Endovascular Treatment of Late Aortic Erosive Lesion by Pedicle Screw without Screw Removal: Case Report and Literature Review

Accepted Manuscript Endovascular treatment of late aortic erosive lesion by pedicle screw without screw removal. Case report and literature review Antonio Eduardo Zerati, MD, PhD., Researcher, Dafne Braga Diamante Leiderman, MD., Resident, William Gemio Jacobsen Teixeira, MD., Assistant physician, Douglas Kenji Narazaki, MD., Assistant physician, Alexandre Fogaça Cristante, MD, PhD., Assistant physician, Nelson Wolosker, MD, PhD., Associate professor, Nelson de Luccia, MD, PhD., Chief professor, Tarcísio Eloy Pessoa de Barros Filho, MD, PhD., Chief professor PII:

S0890-5096(16)30823-8

DOI:

10.1016/j.avsg.2016.06.020

Reference:

AVSG 3005

To appear in:

Annals of Vascular Surgery

Received Date: 12 February 2016 Revised Date:

20 May 2016

Accepted Date: 15 June 2016

Please cite this article as: Zerati AE, Diamante Leiderman DB, Jacobsen Teixeira WG, Narazaki DK, Cristante AF, Wolosker N, de Luccia N, Pessoa de Barros Filho TE, Endovascular treatment of late aortic erosive lesion by pedicle screw without screw removal. Case report and literature review, Annals of Vascular Surgery (2016), doi: 10.1016/j.avsg.2016.06.020. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT 1

CASE REPORT

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Endovascular treatment of late aortic erosive lesion by pedicle screw without screw

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removal. Case report and literature review

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Running title: Aortic lesion by pedicle screw

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Antonio Eduardo Zerati1, Dafne Braga Diamante Leiderman2, William Gemio Jacobsen

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Teixeira3, Douglas Kenji Narazaki3, Alexandre Fogaça Cristante4, Nelson Wolosker5,

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Nelson de Luccia6, Tarcísio Eloy Pessoa de Barros Filho7

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Paulo (FMUSP), São Paulo, Brazil.

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(FMUSP), São Paulo, Brazil.

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Traumatologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo

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(IOT-HCFMUSP), São Paulo, Brazil.

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Instituto de Ortopedia e Traumatologia, Hospital das Clínicas da Faculdade de Medicina da

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Universidade de São Paulo (IOT-HCFMUSP), São Paulo, Brazil.

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MD, PhD. Researcher at Hospital das Clínicas, Faculdade de Medicina da Universidade de São

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MD. Resident at Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo

MD. Assistant physician, Spine Surgery Division, Spinal Tumors, Instituto de Ortopedia e

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MD, PhD. Assistant physician, Spine Surgery Division, Laboratory of Medical Investigation,

MD, PhD. Associate professor, Faculdade de Medicina da Universidade de São Paulo

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(FMUSP), São Paulo, Brazil

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Universidade de São Paulo (FMUSP), São Paulo, Brazil

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Instituto de Ortopedia e Traumatologia, Hospital das Clínicas da Faculdade de Medicina da

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Universidade de São Paulo (IOT-HCFMUSP), São Paulo, Brazil.

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MD, PhD. Chief professor, Laboratory of Medical Investigation, Spine Surgery Division,

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MD, PhD. Chief professor, Vascular Surgery Department, Faculdade de Medicina da

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Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São

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Paulo, Brazil.

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Source of funding: none

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Conflicts of interest: none.

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1

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Corresponding author:

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Alexandre Fogaça Cristante

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Rua Dr. Ovídio Pires de Matos, 333

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CEP 04018-001

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São Paulo (SP) - Brasil

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Telephone/Fax: (+55 11) 2661-6912

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E-mail: [email protected]

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ABSTRACT

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Objective: To describe the endovascular treatment of late aortic erosive lesion by

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pedicle screw without screw removal.

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Design: Case report.

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Methods and results: A breast cancer patient had a pathological fracture on T10, with

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spinal cord compression, and a pseudoaneurysm of the aorta in contact with an

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anterolateral pedicle screw. Endovascular surgery corrected the aortic lesion and

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allowed decompression, a week later, by posterior arthrodesis (T7-L1), with screw

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maintainance. There was no contrast leakage at thorax angiotomography in two years,

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and she died of meningeal carcinomatosis.

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Conclusions: Screw maintenance was safe in the endovascular treatment of aortic

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lesion by erosion.

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Keywords: Aneurysm, False; Aorta; Aorta, Thoracic; Bone Screws; Spine; Pedicle

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Screws

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Introduction

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Aortic lesions are uncommon complications in spine surgery, but potentially

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fatal. They may occur in spinal surgeries using the anterior approach1-3 or due to poor

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positioning of implants, causing massive bleeding and hemodynamic instability.4-8 Late

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aortic lesions can be attributed to the erosion of the vascular wall, due to prolonged

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contact of the vessel with the screw, but few cases have been reported.9-22 This is a

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complication difficult to diagnose, because patients can be asymptomatic or symptoms

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can be unspecific. Still, late aortic lesion can be fatal and must be treated. Classically,

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the treatment involves vascular wall repair and implant removal, because the screw

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could also lead to erosion of the replacement arterial tissue.

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Clinical presentation

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A 69-year old woman was admitted in the emergency room in July 2011 with

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signs and symptoms of acute spinal cord compression with a pathological fracture of

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D10 vertebra. The fracture was considered as secondary to breast cancer, which had

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been treated in June 2007 with radical mastectomy and chemotherapy (paclitxel and

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carboplatin, finished in April 2008). The patient was under full anticoagulation therapy

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with warfarin for the treatment of proximal deep vein thrombosis of the left leg since

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the postoperative mastectomy. She used anastrozole until June 2011.

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The patient had been treated for a multiple myeloma with autologous bone

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marrow transplantation seven years before, followed by thalidomide and pamidronate

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disodium (this last medication had been suspended one month before admission in our

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service). Because of a spinal instability caused by the multiple myeloma, in 2002, she

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had also been submitted to T5 and T6 corpectomy, by anterior approach through a right-

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sided thoracotomy, with a spacer filled with bone graft and vertebral body fixed with

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pedicular screws at D4 and D7. The screw crossed the lateral cortex of the vertebral

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body to the left, where it was in contact with the aorta. Chart 1 summarizes the clinical

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events.

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In the emergency room, a computed tomography (CT) of the spine was made for

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surgical decompression planning, revealing a pseudo-aneurysm on the posterior wall of

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the aorta arch, close to the screw used for spinal fixation (Figure 1). The patient was

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hemodynamically stable. Anticoagulant medication was discontinued immediately. It 4

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was decided that she should be submitted to endovascular treatment first, with the

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orthopedic treatment planned for a second time. The patient was operated under general anesthesia. A 28 x 140 mm Zenith TX2

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(Cook Medical) endoprosthesis was inserted, by means of the dissection of the right

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femoral artery, supported proximally at the point just below the left subclavian artery.

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Control arteriography confirmed proper placement of the endoprosthesis, without

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contrast extravasation, indicating the exclusion of the pseudoaneurysm. Because the

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thoracic spine surgery had been made in another institution, the surgeons could not

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determine the brand or model of the orthopedic fixation material used, which would

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hinder the removal of the screw, and thus they decided to avoid a new thoracotomy.

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Spinal cord decompression and fracture stabilitization was done through a

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posterior approach with a fusion from D7 to L1. The anatomopathological exam result

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was compatible with breast carcinoma on D10. The clinical evolution was satisfactory,

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and the patient was discharged from hospital on the fifth postoperative day of

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orthopedic surgery, with total reversal of symptoms related to spinal cord compression.

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Follow-up was made with CT-scans for 18 months after the endovascular surgery,

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without signs of contrast extravasation (Figure 2). The patient died 26 months after the

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endovascular surgery, due to systemic progression of the breast cancer.

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Discussion

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Penetrating injuries of the aorta by orthopedic implants are rare events. The

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vascular trauma during surgery is often easily identifiable by the often heavy bleeding,

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leading to hemodynamic instability, enabling early treatment. Some injuries, however,

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may be due to progressive erosion of the vascular wall caused by the pulsating artery

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against the implant material.22 In such cases, diagnosis occurs weeks to years after the

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procedure,19 and patients can go undiagnosed. The aortic injury cases diagnosed late

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that have been described in the literature are described in Table 1.

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Symptoms are often inespecific or the patient can be entirely asymptomatic, with

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the diagnosis made upon imaging exams performed for other reasons. The most

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common exam to confirm diagnosis is thorax CT, while digital angiography is used in

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endovascular procedures, rarely used in purely diagnostic investigations. Akinrinlola

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and Brinster8 described the role of endovascular ultrasound as an alternative diagnostic

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tool. 5

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potentially fatal and require treatment. This requires vascular repair, by open or

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endovascular approach. The open repair of an aortic lesion is a very invasive procedure,

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with considerable morbidity, because ample access is needed for proximal and distal

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control of the lesion, as well as the artery clamping, with temporarily interruption of

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perfusion to organs and tissues. Perfusion of the distal aorta during clamping may be

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also necessary. Repair can be performed by primary suture,4,11 patch angioplasty18-20 or

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interposition of synthetic prosthesis.21 Endovascular approach has been considered the

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best choice, with morbidity and mortality reduction.23-25

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In the case described here, the aortic lesion was diagnosed seven years after

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implant insertion, inadequately positioned in a spinal surgery by the anterior approach.

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Diagnosis was an incidental finding during the investigation of medular compression

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secondary to breast cancer metastasis. The pulsation of the aorta, in close contact with

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the screw, was probably the cause, and it is possible that the formation of the pseudo-

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aneurysm was facilitated by the four years of anticoagulant treatment. Despite the use of

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warfarin, bleeding was stable for many years. We avoided vigorous ballooning of the

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stent graft, using just the enough ballooning necessary to accommodate the device in the

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intravascular space. This avoided intimal injuries, since the aortic wall did not have the

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degenerative changes typical of aneurismatic diseases.

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Most authors in the literature describe the implant removal in cases of vascular

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lesions due to the possibility of further damage to the arterial substitution tissue

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(conventional prosthesis or endoprosthesis). The screw removal impossibility in our

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case required a very close follow up of the patient, with clinical and imaging exams at 3,

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6, 12 and 18 months after surgery, and until patient died because of cancer. At 18

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months, the endoprosthesis material was intact, as seen in the angiotomography. In the

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cases described by Been et al.17 and Ip et al.,22 the screw was not removed either, and

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the patients had a good clinical evolution at 60 and at 6 months respectively, also

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without abrasion of the substitution vascular tissue. In the three cases described so far in

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which the screw was maintained, the artery lesion was treated by the endovascular

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approach. Endoprosthesis causes a reduction in the pulse width compared to the native

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artery, and thus it reduces the contact trauma. Another possibility is to use external

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stents, which would act as an exoskeleton that may protect the stent from erosion by the

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contact with the screw.26 It is not possible to state that the maintenance of the implant

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material is safe in other techniques of vascular repair.

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Conclusion

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Screw maintenance was safe in the endovascular treatment of arterial lesions by

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erosion in patients submitted to surgical treatment of the spine with implant positioned

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in close contact with the aorta.

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References

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2. Chiriano J, Abou-Zamzam AM Jr, Urayeneza O, Zhang WW, Cheng W. The role of

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the vascular surgeon in anterior retroperitoneal spine exposure: preservation of open

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3. Quraishi NA, Konig M, Booker SJ, Shafafy M, Boszczyk BM, Grevitt MP, et al.

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Access related complications in anterior lumbar surgery performed by spinal surgeons.

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4. Smythe WR, Carpenter JP. Upper abdominal aortic injury during spinal surgery. J

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5. Aydinli U, Ozturk C, Saba D, Ersozlu S. Neglected major vessel injury after anterior

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spinal surgery: a case report. Spine (Phila Pa 1976) 2004;29(15):E318-20.

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6. Martín-Pedrosa JM, Gutiérrez V, González-Fajardo JA, Vaquero C. Endovascular

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7. Carmignani A, Lentini S, Acri E, Vazzana G, Campello M, Volpe P, et al. Combined

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thoracic endovascular aortic repair and neurosurgical intervention for injury due to

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posterior spine surgery. J Card Surg 2013;28(2):163-7.

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9. Jendrisak MD. Spontaneous abdominal aortic rupture from erosion by a lumbar spine

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13. Lim KE, Fan KF, Wong YC, Hsu YY. Iatrogenic upper abdominal aortic injury with

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14. Ohnishi T, Neo M, Matsushita M, Komeda M, Koyama T, Nakamura T. Delayed

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20. Lavigne F, Mascard E, Laurian C, Dubousset J, Wicart P. Delayed-iatrogenic injury

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of the thoracic aorta by an anterior spinal instrumentation. Eur Spine J 2009;18 Suppl

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2:265-8.

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21. Sandhu HK, Charlton-Ouw KM, Azizzadeh A, Estrera AL, Safi HJ. Spinal screw

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penetration of the aorta. J Vasc Surg 2013;57(6):1668-70.

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22. Ip EW, Bourke VC, Stacey MC, Begley P, Ritter JC. Hard to diagnose and

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potentially fatal: slow aortic erosion post spinal fusion. J Emerg Med 2014;46(3):335-

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40.

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23. Narayan P, Wong A, Davies I, Angelini GD, Bryan AJ, Wilde P, et al. Thoracic

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endovascular repair versus open surgical repair – Which is the more cost-effective

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intervention for descending thoracic aortic pathologies? Eur J Cardiothorac Surg

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24. Grabenwöger M, Alfonso F, Bachet J, Bonser R, Czerny M, Eggebrecht H, et al.

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Thoracic endovascular aortic repair (TEVAR) for the treatment of aortic diseases: A

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position statement from the European Association for Cardio-Thoracic Surgery

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(EACTS) and the European Society of Cardiology (ESC), in collaboration with the

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European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J

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25. Carmona AF, Redondo AD, Pareja JC, Maldonado LP. Endovascular treatment of

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descending thoracic aortic rupture: Mid- to long-term results in a single-centre registry.

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J Cardiovasc Med (Hagerstown) 2012;13(4):266-8.

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26. Loh AS, Maldonado TS, Rockman CB, Lamparello PJ, Adelman MA, Kalhorn SP,

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et al. Endovascular solutions to arterial injury due to posterior spine surgery. J Vasc

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Surg 2012;55(5):1477-81.

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Legends to illustrations

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Figure 1. Pseudoaneurysm of the thoracic aorta in close relation with the orthopedic

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screw.

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Ao = aorta; *pseudoaneurysm

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Figure 2. Postoperative follow-up (18 months) showing absence of contrast

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extravasation.

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Ao = aorta; *screw

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ACCEPTED MANUSCRIPT Table 1. Late arterial lesions secondary to spinal surgery, anterior (A) or posterior (P) approach, period of time until diagnosis, type of vascular repair (by open or

Year

Jendrisak9

1986

Woolsey10

1986

Symptoms Retroperitoneal hematoma Retroperitoneal hematoma

Time for

Vascular

Implant

diagnosis

repair

removal

A

3 weeks

Open

Yes

A

6 weeks

Open

Yes

A

Open

Yes

Open

Yes

Access

Chest pain, Sokolic et al.11

1991

dyspnea, hemoptysis,

5 months

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fever, anemia

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First author

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endovascular surgery) and removal of orthopedic implant material

Incidental CT Matsuzaki

et

al.12

1993

scan finding

during follow-

A

6 months

P

10 months

A

20 months

Open

Yes

P

14 months

Open

Yes

P

1 month

Endosurgery

Yes

A

20 years

Endosurgery

No

up

Lim et al.13

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Lower back pain 1999

and bowel habit change, tender

Patient refused treatment

abdominal mass

Ohnishi et al.14

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Progressive

2001

gastrointestinal

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symptoms

Choi et al.15

Minor et al.16

2001

2004

Back pain Incidental CT scan finding during followup Incidental

Been et al.17

2006

finding of a CT performed for a dyspnea

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Low back pain

A

5 years

Open

Yes

A

11 months

Open

Yes

P

13 months

Open

Yes

Back pain

A

7 years

Open

Yes

Back pain

A

2 years

Open

Yes

P

10 years

Open

Yes

Infected Kakkos et al.19

2008

pseudoaneurysm Incidental CT scan finding

Lavigne et al.20

2009

Incintal finding 2013

of a CT scan performed after

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Sandhu et al.21

motor vehicle accident 2014

This report

2014

Back pain,

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Ip et al.22

hemoptysis

Incidental CT finding

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CT = computed tomography

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Higashino18

A

5 years

Endosurgery

No

A

7 years

Endosurgery

No

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