- Email: [email protected]
Simultaneous Endovascular Repair of a Thoracic Aortic Injury during Posterior Pedicle Screw Removal: A Case Report
Accepted Manuscript Case Report: Simultaneous Endovascular Repair of a Thoracic Aortic Injury during Posterior Pedicle Screw Removal Miss Serena Martin, MB BCh BAO Hons BSc Hons MRCS, Core Trainee, Dr Richard Lindsay, Consultant Interventional Radiologist, Mr Robin C. Baker, MD, Consultant Vascular Surgeon PII:
S0890-5096(16)31296-1
DOI:
10.1016/j.avsg.2017.10.021
Reference:
AVSG 3637
To appear in:
Annals of Vascular Surgery
Received Date: 28 November 2016 Revised Date:
26 July 2017
Accepted Date: 19 October 2017
Please cite this article as: Martin S, Lindsay R, Baker RC, Case Report: Simultaneous Endovascular Repair of a Thoracic Aortic Injury during Posterior Pedicle Screw Removal, Annals of Vascular Surgery (2018), doi: 10.1016/j.avsg.2017.10.021. 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 2
Case Report: Simultaneous Endovascular Repair of a Thoracic Aortic Injury during
3
Posterior Pedicle Screw Removal
7
1. Miss Serena Martin MB BCh BAO Hons BSc Hons MRCS1 , Core Trainee, Royal Victoria Hospital Belfast (Corresponding author)
8
[email protected]
9
Tel: +447746203241
11
2. Dr Richard Lindsay1, Consultant Interventional Radiologist, Royal Victoria Hospital Belfast
TE D
10
SC
6
Authors
M AN U
5
RI PT
4
[email protected]
13
3. Mr Robin C. Baker MD1, Consultant Vascular Surgeon, Royal Victoria Hospital Belfast
14
[email protected]
16 17
AC C
15
EP
12
1. Vascular Unit, Royal Victoria Hospital, 274 Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
18 19 20 1
ACCEPTED MANUSCRIPT Case Report: Simultaneous Endovascular Repair of a Thoracic Aortic Injury during Posterior
22
Pedicle Screw Removal
23
Abstract
24
Introduction
25
Posterior spinal stabilisation is a technically demanding procedure which is increasing in popu-
26
larity. Since this increase in popularity, complications, including screws misplacement, are be-
27
ing highlighted. Accuracy rates are higher when imaging modalities are used intra-operatively.
28
Vascular injuries following posterior spinal stabilisation are rare and are usually discovered late
29
on subsequent imaging. Immediate peri-operative compromise is rare, but nonetheless, re-
30
sultant vascular injuries can be life threatening.
31
Case History
32
A 72year old lady had a posterior spinal stabilisation for severe pain caused by discitis. Routine
33
CT scan two weeks post-operatively detected an incidental thoracic aortic injury due to a mis-
34
placed pedicle screw. Given the rarity of this complication there is no guideline for the man-
35
agement of resultant aortic injuries. Options described in the literature include; thoracotomy
36
with open vascular repair and newer endovascular techniques.
37
We describe a novel method of simultaneous endovascular repair of a thoracic aortic injury
38
during posterior pedicle screw removal with the patient in the right decubitus position.
39
Conclusions
40
Surgeons operating near high risk vascular structures should use intra-operative imaging mo-
41
dalities to guide screw placement and reduce subsequent complication rates. During endovas-
42
cular repair of resultant aortic injuries several factors must be considered. In particular, the
43
challenge of turning a patient with open groin access and an endovascular stent in place. This
AC C
EP
TE D
M AN U
SC
RI PT
21
2
ACCEPTED MANUSCRIPT must be carried out with extreme care to avoid the following risks; loss of access, damage to
45
the access vessels and bleeding, displacement of the stent or deployment wires and loss of the
46
sterile field.
47
Introduction
48
Vascular injuries following spinal stabilisation are rare but have potentially fatal complications.
49
The majority of vascular complications are identified late, ranging from 6 weeks to 20 years.
50
Discovery of these vascular injuries can often be an incidental finding on subsequent imaging,
51
others are diagnosed following prolonged symptoms of back pain or anaemia.[1] We report a
52
case of a rare vascular complication following pedicle screw misplacement for posterior spinal
53
stabilisation, as well as a novel variation of endovascular management.
54
Case History
55
A 72yr old lady presented to the orthopaedic clinic with a 5 week history of lower back pain
56
following a mechanical injury. She had an acute worsening of pain in the two weeks leading up
57
to admission, which had greatly limited her mobility. She was admitted to hospital and had an
58
MRI spine which revealed acute discitis affecting T11-T12. Blood cultures were positive for
59
Staphylococcus aureus and she was commenced on IV antibiotics for a planned 6 week course.
60
Due to ongoing severe pain, surgical intervention was deemed necessary. She proceeded to
61
have a posterior stabilisation of T8-L3 vertebrae under fluoroscopic guidance in theatre. This
62
greatly improved her symptoms and mobility.
63
Routine follow up CT to check the position of the screws and fixation device was performed
64
two weeks post-stabilisation. CT revealed the upper left screw which was meant to be con-
65
tained within the T8 vertebrae, had breached the anterior cortex and penetrated the lower
66
thoracic aorta. A CT angiogram of the thoracic aorta was performed to assess the extent of
AC C
EP
TE D
M AN U
SC
RI PT
44
3
ACCEPTED MANUSCRIPT aortic involvement. The angiogram showed the tip of the left, upper T8 screw had penetrated
68
the posterior thoracic aorta but had not caused any extravasation of contrast. (Fig 1 and Fig 2.)
69
The patient was referred to the endovascular team the same day. A decision was made to sim-
70
ultaneously withdraw the upper pedicle screw whilst maintaining haemostasis by placing a
71
covered endovascular stent. She proceeded to theatre under joint orthopaedic and vascular
72
care. The right common femoral artery was used for access. A GORE® C TAG® thoracic stent
73
was placed in position, but not deployed, in the thoracic aorta. [Fig. 3] The patient was then
74
rotated into a right decubitus position to allow for screw removal. As the orthopaedic team
75
removed the misplaced T8 screw, the vascular team simultaneously deployed the stent over
76
the affected area of the thoracic aorta. [Fig. 4] Three-planar aortography was performed after
77
stent deployment and confirmed successful endograft placement with no evidence of leak.
78
[Fig. 5]
79
This lady recovered well and was discharged home on long-term antibiotics. Following stent
80
placement her planned antibiotic course of 6 weeks was extended to 3 months. She is now
81
more than one year post-thoracic stent and has had no further complications. Follow up CT
82
angiogram at 6 months confirmed a patent stent with no endoleak. It also confirmed the met-
83
alwork remained in a satisfactory position with no compromise of the orthopaedic stabilisa-
84
tion.
85
Discussion
86
Posterior Spinal Stabilisation
87
Posterior spinal stabilisation is a technically demanding procedure which is becoming increas-
88
ingly popular. With this increase in popularity, various complications caused by malposition of
89
the pedicle screws have been recognised. Complications can be categorised as mechanical,
90
neurological or vascular. [2] The rate of cortical perforation from misplaced pedicle screws has
AC C
EP
TE D
M AN U
SC
RI PT
67
4
ACCEPTED MANUSCRIPT led to advances and alterations in surgical technique to improve operative safety. The use of
92
intra-operative imaging has been shown to reduce the rate of screw misplacement. Rates of
93
screw misplacement range from 3-36% with intra-operative imaging compared to 16-55%
94
when bony landmarks are used alone. [3]
95
Studies in the literature have compared the use of intra-operative imaging modalities to guide
96
screw placement, including the use of 2D and 3D fluoroscopy and the use of intra-operative CT
97
scanning. [4] A meta-analysis of 7,533 pedicle screws to determine accuracy rates with various
98
imaging modalities has been published. Overall, positional accuracy rates were 90% for CT
99
guided navigation and 85% for 2D fluoroscopy-based navigation. This discrepancy increased
100
further in thoracic stabilisation compared to lumbar stabilisation, most likely due to anatomi-
101
cal variances. [4]
102
Posterior stabilisation in this case, was performed under multi-planar fluoroscopic guidance in
103
theatre and the misplaced screws were not detected on the imaging at the time of surgery.
104
One of the known limitations of multi-planar fluoroscopy in thoracic imaging includes ob-
105
scured bony anatomy due to the nearby mediastinal structures and ribs. The 2D images ob-
106
tained also require experienced operators with the ability to accurately interpret the spatial
107
position of the pedicles prior to screw insertion. [3]
108
Vascular Injury
109
Aortic injury following misplaced pedicle screws is rare. Incidence rates are therefore un-
110
known, with less than a handful of cases described in the literature. It is known, however, that
111
the majority of aortic injuries resulting from misplaced screws are asymptomatic and diag-
112
nosed incidentally. There are rarely reports of immediate vascular compromise in the peri-
113
operative period. [5] There is a risk of chronic irritation to the aorta from the tip of the mis-
114
placed screw, with potential weakening of the aorta, leading to tears/lacerations or the for-
115
mation of a pseudoaneurysm if the misplaced screw is left in-situ.
AC C
EP
TE D
M AN U
SC
RI PT
91
5
ACCEPTED MANUSCRIPT Given the rarity of this complication, there is no guideline for the management of subsequent
117
aortic injuries. Studies published in the literature to date have highlighted several methods of
118
managing aortic injuries resulting from orthopaedic procedures, ranging from thoracotomy
119
and open repair to endovascular stent placement. [5]
120
Thoracic aorta repair by open thoracotomy is a major operation. It requires the aorta to be
121
clamped both proximally and distally to allow for a patch angioplasty repair. This operation
122
carries a higher morbidity and mortality especially in the elderly population, who are the popu-
123
lation most likely to require spinal stabilisation. Given the advancement of endovascular tech-
124
niques for aortic aneurysm repair in the past three decades, and the associated lower morbidi-
125
ty and mortality rates, endovascular techniques would be ideally suited for the management
126
of these traumatic aortic injuries. [5]
127
The timing of endovascular stent placement varies between the few published case reports.
128
One report placed the stent graft after two misplaced screws were partially removed [6], an-
129
other reported full stent placement and deployment over the misplaced screw and injured
130
aorta prior to screw removal.[5] In our case, the stent graft was placed, but not deployed, the
131
patient was then turned on her side and the misplaced screw was removed and the stent was
132
deployed.
133
Turning a patient with an endovascular stent in place with open groin access is a challenge and
134
needs to be carried out with extreme care. Risks include damage to the access vessels, bleed-
135
ing, loss of access, displacement of the stent or deployment wires and loss of the sterile field.
136
Prior to placing the patient in the lateral decubitus position team roles were assigned to en-
137
sure this was performed as safely as possible. The vascular team were responsible for main-
138
taining the femoral access and stent, while theatre nursing staff helped to support the patient
139
in position during the procedure. To our knowledge this is the first report of simultaneous
140
screw removal and endovascular stent deployment with the patient on their side.
AC C
EP
TE D
M AN U
SC
RI PT
116
6
ACCEPTED MANUSCRIPT 141 142
On behalf of all authors, the corresponding author states that there is no conflict of interest.
144 145
References
RI PT
143
1. Akinrinlola. A and Brinster. D.R, Endovascular Treatment of a Malpositioned Screw in the Thoracic Aorta After Anterior Spinal Instrumentation: The Screwed Aorta. Vascular
147
and Endovascular Surgery, 2013; 47 (7); 555-557
SC
146
2. Wegener. B, Birkenmaier. C, Fottner. A, Jansson. V, Duur. H.R. Delayed perforation of
149
the aorta by a thoracic pedicle screw, Eur Spine J, 2008; 17 (Suppl 2); S351-S354
M AN U
148
150
3. Zeiller. S.C, Lee. J, Lim. M, Vaccaro. A.R, Posterior thoracic segmental pedicle screw in-
151
strumentation: Evolving methods of safe and effective placement, Neurol India, 2005;
152
53:458-65 4.
154 155
Tian. N-F, Xu. H-Z, Image-guided pedicle screw insertion accuracy: a meta-analysis, In-
TE D
153
ternational Orthopaedics, 2009; 33:895-903 5.
Hu. HT, Shin. J.H, Hwang. J-Y, Cho. Y.J, Ko. G-Y, Yoon. H.K. Thoracic Aortic Stent-Graft Placement for Safe Removal of a Malpositioned Pedicle Screw, Cardiovasc Interven-
157
tional Radiology, 2010, 33:1040-1043
159 160
6. Kopp. R, Beisse. R, Weidenhagen. R, Piltz. S, Hauck. S, Becker. C, Pieske. O, Bühren. V,
AC C
158
EP
156
Jauch. K, Lauterjung. L. Strategies for Prevention and Operative Treatment of Aortic Lesions Related to Spinal Interventions, Spine 2007, 32:E753–E760
161 162 163 164 165
Figure Legends 7
ACCEPTED MANUSCRIPT Fig 1. Sagital CT image showing the screw penetrating the thoracic aorta.
167
Fig 2. Transverse CT image showing the screw penetrating the thoracic aorta.
168
Fig 3. Thoracic endograft in position prior to deployment and removal of the superior mis-
169
placed pedicle screw. Arrow shows misplaced screw.
170
Fig 4. Endograft in position as misplaced screw is removed
171
Fig 5. Thoracic endograft after deployment showing no contrast extravasation
AC C
EP
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M AN U
SC
RI PT
166
8
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
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M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
Fig. 3 Thoracic endograft in position prior to deployment and removal of the superior misplaced pedicle screw. Arrow shows misplaced screw.
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
Fig. 4 Endograft in position as misplaced screw is removed
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
Fig. 5 Thoracic endograft after deployment showing no contrast extravasation
S0890-5096(16)31296-1
DOI:
10.1016/j.avsg.2017.10.021
Reference:
AVSG 3637
To appear in:
Annals of Vascular Surgery
Received Date: 28 November 2016 Revised Date:
26 July 2017
Accepted Date: 19 October 2017
Please cite this article as: Martin S, Lindsay R, Baker RC, Case Report: Simultaneous Endovascular Repair of a Thoracic Aortic Injury during Posterior Pedicle Screw Removal, Annals of Vascular Surgery (2018), doi: 10.1016/j.avsg.2017.10.021. 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 2
Case Report: Simultaneous Endovascular Repair of a Thoracic Aortic Injury during
3
Posterior Pedicle Screw Removal
7
1. Miss Serena Martin MB BCh BAO Hons BSc Hons MRCS1 , Core Trainee, Royal Victoria Hospital Belfast (Corresponding author)
8
[email protected]
9
Tel: +447746203241
11
2. Dr Richard Lindsay1, Consultant Interventional Radiologist, Royal Victoria Hospital Belfast
TE D
10
SC
6
Authors
M AN U
5
RI PT
4
[email protected]
13
3. Mr Robin C. Baker MD1, Consultant Vascular Surgeon, Royal Victoria Hospital Belfast
14
[email protected]
16 17
AC C
15
EP
12
1. Vascular Unit, Royal Victoria Hospital, 274 Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
18 19 20 1
ACCEPTED MANUSCRIPT Case Report: Simultaneous Endovascular Repair of a Thoracic Aortic Injury during Posterior
22
Pedicle Screw Removal
23
Abstract
24
Introduction
25
Posterior spinal stabilisation is a technically demanding procedure which is increasing in popu-
26
larity. Since this increase in popularity, complications, including screws misplacement, are be-
27
ing highlighted. Accuracy rates are higher when imaging modalities are used intra-operatively.
28
Vascular injuries following posterior spinal stabilisation are rare and are usually discovered late
29
on subsequent imaging. Immediate peri-operative compromise is rare, but nonetheless, re-
30
sultant vascular injuries can be life threatening.
31
Case History
32
A 72year old lady had a posterior spinal stabilisation for severe pain caused by discitis. Routine
33
CT scan two weeks post-operatively detected an incidental thoracic aortic injury due to a mis-
34
placed pedicle screw. Given the rarity of this complication there is no guideline for the man-
35
agement of resultant aortic injuries. Options described in the literature include; thoracotomy
36
with open vascular repair and newer endovascular techniques.
37
We describe a novel method of simultaneous endovascular repair of a thoracic aortic injury
38
during posterior pedicle screw removal with the patient in the right decubitus position.
39
Conclusions
40
Surgeons operating near high risk vascular structures should use intra-operative imaging mo-
41
dalities to guide screw placement and reduce subsequent complication rates. During endovas-
42
cular repair of resultant aortic injuries several factors must be considered. In particular, the
43
challenge of turning a patient with open groin access and an endovascular stent in place. This
AC C
EP
TE D
M AN U
SC
RI PT
21
2
ACCEPTED MANUSCRIPT must be carried out with extreme care to avoid the following risks; loss of access, damage to
45
the access vessels and bleeding, displacement of the stent or deployment wires and loss of the
46
sterile field.
47
Introduction
48
Vascular injuries following spinal stabilisation are rare but have potentially fatal complications.
49
The majority of vascular complications are identified late, ranging from 6 weeks to 20 years.
50
Discovery of these vascular injuries can often be an incidental finding on subsequent imaging,
51
others are diagnosed following prolonged symptoms of back pain or anaemia.[1] We report a
52
case of a rare vascular complication following pedicle screw misplacement for posterior spinal
53
stabilisation, as well as a novel variation of endovascular management.
54
Case History
55
A 72yr old lady presented to the orthopaedic clinic with a 5 week history of lower back pain
56
following a mechanical injury. She had an acute worsening of pain in the two weeks leading up
57
to admission, which had greatly limited her mobility. She was admitted to hospital and had an
58
MRI spine which revealed acute discitis affecting T11-T12. Blood cultures were positive for
59
Staphylococcus aureus and she was commenced on IV antibiotics for a planned 6 week course.
60
Due to ongoing severe pain, surgical intervention was deemed necessary. She proceeded to
61
have a posterior stabilisation of T8-L3 vertebrae under fluoroscopic guidance in theatre. This
62
greatly improved her symptoms and mobility.
63
Routine follow up CT to check the position of the screws and fixation device was performed
64
two weeks post-stabilisation. CT revealed the upper left screw which was meant to be con-
65
tained within the T8 vertebrae, had breached the anterior cortex and penetrated the lower
66
thoracic aorta. A CT angiogram of the thoracic aorta was performed to assess the extent of
AC C
EP
TE D
M AN U
SC
RI PT
44
3
ACCEPTED MANUSCRIPT aortic involvement. The angiogram showed the tip of the left, upper T8 screw had penetrated
68
the posterior thoracic aorta but had not caused any extravasation of contrast. (Fig 1 and Fig 2.)
69
The patient was referred to the endovascular team the same day. A decision was made to sim-
70
ultaneously withdraw the upper pedicle screw whilst maintaining haemostasis by placing a
71
covered endovascular stent. She proceeded to theatre under joint orthopaedic and vascular
72
care. The right common femoral artery was used for access. A GORE® C TAG® thoracic stent
73
was placed in position, but not deployed, in the thoracic aorta. [Fig. 3] The patient was then
74
rotated into a right decubitus position to allow for screw removal. As the orthopaedic team
75
removed the misplaced T8 screw, the vascular team simultaneously deployed the stent over
76
the affected area of the thoracic aorta. [Fig. 4] Three-planar aortography was performed after
77
stent deployment and confirmed successful endograft placement with no evidence of leak.
78
[Fig. 5]
79
This lady recovered well and was discharged home on long-term antibiotics. Following stent
80
placement her planned antibiotic course of 6 weeks was extended to 3 months. She is now
81
more than one year post-thoracic stent and has had no further complications. Follow up CT
82
angiogram at 6 months confirmed a patent stent with no endoleak. It also confirmed the met-
83
alwork remained in a satisfactory position with no compromise of the orthopaedic stabilisa-
84
tion.
85
Discussion
86
Posterior Spinal Stabilisation
87
Posterior spinal stabilisation is a technically demanding procedure which is becoming increas-
88
ingly popular. With this increase in popularity, various complications caused by malposition of
89
the pedicle screws have been recognised. Complications can be categorised as mechanical,
90
neurological or vascular. [2] The rate of cortical perforation from misplaced pedicle screws has
AC C
EP
TE D
M AN U
SC
RI PT
67
4
ACCEPTED MANUSCRIPT led to advances and alterations in surgical technique to improve operative safety. The use of
92
intra-operative imaging has been shown to reduce the rate of screw misplacement. Rates of
93
screw misplacement range from 3-36% with intra-operative imaging compared to 16-55%
94
when bony landmarks are used alone. [3]
95
Studies in the literature have compared the use of intra-operative imaging modalities to guide
96
screw placement, including the use of 2D and 3D fluoroscopy and the use of intra-operative CT
97
scanning. [4] A meta-analysis of 7,533 pedicle screws to determine accuracy rates with various
98
imaging modalities has been published. Overall, positional accuracy rates were 90% for CT
99
guided navigation and 85% for 2D fluoroscopy-based navigation. This discrepancy increased
100
further in thoracic stabilisation compared to lumbar stabilisation, most likely due to anatomi-
101
cal variances. [4]
102
Posterior stabilisation in this case, was performed under multi-planar fluoroscopic guidance in
103
theatre and the misplaced screws were not detected on the imaging at the time of surgery.
104
One of the known limitations of multi-planar fluoroscopy in thoracic imaging includes ob-
105
scured bony anatomy due to the nearby mediastinal structures and ribs. The 2D images ob-
106
tained also require experienced operators with the ability to accurately interpret the spatial
107
position of the pedicles prior to screw insertion. [3]
108
Vascular Injury
109
Aortic injury following misplaced pedicle screws is rare. Incidence rates are therefore un-
110
known, with less than a handful of cases described in the literature. It is known, however, that
111
the majority of aortic injuries resulting from misplaced screws are asymptomatic and diag-
112
nosed incidentally. There are rarely reports of immediate vascular compromise in the peri-
113
operative period. [5] There is a risk of chronic irritation to the aorta from the tip of the mis-
114
placed screw, with potential weakening of the aorta, leading to tears/lacerations or the for-
115
mation of a pseudoaneurysm if the misplaced screw is left in-situ.
AC C
EP
TE D
M AN U
SC
RI PT
91
5
ACCEPTED MANUSCRIPT Given the rarity of this complication, there is no guideline for the management of subsequent
117
aortic injuries. Studies published in the literature to date have highlighted several methods of
118
managing aortic injuries resulting from orthopaedic procedures, ranging from thoracotomy
119
and open repair to endovascular stent placement. [5]
120
Thoracic aorta repair by open thoracotomy is a major operation. It requires the aorta to be
121
clamped both proximally and distally to allow for a patch angioplasty repair. This operation
122
carries a higher morbidity and mortality especially in the elderly population, who are the popu-
123
lation most likely to require spinal stabilisation. Given the advancement of endovascular tech-
124
niques for aortic aneurysm repair in the past three decades, and the associated lower morbidi-
125
ty and mortality rates, endovascular techniques would be ideally suited for the management
126
of these traumatic aortic injuries. [5]
127
The timing of endovascular stent placement varies between the few published case reports.
128
One report placed the stent graft after two misplaced screws were partially removed [6], an-
129
other reported full stent placement and deployment over the misplaced screw and injured
130
aorta prior to screw removal.[5] In our case, the stent graft was placed, but not deployed, the
131
patient was then turned on her side and the misplaced screw was removed and the stent was
132
deployed.
133
Turning a patient with an endovascular stent in place with open groin access is a challenge and
134
needs to be carried out with extreme care. Risks include damage to the access vessels, bleed-
135
ing, loss of access, displacement of the stent or deployment wires and loss of the sterile field.
136
Prior to placing the patient in the lateral decubitus position team roles were assigned to en-
137
sure this was performed as safely as possible. The vascular team were responsible for main-
138
taining the femoral access and stent, while theatre nursing staff helped to support the patient
139
in position during the procedure. To our knowledge this is the first report of simultaneous
140
screw removal and endovascular stent deployment with the patient on their side.
AC C
EP
TE D
M AN U
SC
RI PT
116
6
ACCEPTED MANUSCRIPT 141 142
On behalf of all authors, the corresponding author states that there is no conflict of interest.
144 145
References
RI PT
143
1. Akinrinlola. A and Brinster. D.R, Endovascular Treatment of a Malpositioned Screw in the Thoracic Aorta After Anterior Spinal Instrumentation: The Screwed Aorta. Vascular
147
and Endovascular Surgery, 2013; 47 (7); 555-557
SC
146
2. Wegener. B, Birkenmaier. C, Fottner. A, Jansson. V, Duur. H.R. Delayed perforation of
149
the aorta by a thoracic pedicle screw, Eur Spine J, 2008; 17 (Suppl 2); S351-S354
M AN U
148
150
3. Zeiller. S.C, Lee. J, Lim. M, Vaccaro. A.R, Posterior thoracic segmental pedicle screw in-
151
strumentation: Evolving methods of safe and effective placement, Neurol India, 2005;
152
53:458-65 4.
154 155
Tian. N-F, Xu. H-Z, Image-guided pedicle screw insertion accuracy: a meta-analysis, In-
TE D
153
ternational Orthopaedics, 2009; 33:895-903 5.
Hu. HT, Shin. J.H, Hwang. J-Y, Cho. Y.J, Ko. G-Y, Yoon. H.K. Thoracic Aortic Stent-Graft Placement for Safe Removal of a Malpositioned Pedicle Screw, Cardiovasc Interven-
157
tional Radiology, 2010, 33:1040-1043
159 160
6. Kopp. R, Beisse. R, Weidenhagen. R, Piltz. S, Hauck. S, Becker. C, Pieske. O, Bühren. V,
AC C
158
EP
156
Jauch. K, Lauterjung. L. Strategies for Prevention and Operative Treatment of Aortic Lesions Related to Spinal Interventions, Spine 2007, 32:E753–E760
161 162 163 164 165
Figure Legends 7
ACCEPTED MANUSCRIPT Fig 1. Sagital CT image showing the screw penetrating the thoracic aorta.
167
Fig 2. Transverse CT image showing the screw penetrating the thoracic aorta.
168
Fig 3. Thoracic endograft in position prior to deployment and removal of the superior mis-
169
placed pedicle screw. Arrow shows misplaced screw.
170
Fig 4. Endograft in position as misplaced screw is removed
171
Fig 5. Thoracic endograft after deployment showing no contrast extravasation
AC C
EP
TE D
M AN U
SC
RI PT
166
8
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
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M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
Fig. 3 Thoracic endograft in position prior to deployment and removal of the superior misplaced pedicle screw. Arrow shows misplaced screw.
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
Fig. 4 Endograft in position as misplaced screw is removed
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
Fig. 5 Thoracic endograft after deployment showing no contrast extravasation