Iatrogenic major vascular injury during lumbar discectomy: report of three cases.

Abstract

Iatrogenic vascular injury rarely occurs during lumbar disc surgery and can be fatal if it is not recognized instantly. In this paper we aim to introduce three iatrogenic vascular injuries that occurred during the lumbar disc surgery. The first case was consulted because of the sudden hypotension attack during lumbar disc surgery. The left common iliac artery and bilateral common iliac vein injuries were detected in emergency laparotomy, and repaired primarily. The second case was consulted to our clinic because of the hypotension attack at the first postoperative day. Left common iliac artery and vein injuries were diagnosed by CT angiography. Left common iliac vein was ligated and left common iliac arterial injury was repaired primarily by laparotomy. The third case was referred to our clinic for left lower extremity ischemia. Left common iliac artery injury was diagnosed by simple physical examination. Reconstruction by PTFE graft interposition was performed. The first patient died due to disseminated intravascular coagulation at the early postoperative period. Pulmonary embolus developed in the iliac vein ligated patient but was well treated by anticoagulant therapy. The last patient was discharged without any problem. Two of the patients are well on long-term follow-up. KeywoRds: Discectomy, Vascular injury, Reconstruction, Ven ligation ÖZLomber disk cerrahisi sırasında iyatrojenik damar yaralanmaları, ender görülen ve geç fark edildiğinde mortaliteye neden olabilen bir komplikasyondur. Bu yazımızda, lomber fıtık disk cerrahisi esnasında oluşan iyatrojenik damar yaralanması nedeniyle ameliyat ettiğimiz üç olguyu sunmayı amaçladık. İlk olgu lomber herniektomi girişimi sırasında gelişen ani hipotansiyon nedeniyle konsülte edildi. Tanısal laparotomide sol ana iliak arter yaralanması, bilateral ana iliak ven yaralanması tespit edildi ve primer tamir yapıldı. Ameliyat sonrası (AS) birinci günde gelişen hipotansiyon nedeniyle kliniğimize sevk edilen ikinci olguda sol ana iliak arter ve ven yaralanması saptandı. Ana iliak ven ligasyonu ve ana iliak artere primer tamir yapıldı. Alt ekstremitede iskemik bulgular nedeniyle kliniğimize sevk edilen üçüncü olguda da sol ana iliak arter yaralanması saptayarak, kısmi arter rezeksiyonu ve PTFE (politetrafloretilen) greft interposizyonu uygulandı. İlk hasta ameliyat sonrası erken dönemde dissemine intravasküler koagulasyon nedeniyle kaybedilirken , diğer iki hasta ise şifa ile taburcu edildi.

Morphometric Analysis of Significant Vascular Structures in Posterior Disc Surgery in Computed Tomography Angiography

“…Vascular injury probability after LDS is between 0.05% and 0.1%. [1,3,7,8] In acute stages, vascular injuries result in shock status and death. In chronicle stages, it results in pseudoaneurysm and arteriovenous fistula.…”

“…In chronicle stages, in addition to arteriovenous fistula and pseudoaneurysm, findings of abdominal murmur, abdominal pain, abdominal bulk, cardiac failure arise. [1,3,5,7,8] When lumbar disc is excised, disc curette or forceps destroys the integrity of annulus fibrosis and ALL, and causes vascular injury by passing front border of vertebra corpus. These injuries most frequently occur in discectomies at L4-5, and generally CIA and CIV get injured.…”

A rare cause of ureteral injuries; simultaneous common iliac artery and ureter injury during posterior lumbar disc surgery

“…[3] Most frequently ureter is injured at the level of L4-L5. [5,6] Complete ureteral rupture is rarely seen. [3] In our case the location of both injured ureter, and internal iliac artery complies with the abovementioned anatomic characteristics, and described pathogenic mechanisms.…”

Iatrogenic left common iliac artery and vein perforation during lumbar discectomy: A fatal case

“…The level of lumbar discectomy determines the localization of vascular injury. As the aorta bifurcates at the level of L4-L5 intervertebral space, and L4-L5 level is the most common site for discectomy, most of the vascular injuries are detected in the right or left common iliac arteries and veins (15). …”

“…Bleeding from venous injuries during surgery can remain undetected and may even stop spontaneously. Sometimes this bleeding can be neglected and the consequence transient hypotension is frequently linked to another cause [14][15][16].…”