Journal of Vascular Surgery
Volume 44, Issue 6 , Pages 1353-1356, December 2006

Successful endovascular management of an acute iliac venous injury during lumbar discectomy and anterior spinal fusion

  • Joseph R. Schneider, MD, PhD

      Affiliations

    • Endovascular Center, Evanston Northwestern Healthcare, Evanston, Ill
    • Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
    • Corresponding Author InformationCorrespondence: Joseph R. Schneider, MD, PhD, Division of Vascular Surgery, Northwestern University Medical School, Burch 100, Evanston Hospital, 2650 Ridge Ave, Evanston, IL 60201.
    • ,
  • Marc J. Alonzo, MD

      Affiliations

    • Endovascular Center, Evanston Northwestern Healthcare, Evanston, Ill
    • Division of Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill.
    • ,
  • David Hahn, MD

      Affiliations

    • Endovascular Center, Evanston Northwestern Healthcare, Evanston, Ill
    • Division of Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, Ill.

Received 25 April 2006; accepted 6 July 2006.

Article Outline

A 61-year-old woman experienced laceration of the left common iliac vein with significant hemorrhage during lumbar discectomy. An endovascular approach using stent grafts provided a minimally invasive and successful solution to the problem.

 

Vascular injuries are a known potential complication of lumbosacral spine surgery. Nearly all of these complications have been managed with laparotomy and direct repair in the past and have frequently been associated with major morbidity and mortality. We describe a minimally invasive endovascular solution to the problem of acute hemorrhage from a venous injury occurring during lumbosacral spine surgery.

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Case report 

A 61-year-old woman was undergoing an L4 to L5–level discectomy and spinal fusion from a minimally invasive left lateral retroperitoneal approach. The surgeon encountered significant bleeding during removal of the nucleus pulposus and consulted the vascular surgery service. The wound had been packed with gauze to achieve temporary hemostasis for a significant period, estimated to be 30 minutes, but significant bleeding was still apparent with removal of the packing. The rate of bleeding was substantial, the operative site filled with blood immediately with removal of the packing, and we concluded that this was unlikely to stop without direct control or exclusion of the source of bleeding. The bleeding was clearly venous, and the spine surgeon confirmed that the bleeding began during removal of the material in the right anterior portion of the disc space. We concluded that this most likely represented an injury to the inferior vena cava, an iliac vein, or a lumbar vein.

The wound was repacked, the patient was rolled into the supine position, and a left iliac venogram was performed via a percutaneous left transfemoral venous approach. This revealed a laceration of the left common iliac vein adjacent to the common iliac vein/inferior vena caval confluence. The injury seemed to be amenable to an endovascular solution, but we believed that it was too close to the inferior vena cava to allow placement of a single stent or stent graft without compromising the right common iliac vein. Percutaneous right transfemoral venous access was achieved. The venogram was repeated with simultaneous hand injection through sheaths in both femoral veins and in the presence of a calibrated marker pigtail catheter in the left iliac vein. The repeat venogram further confirmed the proximity of the injury to the iliac venous confluence (Fig 1). Consequently, we elected to place kissing stents, as is commonly performed for common iliac artery stenoses located in close proximity to the aortic bifurcation.1 We estimated the common iliac veins to be 14 mm in diameter on the basis of measurement using the marker catheter calibration.

  • View full-size image.
  • Fig 1. 

    Iliocaval venogram (simultaneous injections via bilateral femoral venous sheaths) demonstrates a large laceration (arrow) of the left common iliac to inferior vena caval junction. The radiopaque indicators on the gauze sponges used to pack the wound to control bleeding may be identified just below and to the right (patient’s left) of the arrow.

We advanced 185-cm-long, 0.035-inch-diameter Meier guidewires (Boston Scientific, Natick, Mass) to the level of the right atrium through each of the femoral vein accesses. We then advanced 30-cm-long 16F sheaths (Cook Inc, Bloomington, Ind) over the guide wires up to the common iliac veins on both sides and positioned two 5.5-cm-long AneuRx self-expanding polyester-lined extension limb stent grafts, 15 mm in diameter on the right and 16 mm in diameter on the left (Medtronic AVE, Santa Rosa, Calif). The stent grafts were deployed simultaneously by using the kissing stent technique to cover the laceration. A repeat venogram via simultaneous injections through the sheaths confirmed exclusion of the bleeding site with maintenance of iliac venous patency bilaterally (Fig 2). The sheaths were withdrawn without use of any closure device, and pressure was maintained over the puncture sites for 15 minutes. The patient was returned to the right lateral decubitus position, and the spine operation was completed. There was no evidence of persistent hemorrhage when the spine surgeon re-exposed the operative site.

  • View full-size image.
  • Fig 2. 

    Bilateral iliac venous kissing stent grafts have been placed from the common iliac veins extending into the inferior vena cava, successfully excluding the injury.

We were concerned that the iliac veins were at high risk to thrombose in the presence of the prosthetic material and the low-velocity-flow environment. Consequently, the patient received anticoagulation therapy with heparin beginning on the second postoperative day, transitioned to warfarin, and discharged home on the eighth postoperative day. She experienced a fall at home and returned on the 10th postoperative day complaining of left lower abdominal and flank pain and was noted to have had a significant decrease in hematocrit. Computed tomographic scan of the abdomen with intravenous contrast revealed a hematoma in the left retroperitoneum and confirmed patency of the iliac veins and inferior vena cava (Fig 3). There was no evidence of extravasation of contrast. Anticoagulation was withdrawn for several days and resumed later when we were confident that her hematocrit was stable. She returned for an outpatient follow-up visit on the 70th postoperative day. No imaging was performed at that time, but she did not have discernible leg swelling, and handheld continuous wave Doppler interrogation of her femoral veins showed normal respiratory phasicity and a normal response to the Valsalva maneuver.

  • View full-size image.
  • Fig 3. 

    Computed tomographic scan on the 13th postoperative day reveals the stent grafts in place (arrow) adjacent to the spinal fusion hardware (posteromedial to the stent grafts). Timing was not optimized for venous phase examination, but review of all images, including sagittal and coronal reconstructions, made it clear that both common iliac veins and the inferior vena cava remained patent. There was no evidence on this scan of any associated arterial injury.

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Discussion 

Aortoiliac arterial and iliocaval venous injuries are a known potential complication of spinal surgery. Acute complications are dominated by hemorrhage from arterial or venous injury and may be associated with mortality as high as 80%.2 Most reported complications of lumbosacral discectomy seem to be chronic and are primarily arteriovenous fistulas and pseudoaneurysms. Linton and White3 first described treatment of an arteriovenous fistula associated with previous spine surgery in 1945. DeSaussure4 published the results of a survey of surgeons performing spine surgery, concluded that the risk of vascular complications was substantial and likely underreported, and provided an interesting contrast between acute (hemorrhagic) and chronic vascular complications of disc surgery. Chronic complications seem to be more common overall and seem to be dominated by arteriovenous fistulas.4 Nevertheless, both acute and chronic vascular injuries have been treated almost exclusively by laparotomy, and some surgeons5 have recommended this approach as recently as 2004. Laparotomy and open repair are usually associated with significant blood loss and may even require division of the right iliac artery or other structures to allow exposure of the area of injury.2, 6, 7, 8, 9 Late complications associated with open repair may also be quite morbid.5

A MEDLINE search of English-language articles using terms including “(vein OR venous) AND (injury OR laceration) AND (disc surgery OR discectomy OR laminectomy)” yielded 50 citations, 14 of which seemed to have some possible pertinence to this patient’s injury.5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 Of these 14 citations, 10 described a total of 21 patients treated emergently for acute hemorrhage after spine surgery. Laparotomy would have been unusually difficult in our patient because of her obesity and previous abdominal operations. It is unlikely we would have been comfortable allowing the spine surgeon to complete the original operation after a difficult laparotomy, but we were quite comfortable in this case recommending that the spine surgeon proceed once we had dealt with the venous injury.

Further searching in MEDLINE using the search terms “(iliac vein OR inferior vena cava) AND (stent OR stent graft OR covered stent)” identified a substantial number of citations regarding the placement of stents for chronic venous occlusive disease. However, few of these articles addressed placement of venous stents or stent grafts for acute or chronic venous injuries.6, 19, 20, 21, 22, 23 Among these previous reports, we noted that Ventura et al.,20 who placed a stent graft in an iliac artery to exclude an arteriovenous fistula a few weeks after spine surgery, were the only previous writers to describe the use of an AneuRx graft to treat a vascular complication of spine surgery. We were unable to identify any previous description of endovenous treatment for acute hemorrhage related to lumbosacral spine surgery. We acknowledge that arterial injuries may occur during spine surgery and that articles describing purely arterial injuries might have been missed with the search strategies described previously, but purely arterial injuries would not have been within the scope of this article.

With respect to the use of the kissing stent technique, we believed that this technique was necessary to secure the position of the left iliac stent and to preserve the patency of the contralateral iliac vein. Alemany and Gortz24 successfully used a similar technique to treat occlusion of the iliac vein to the inferior vena caval confluence. Others may have used the kissing stent technique, but chronic venous occlusive disease seems amenable to unilateral treatment in most cases.25

In the setting of acute vascular injury, stent selection largely depends on the immediate availability and access to stents and on operator familiarity with various endovascular solutions. In this particular case, initial venography with a marker catheter in place determined the iliac veins to be nearly 15 mm in diameter, which exceeded the maximal diameter of the self-expanding bare metal stents and conventional medium-diameter covered stents in our inventory. Aortic stent graft repair is performed in the operating room at our institution, and, therefore, we had access to a wide variety of iliac extension limbs commonly used in such repairs. Our decision to use the AneuRx extension limbs was mainly due to the fact that we had two of similar sizes to deploy in a kissing fashion and to the fact that they are deployed through 16F sheaths, which do not require femoral cutdown to access the venous system.

Initial technical success does not guarantee long-term success. We anticoagulated the patient because of concern that the stent graft might be thrombogenic, but the reconstruction remains patent thus far. Although we could not find a description of similar iliac vein repairs in the literature, the use of self-expanding stents in the iliac veins for treatment of May-Thurner syndrome has been well described. For example, Hood and Alexander25 reported good initial experience in a small series of patients by using Wallstents (Boston Scientific). O’Sullivan et al.,26 in a larger series with longer follow-up, reported 1-year patency of 93.6% in iliac veins treated with Wallstents. Raju et al.27 reported results with iliac venous stents in more than 300 patients, approximately half of which were for nonthrombotic disease, with 90% secondary patency at 24 months. Thus, despite concerns about placement of prosthetic devices in the venous circulation, patency in stented iliac veins is surprisingly good in the experience reported to date. Furthermore, iliocaval thrombosis would be a risk even after open repair.

In summary, we present an endovascular solution to an occasional problem associated with lumbosacral spine surgery. This solution seems to have had a minimal effect on the patient, in clear contradistinction to standard open repair as practiced over the previous 60 years. Endovascular solutions should be considered for both early and late vascular complications of spine surgery.

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References 

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 Competition of interest: none.

PII: S0741-5214(06)01376-0

doi:10.1016/j.jvs.2006.07.049

Journal of Vascular Surgery
Volume 44, Issue 6 , Pages 1353-1356, December 2006

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