus position, while avoiding contamination of the spine exposure. Although open aortic repair would have been the treatment of choice in the past, this was not possible and endovascular techniques allowed us to successfully treat this patient.

After we obtained wire access into the proximal aorta and confirmed the injury on angiography, we opted to proceed immediately with endograft delivery. Balloon occlusion for control of the massive hemorrhage from the thoracic aorta would have been difficult and the additional time required for this step would have only delayed his treatment. The endograft was chosen on the basis of the patient's available preoperative imaging. After deployment, we did perform gentle balloon molding to conform the device against the aortic wall. However, routine balloon angioplasty of the endograft is probably not necessary and should only be performed to conform the endograft as needed or to correct any identified endoleaks. In fact, aggressive dilation can be dangerous in iatrogenic or traumatic aortic injuries. Overall, the patient tolerated the injury extremely well but was left with lower extremity paraparesis in the immediate postoperative period. A spinal drain was inserted after the operation and the patient was placed on a strict spinal perfusion protocol with maintenance of adequate blood pressures. However, this did not significant alter his symptomatology, and his neurologic deficit simply resolved slowly with time. The cause of his transient neurologic deficit is probably related to the periods of hypotension sustained intraoperatively.

In summary, we present a rare case of thoracic aortic injury during all-posterior VCR surgery. The patient was successfully treated with emergent placement of a thoracic endograft and recovered without any significant clinical sequelae. Our experience suggests that even in the hemodynamically unstable patient, endovascular repair may be a safe and preferred option for spinal surgery complicated by intraoperative aortic injury. We therefore recommend that institutions performing all-posterior VCR maintain the ability to undertake endovascular treatment of these rare but potentially lethal occurrences.

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References 

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PII: S0890-5096(10)00219-0

doi:10.1016/j.avsg.2010.04.002

Annals of Vascular Surgery
Volume 25, Issue 1 , Pages 132.e1-132.e6, January 2011

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