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Endovascular Treatment of Iatrogenic Iliac Artery Disruption in Lumbar Disc Surgery
Endovascular Treatment of Iatrogenic Iliac Artery Disruption in Lumbar Disc Surgery Ching-Yang Wu,1 Yen-Ni Hung,2 Yun-Hen Liu,1 and Po-Jen Ko,1 TaoYuan, Taiwan
Major vessel (aorta or iliac vessels) injury is a rare yet catastrophic complication of spinal surgery. Prompt diagnosis is vital for effectively treating these injuries. A 56-year-old female with iliac artery iatrogenic injury during lumbar discectomy was successfully treated by percutaneous placement of a self-expanding stent graft in an emergent setting in an angiography suite. Postprocedural angiogram demonstrated complete exclusion of the pseudoaneurysm without contrast agent leakage. Endovascular treatment is suggested as an excellent alternative to open surgery for iatrogenic great vessel injuries, particularly in critical conditions.
Major vessel (aorta or iliac vessels) injury is a rare yet catastrophic complication of spinal surgery. The incidence of symptomatic vascular complication ranges 0.016-0.17%.1-3 Iatrogenic injury of the lower abdominal aorta and iliac vessels during spinal surgery was first reported by Linton and White in 1945.1 This major vessel injury must be diagnosed and managed immediately to stabilize the patient. Conventional surgical approaches for repairing injured aortoiliac vessels require large incisions for proximal and distal control prior to repair of the artery. Recently developed endovascular techniques may offer less invasive alternatives for this injury. We describe a patient with left common iliac artery injury due to spinal surgery who was successfully treated by emergency endovascular repair using a stent graft (covered stent).
CASE REPORT A 56-year-old female patient diagnosed with a herniated lumbar disc presented with lower back pain with bilateral 1 Division of Thoracic and Cardiovascular Surgery, Chang-Gung Memorial Hospital, Chang-Gung University, TaoYuan, Taiwan. 2 Institution of Public Health, National Yang-Ming University, Taipei, Taiwan.
Correspondence to: Po-Jen Ko, MD, Department of Thoracic and Cardiovascular Surgery, Chang-Gung Memorial Hospital, 5 Fu-Hsing Street, Kwei-Shan Hsiang, TaoYuan, Taiwan 333, E-mail: [email protected] Ann Vasc Surg 2009; 23: 255.e7-255.e11 DOI: 10.1016/j.avsg.2008.02.014 Ó Annals of Vascular Surgery Inc. Published online: May 6, 2008
leg radiation, limb weakness, and intermittent claudication. Lumbar spine X-ray showed grade I spondylolisthesis between the fourth and fifth vertebrae. Magnetic resonance imaging further revealed a posterior herniated intervertebral disc between the fourth and fifth vertabrae in the lumbar spine. Spinal surgery for spondylolisthesis and herniated intervertebral disc was arranged to alleviate these symptoms. The patient was placed in a prone position under general anesthesia. Decompression surgery and posterior fusion with transpedicle screw and autograft were performed by an experienced neurosurgeon via a posterior approach. At the conclusion of spinal surgery, the patient suffered an unexpected drop in blood pressure refractory to inotropic agent and fluid resuscitation. Additionally, immediate cyanotic changes were noted in the left leg, as well as a sudden drop in body temperature. Under the assumption of iatrogenic artery injury, the patient was transferred to the radiology suite for angiographic examination via right femoral puncture. The arteriogram demonstrated total disruption of the left common iliac due to possible nail injury, with severe and active contrast extravasation (Fig. 1). Vascular surgeons were immediately dispatched to address this emergent situation. Due to the unstable hemodynamic condition of the patient, the lesion was treated in the angiography suite to avoid transferring her back to the operating theater. A guidewire was inserted from the right femoral common artery over the aortic bifurcation to the end of the disrupted left common iliac artery. Cannulation of the left external iliac artery was attempted using a crossover technique but eventually failed. The lesion was therefore approached in a retrograde manner via the left common femoral artery. Exploration of the left
255.e7
255.e8 Case reports
Annals of Vascular Surgery
Fig. 1. Emergent angiography. A Intact aorta. B Lack of contrast opacification below bifurcation of left iliac artery. C, D Persistent contrast extravasation rules out left common iliac artery total disruption.
common femoral artery was followed by insertion of an 8F catheter introducer sheath (Axcess; Argon Medical Devices, Athens, Greece). After cautious manipulation, an angled floppy tip hydrophilic guidewire (Roadrunner; Cook, Bloomington, IN) was advanced through the defect on the proximal left external iliac artery and then into the common iliac artery stump. After securing the guidewire in position, an 8 mm x 6 cm selfexpanding nitinol stent graft (Fluency; Bard, Tempe, AZ) was successfully deployed to seal the defect in the iliac artery and restore normal left leg arterial flow (Fig. 2). Following deployment of the stent graft, blood pressure stabilized. Complete angiography revealed proper positioning of the stent graft with no contrast medium leakage. Normal left lower leg arterial flow was also confirmed. No anticoagulation medication was required during or after the procedure. The patient was transferred to the intensive care unit and eventually achieved full recovery. The patient has been followed up at our clinic for
over 1 year without symptoms or signs of vascular claudication.
DISCUSSION This report describes successful emergent endovascular treatment using a stent graft for an iatrogenic iliac lesion due to lumbar spine surgery. The severe iliac artery disruption destabilized the hemodynamic status of the patient and precluded open repair of the lesion. Recent advances in endovascular techniques enable immediate treatment of such lesions in the angiography suite after identifying the arterial injury. The lesion in this case was noninvasively sealed off by the stent graft without requiring direct exploration of the iliac vessels via the transperitoneal or retroperitoneal approach. Endovascular stent graft implantation has reportedly produced excellent
Vol. 23, No. 2, March 2009
Case reports 255.e9
Fig. 2. Stenting of the defect. A Cannulated abdominal aorta via left common femoral artery with guidewire. B Stent graft placed over site of injury. C, D Continuity of left common iliac, external iliac, and common femoral artery after stent grafting.
results in patients with hemodynamic instability due to rapid and comprehensive blood exsanguinations. Iatrogenic vascular injuries due to spinal surgery are rare.1,2,4 Great vessels, which are in proximity to the vertebral column, are at risk of intraoperative injury because of their location. The injuries predominantly associated with proximal lumbar operations are those to the aorta and the inferior vena cava. Iliac vessel injuries, however, are more common in distal lumbar surgery.2,3 The direct cause of such injuries may be a deep bite with rongeur beyond the anterior spinal ligament or a penetrating injury caused by a transpedicle screw, as in the case described here.5 Previous studies of massive retroperitoneal hemorrhage and shock due to iatrogenic vessel injuries in spinal surgery emphasize the importance of early diagnosis and urgent surgical intervention.
However, neither the retroperitoneal nor the transperitoneal approach has clearly proven to be superior. As methods and technology advance, various endovascular treatments have been reported for various vascular injuries, including arteriovenous fistula, arterial false aneurysm, and venous injuries.6-15 Few reports published in the English language have discussed the emergent application of a stent graft for iatrogenic iliac artery disruption during lumbar spine surgery.16,17 Endovascular treatment of iatrogenic arterial injuries does offer notable advantages. In contrast with open repair, a smaller incision is required to treat the lesion via the endovascular approach. Invasive wounds to explore the iliac vessels and control the vessels proximally and distally are not required. Thus, blood loss and exploration time are minimized. In the present case, direct arterial or
255.e10 Case reports
venous perforations resulted in rapid exsanguination and shock. Endovascular balloon tamponade in the aorta would have been an ideal method to prevent further massive blood loss from the arterial defect before definite repair of the arterial injury. However, this was impossible because of no suitable size of balloon available in our hospital at that time. Since the patient was already in the angiography suite, transporting her back to the operating theater for open exploration and repair would have been more time-consuming than intervention or exploration in the angiography suite. Sealing the lesion on the angiography table to stop bleeding immediately after diagnosis appeared reasonable and technically feasible. Therefore, once angiography revealed the left common iliac artery injury, immediate endovascular repair of the lesion was attempted in the least invasive fashion. The defect was apparently located on the distal common iliac artery near the orifice of the internal iliac artery. Thus, the intention was to seal the artery injury using a stent graft. Embolization of the iliac artery would have been problematic because of active extravasation and the strong flow of the common iliac artery. The failure of initial antegrade cannulation of the left external iliac artery may have been due to collapse and spasm of the external iliac artery stump after severe injury of the iliac artery. The active blood flow continued to flush the guidewire out of the arterial lumen and into the retroperitoneal space, thus preventing the guidewire from reentering the true lumen of the external iliac artery. Retrograde cannulation from the left femoral artery was then attempted. The strong antegrade blood flow kept the common iliac artery wide open. The guidewire could thus pass from the collapsed external iliac artery into the easily accessible common iliac artery in a retrograde fashion. Once the guidewire had passed the vessel defect into the common iliac artery, the stent graft could be deployed to seal the defect along the wire. Postprocedural arteriogram demonstrated good stent position with no further contrast leakage. The patient eventually stabilized. Systemic anticoagulation is a common practice in peripheral artery intervention. Due to the massive blood loss in this patient, anticoagulation with heparin was considered inappropriate. The emergent salvage of this patient by stent graft deployment may have been possible because of the lack of arterial disruption, which enabled the guidewire to be passed through the artery and the stent graft to be implanted with a good seal. Once a through-and-through injury prevents satisfactory sealing by the endovascular method, prompt
Annals of Vascular Surgery
exploration and open repair must be done to deal with the lesion. Open repair should remain a basic skill of vascular surgeons dealing with this kind of arterial trauma. Other authors have also described the successful use of stent grafts for iliac lesions.18-20 Our experience suggests that emergent stent grafting for iatrogenic common iliac artery injury is technically feasible and effective, even if the patient is hemodynamically unstable. Approaching the arterial lesion in an ipsilateral retrograde fashion from the femoral artery is easier and faster than an antegrade fashion via the contralateral approach, which is common during elective iliac stenting. Once the necessary endovascular equipment is installed in the angiography suite, endovascular treatment is a promising alternative to open repair for this condition, especially in emergent conditions.
REFERENCES 1. Raptis S, Quigley F, Barker S. Vascular complications of elective lower lumbar disc surgery. Aust. N.Z.J. Surg 1994;64: 216-219. 2. Papadoulas S, Konstantinou D, Kourea HP, et al. Vascular injury complicating lumbar disc surgery. A systematic review. Eur. J. Vasc. Endovasc. Surg 2002;24:189-195. 3. Sande E, Myhre HO, Witsoe E, et al. Vascular complications of lumbar disc surgery. Case report. Eur. J. Surg 1991;157: 141-143. 4. Anda S, Aakhus S, Skaanes KO, et al. Anterior perforations in lumbar discectomies. A report of four cases of vascular complications and a CT study of the prevertebral lumbar anatomy. Spine 1991;16:54-60. 5. Minor ME, Morrissey NJ, Peress R, et al. Endovascular treatment of an iatrogenic thoracic aortic injury after spinal instrumentation: case report. J. Vasc. Surg 2004;39: 893-896. 6. Bautista-Hernandez V, Moya J, Martinell J, et al. Successful stent-grafting for perforation of the thoracic aorta by an intraaortic balloon pump. Ann. Thorac. Surg 2002;73: 956-958. 7. Been HD, Kerkhoffs GM, Balm R. Endovascular graft for late iatrogenic vascular complication after anterior spinal instrumentation: a case report. Spine 2006;31: E856-E858. 8. Zhou W, Bush RL, Terramani TT, et al. Treatment options of iatrogenic pelvic vein injuries: conventional operative versus endovascular approachdcase reports. Vasc. Endovascular Surg 2004;38:569-573. 9. Vaninbroukx I, Vandekerkhof J. Endovascular stent graft treatment for iatrogenic arteriovenous fistulas after femoral catheterisation. Acta Chir. Belg 2004;104:584-587. 10. Wang EA, Lee MH, Wang MC, et al. Iatrogenic left iliaccaval fistula: imaging and endovascular treatment. A.J.R. Am. J. Roentgenol 2004;183:1032-1034. 11. Stella N, Pellicciotti A, Udini M. Endovascular exclusion of iatrogenic femoral artery pseudoaneurysm with the Wallgraft-endoprosthesis. J. Cardiovasc. Surg. (Torino) 2003;44:259-262.
Vol. 23, No. 2, March 2009
12. Hart JP, Wallis F, Kenny B, et al. Endovascular exclusion of iliac artery to iliac vein fistula after lumbar disk surgery. J. Vasc. Surg 2003;37:1091-1093. 13. Siablis D, Panagopoulos C, Karamessini M, et al. Delayed diagnosis of a false aneurysm after lumbar arterial injury: treatment with endovascular embolization: a case report. Spine 2003;28:E71-E73. 14. Hong SJ, Oh JH, Yoon Y. Percutaneous endovascular stentgraft for iliac pseudoaneurysm following lumbar discectomy. Cardiovasc. Intervent. Radiol 2000;23:475-477. 15. Lee KH, Park JH, Chung JW, et al. Vascular complications in lumbar spinal surgery: percutaneous endovascular treatment. Cardiovasc. Intervent. Radiol 2000;23:65-69. 16. Bierdrager E, Van Rooij WJ, Sluzewski M. Emergency stenting to control massive bleeding of injured iliac artery
Case reports 255.e11
17.
18.
19.
20.
following lumbar disk surgery. Neuroradiology 2004;46: 404-406. Chang CP, Lee WS, Lee SC. Left internal iliac artery and vein tear during microendoscopic lumbar discectomyda case report. Minim. Invasive Ther. Allied Technol 2006;15: 155-158. Scheinert D, Schroder M, Steinkamp H, et al. Treatment of iliac artery aneurysms by percutaneous implantation of stent grafts. Circulation 2000;102:III253-III258. Scheinert D, Ludwig J, Steinkamp HJ, et al. Treatment of catheter-induced iliac artery injuries with self-expanding endografts. J. Endovasc. Ther 2000;7:213-220. Lagana D, Carrafiello G, Mangini M, et al. Emergency percutaneous treatment of arterial iliac axis ruptures. Emerg. Radiol 2007;14:173-179.
Major vessel (aorta or iliac vessels) injury is a rare yet catastrophic complication of spinal surgery. Prompt diagnosis is vital for effectively treating these injuries. A 56-year-old female with iliac artery iatrogenic injury during lumbar discectomy was successfully treated by percutaneous placement of a self-expanding stent graft in an emergent setting in an angiography suite. Postprocedural angiogram demonstrated complete exclusion of the pseudoaneurysm without contrast agent leakage. Endovascular treatment is suggested as an excellent alternative to open surgery for iatrogenic great vessel injuries, particularly in critical conditions.
Major vessel (aorta or iliac vessels) injury is a rare yet catastrophic complication of spinal surgery. The incidence of symptomatic vascular complication ranges 0.016-0.17%.1-3 Iatrogenic injury of the lower abdominal aorta and iliac vessels during spinal surgery was first reported by Linton and White in 1945.1 This major vessel injury must be diagnosed and managed immediately to stabilize the patient. Conventional surgical approaches for repairing injured aortoiliac vessels require large incisions for proximal and distal control prior to repair of the artery. Recently developed endovascular techniques may offer less invasive alternatives for this injury. We describe a patient with left common iliac artery injury due to spinal surgery who was successfully treated by emergency endovascular repair using a stent graft (covered stent).
CASE REPORT A 56-year-old female patient diagnosed with a herniated lumbar disc presented with lower back pain with bilateral 1 Division of Thoracic and Cardiovascular Surgery, Chang-Gung Memorial Hospital, Chang-Gung University, TaoYuan, Taiwan. 2 Institution of Public Health, National Yang-Ming University, Taipei, Taiwan.
Correspondence to: Po-Jen Ko, MD, Department of Thoracic and Cardiovascular Surgery, Chang-Gung Memorial Hospital, 5 Fu-Hsing Street, Kwei-Shan Hsiang, TaoYuan, Taiwan 333, E-mail: [email protected] Ann Vasc Surg 2009; 23: 255.e7-255.e11 DOI: 10.1016/j.avsg.2008.02.014 Ó Annals of Vascular Surgery Inc. Published online: May 6, 2008
leg radiation, limb weakness, and intermittent claudication. Lumbar spine X-ray showed grade I spondylolisthesis between the fourth and fifth vertebrae. Magnetic resonance imaging further revealed a posterior herniated intervertebral disc between the fourth and fifth vertabrae in the lumbar spine. Spinal surgery for spondylolisthesis and herniated intervertebral disc was arranged to alleviate these symptoms. The patient was placed in a prone position under general anesthesia. Decompression surgery and posterior fusion with transpedicle screw and autograft were performed by an experienced neurosurgeon via a posterior approach. At the conclusion of spinal surgery, the patient suffered an unexpected drop in blood pressure refractory to inotropic agent and fluid resuscitation. Additionally, immediate cyanotic changes were noted in the left leg, as well as a sudden drop in body temperature. Under the assumption of iatrogenic artery injury, the patient was transferred to the radiology suite for angiographic examination via right femoral puncture. The arteriogram demonstrated total disruption of the left common iliac due to possible nail injury, with severe and active contrast extravasation (Fig. 1). Vascular surgeons were immediately dispatched to address this emergent situation. Due to the unstable hemodynamic condition of the patient, the lesion was treated in the angiography suite to avoid transferring her back to the operating theater. A guidewire was inserted from the right femoral common artery over the aortic bifurcation to the end of the disrupted left common iliac artery. Cannulation of the left external iliac artery was attempted using a crossover technique but eventually failed. The lesion was therefore approached in a retrograde manner via the left common femoral artery. Exploration of the left
255.e7
255.e8 Case reports
Annals of Vascular Surgery
Fig. 1. Emergent angiography. A Intact aorta. B Lack of contrast opacification below bifurcation of left iliac artery. C, D Persistent contrast extravasation rules out left common iliac artery total disruption.
common femoral artery was followed by insertion of an 8F catheter introducer sheath (Axcess; Argon Medical Devices, Athens, Greece). After cautious manipulation, an angled floppy tip hydrophilic guidewire (Roadrunner; Cook, Bloomington, IN) was advanced through the defect on the proximal left external iliac artery and then into the common iliac artery stump. After securing the guidewire in position, an 8 mm x 6 cm selfexpanding nitinol stent graft (Fluency; Bard, Tempe, AZ) was successfully deployed to seal the defect in the iliac artery and restore normal left leg arterial flow (Fig. 2). Following deployment of the stent graft, blood pressure stabilized. Complete angiography revealed proper positioning of the stent graft with no contrast medium leakage. Normal left lower leg arterial flow was also confirmed. No anticoagulation medication was required during or after the procedure. The patient was transferred to the intensive care unit and eventually achieved full recovery. The patient has been followed up at our clinic for
over 1 year without symptoms or signs of vascular claudication.
DISCUSSION This report describes successful emergent endovascular treatment using a stent graft for an iatrogenic iliac lesion due to lumbar spine surgery. The severe iliac artery disruption destabilized the hemodynamic status of the patient and precluded open repair of the lesion. Recent advances in endovascular techniques enable immediate treatment of such lesions in the angiography suite after identifying the arterial injury. The lesion in this case was noninvasively sealed off by the stent graft without requiring direct exploration of the iliac vessels via the transperitoneal or retroperitoneal approach. Endovascular stent graft implantation has reportedly produced excellent
Vol. 23, No. 2, March 2009
Case reports 255.e9
Fig. 2. Stenting of the defect. A Cannulated abdominal aorta via left common femoral artery with guidewire. B Stent graft placed over site of injury. C, D Continuity of left common iliac, external iliac, and common femoral artery after stent grafting.
results in patients with hemodynamic instability due to rapid and comprehensive blood exsanguinations. Iatrogenic vascular injuries due to spinal surgery are rare.1,2,4 Great vessels, which are in proximity to the vertebral column, are at risk of intraoperative injury because of their location. The injuries predominantly associated with proximal lumbar operations are those to the aorta and the inferior vena cava. Iliac vessel injuries, however, are more common in distal lumbar surgery.2,3 The direct cause of such injuries may be a deep bite with rongeur beyond the anterior spinal ligament or a penetrating injury caused by a transpedicle screw, as in the case described here.5 Previous studies of massive retroperitoneal hemorrhage and shock due to iatrogenic vessel injuries in spinal surgery emphasize the importance of early diagnosis and urgent surgical intervention.
However, neither the retroperitoneal nor the transperitoneal approach has clearly proven to be superior. As methods and technology advance, various endovascular treatments have been reported for various vascular injuries, including arteriovenous fistula, arterial false aneurysm, and venous injuries.6-15 Few reports published in the English language have discussed the emergent application of a stent graft for iatrogenic iliac artery disruption during lumbar spine surgery.16,17 Endovascular treatment of iatrogenic arterial injuries does offer notable advantages. In contrast with open repair, a smaller incision is required to treat the lesion via the endovascular approach. Invasive wounds to explore the iliac vessels and control the vessels proximally and distally are not required. Thus, blood loss and exploration time are minimized. In the present case, direct arterial or
255.e10 Case reports
venous perforations resulted in rapid exsanguination and shock. Endovascular balloon tamponade in the aorta would have been an ideal method to prevent further massive blood loss from the arterial defect before definite repair of the arterial injury. However, this was impossible because of no suitable size of balloon available in our hospital at that time. Since the patient was already in the angiography suite, transporting her back to the operating theater for open exploration and repair would have been more time-consuming than intervention or exploration in the angiography suite. Sealing the lesion on the angiography table to stop bleeding immediately after diagnosis appeared reasonable and technically feasible. Therefore, once angiography revealed the left common iliac artery injury, immediate endovascular repair of the lesion was attempted in the least invasive fashion. The defect was apparently located on the distal common iliac artery near the orifice of the internal iliac artery. Thus, the intention was to seal the artery injury using a stent graft. Embolization of the iliac artery would have been problematic because of active extravasation and the strong flow of the common iliac artery. The failure of initial antegrade cannulation of the left external iliac artery may have been due to collapse and spasm of the external iliac artery stump after severe injury of the iliac artery. The active blood flow continued to flush the guidewire out of the arterial lumen and into the retroperitoneal space, thus preventing the guidewire from reentering the true lumen of the external iliac artery. Retrograde cannulation from the left femoral artery was then attempted. The strong antegrade blood flow kept the common iliac artery wide open. The guidewire could thus pass from the collapsed external iliac artery into the easily accessible common iliac artery in a retrograde fashion. Once the guidewire had passed the vessel defect into the common iliac artery, the stent graft could be deployed to seal the defect along the wire. Postprocedural arteriogram demonstrated good stent position with no further contrast leakage. The patient eventually stabilized. Systemic anticoagulation is a common practice in peripheral artery intervention. Due to the massive blood loss in this patient, anticoagulation with heparin was considered inappropriate. The emergent salvage of this patient by stent graft deployment may have been possible because of the lack of arterial disruption, which enabled the guidewire to be passed through the artery and the stent graft to be implanted with a good seal. Once a through-and-through injury prevents satisfactory sealing by the endovascular method, prompt
Annals of Vascular Surgery
exploration and open repair must be done to deal with the lesion. Open repair should remain a basic skill of vascular surgeons dealing with this kind of arterial trauma. Other authors have also described the successful use of stent grafts for iliac lesions.18-20 Our experience suggests that emergent stent grafting for iatrogenic common iliac artery injury is technically feasible and effective, even if the patient is hemodynamically unstable. Approaching the arterial lesion in an ipsilateral retrograde fashion from the femoral artery is easier and faster than an antegrade fashion via the contralateral approach, which is common during elective iliac stenting. Once the necessary endovascular equipment is installed in the angiography suite, endovascular treatment is a promising alternative to open repair for this condition, especially in emergent conditions.
REFERENCES 1. Raptis S, Quigley F, Barker S. Vascular complications of elective lower lumbar disc surgery. Aust. N.Z.J. Surg 1994;64: 216-219. 2. Papadoulas S, Konstantinou D, Kourea HP, et al. Vascular injury complicating lumbar disc surgery. A systematic review. Eur. J. Vasc. Endovasc. Surg 2002;24:189-195. 3. Sande E, Myhre HO, Witsoe E, et al. Vascular complications of lumbar disc surgery. Case report. Eur. J. Surg 1991;157: 141-143. 4. Anda S, Aakhus S, Skaanes KO, et al. Anterior perforations in lumbar discectomies. A report of four cases of vascular complications and a CT study of the prevertebral lumbar anatomy. Spine 1991;16:54-60. 5. Minor ME, Morrissey NJ, Peress R, et al. Endovascular treatment of an iatrogenic thoracic aortic injury after spinal instrumentation: case report. J. Vasc. Surg 2004;39: 893-896. 6. Bautista-Hernandez V, Moya J, Martinell J, et al. Successful stent-grafting for perforation of the thoracic aorta by an intraaortic balloon pump. Ann. Thorac. Surg 2002;73: 956-958. 7. Been HD, Kerkhoffs GM, Balm R. Endovascular graft for late iatrogenic vascular complication after anterior spinal instrumentation: a case report. Spine 2006;31: E856-E858. 8. Zhou W, Bush RL, Terramani TT, et al. Treatment options of iatrogenic pelvic vein injuries: conventional operative versus endovascular approachdcase reports. Vasc. Endovascular Surg 2004;38:569-573. 9. Vaninbroukx I, Vandekerkhof J. Endovascular stent graft treatment for iatrogenic arteriovenous fistulas after femoral catheterisation. Acta Chir. Belg 2004;104:584-587. 10. Wang EA, Lee MH, Wang MC, et al. Iatrogenic left iliaccaval fistula: imaging and endovascular treatment. A.J.R. Am. J. Roentgenol 2004;183:1032-1034. 11. Stella N, Pellicciotti A, Udini M. Endovascular exclusion of iatrogenic femoral artery pseudoaneurysm with the Wallgraft-endoprosthesis. J. Cardiovasc. Surg. (Torino) 2003;44:259-262.
Vol. 23, No. 2, March 2009
12. Hart JP, Wallis F, Kenny B, et al. Endovascular exclusion of iliac artery to iliac vein fistula after lumbar disk surgery. J. Vasc. Surg 2003;37:1091-1093. 13. Siablis D, Panagopoulos C, Karamessini M, et al. Delayed diagnosis of a false aneurysm after lumbar arterial injury: treatment with endovascular embolization: a case report. Spine 2003;28:E71-E73. 14. Hong SJ, Oh JH, Yoon Y. Percutaneous endovascular stentgraft for iliac pseudoaneurysm following lumbar discectomy. Cardiovasc. Intervent. Radiol 2000;23:475-477. 15. Lee KH, Park JH, Chung JW, et al. Vascular complications in lumbar spinal surgery: percutaneous endovascular treatment. Cardiovasc. Intervent. Radiol 2000;23:65-69. 16. Bierdrager E, Van Rooij WJ, Sluzewski M. Emergency stenting to control massive bleeding of injured iliac artery
Case reports 255.e11
17.
18.
19.
20.
following lumbar disk surgery. Neuroradiology 2004;46: 404-406. Chang CP, Lee WS, Lee SC. Left internal iliac artery and vein tear during microendoscopic lumbar discectomyda case report. Minim. Invasive Ther. Allied Technol 2006;15: 155-158. Scheinert D, Schroder M, Steinkamp H, et al. Treatment of iliac artery aneurysms by percutaneous implantation of stent grafts. Circulation 2000;102:III253-III258. Scheinert D, Ludwig J, Steinkamp HJ, et al. Treatment of catheter-induced iliac artery injuries with self-expanding endografts. J. Endovasc. Ther 2000;7:213-220. Lagana D, Carrafiello G, Mangini M, et al. Emergency percutaneous treatment of arterial iliac axis ruptures. Emerg. Radiol 2007;14:173-179.