Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 63-65

Iatrogenic arteriovenous fistula after lumbar disc surgery: Case reports and review of literature


1 Department of Vascular Surgery, Sri Ramachandra Medical Centre, Chennai, Tamil Nadu, India
2 Sri Ramachandra Medical Centre, Chennai, Tamil Nadu, India

Date of Web Publication31-Jan-2018

Correspondence Address:
Dr. Pranay Pawar
Department of Vascular Surgery, Sri Ramachandra Medical Centre, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_69_17

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  Abstract 


Iatrogenic arteriovenous fistulas (AVF) after intervertebral disc surgery are rare. The presentation can be varied from potentially fatal to those, which present years after the index surgery with features of, deep vein thrombosis, leg edema, and cardiac failure. The history and physical findings can be indicative of an AVF and the diagnosis is confirmed by computed tomography (CT) CT angiogram (CTA) or digital subtraction angiogram (DSA). Open surgery and endovascular approach can be both used for the treatment of this condition, both with good results, although the endovascular approach is associated with minimal morbidity.

Keywords: Endovascular approach, iatrogenic arteriovenous fistula, lumbar disc surgery


How to cite this article:
Pawar P, Sharma A, Raju R, Ayyappan M K. Iatrogenic arteriovenous fistula after lumbar disc surgery: Case reports and review of literature. Indian J Vasc Endovasc Surg 2018;5:63-5

How to cite this URL:
Pawar P, Sharma A, Raju R, Ayyappan M K. Iatrogenic arteriovenous fistula after lumbar disc surgery: Case reports and review of literature. Indian J Vasc Endovasc Surg [serial online] 2018 [cited 2020 May 29];5:63-5. Available from: http://www.indjvascsurg.org/text.asp?2018/5/1/63/224455




  Introduction Top


Lumbar disc surgery is frequently performed and safe surgery. The iatrogenic vascular injury is a very rare (0.02%–0.06%) complication of this procedure. The injuries can be fatal with massive hemorrhage to those, that present late with features of leg edema and cardiac failure.[1] We describe two cases of iatrogenic arteriovenous fistulas (AVF's), which were managed successfully by open repair and endovascular exclusion.


  Case Reports Top


Case 1

A 28-year-old man presented with the complaints of breathlessness, left leg edema, and abdominal discomfort for the past 6 months. He gave a history of undergoing an L4–L5 laminectomy 3 years before. He had features of high output cardiac failure and abdominal bruit. His echocardiogram depicted a dilated right atrium and ventricle, increased pulmonary arterial pressure and normal ejection fraction a subsequent CTA showed an abnormal fistulous connection between the right common iliac artery (CIA) and the left common iliac vein (CIV) at the L4 level. He also had an anomalous left renal vein draining into the left CIV [Figure 1]. Since the fistula was very close to the aortic bifurcation (9 mm), we proceeded with an open approach with disconnection of the fistula and primary repair of the CIA and the CIV, as there was a limiting landing zone for an endovascular approach. Postoperatively, the pulmonary artery pressures reduced to normal immediately, and he is currently symptom-free at 2 years follow-up [Figure 2].
Figure 1: Computed tomography angiogram volume-rendered image showing fistulous connection between right common iliac artery and left common iliac vein at L4 level, right common iliac artery 12 mm, left common iliac vein 30 mm, aberrant left renal vein draining in left common iliac vein

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Figure 2: Intraoperative picture of the fistula before and after disconnection and return of the pulmonary artery pressure to normal after repair

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Case 2

A 52-year-old female presented to the medicine out patient department with the complaints of dyspnea, abdominal pain, and left leg swelling for the past 1 year. She underwent a CT abdomen for the evaluation of her abdominal complaints. It serendipitously showed an AV fistula between the right CIA and left CIV at L4–L5 level. The fistula was 22 mm distal to the aortic bifurcation [Figure 3]. She gave a history of L4– L5 laminectomy 3 years ago. On examination, she had tachycardia and was dyspneic. Her echocardiogram showed a dilated right atrium and ventricle, increased pulmonary arterial pressure and normal ejection fraction. She had an abdominal bruit and had left leg painless swelling. Since the fistula was 22 mm distal to the aortic bifurcation, she was undertaken for an endovascular approach. A 9F sheath was placed in the right common femoral artery, and the abdominal aorta was catheterized, and a 0.035-inch stiff guide wire was placed. A 12 mm × 60 mm self-expandable stent graft was deployed across the fistula. Poststenting, the angiogram was normal with no flow of contrast across the fistula into the left CIV [Figure 4]. Postoperatively, her tachycardia and dyspnea subsided and her leg swelling resolved in 2 weeks. Currently, at 1 year follow-up, she is symptom-free and doing well.
Figure 3: Computed tomography angiogram volume-rendered image showing arteriovenous fistula between right common iliac artery and left common iliac vein at L4–L5 level, dilatation of left common iliac vein distal to the arteriovenous fistula, fistula 22 mm distal to right common iliac artery origin, common iliac artery 9 mm, common iliac vein 24 mm

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Figure 4: Contrast runs before and after deployment of stent graft showing no flow of contrast across the fistula in the left common iliac vein

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  Discussion Top


Iatrogenic AVF are an unusual (0.02%–0.06%) and potentially fatal complication of lumbar spinal surgery. The presentation of these injuries is usually late, with symptoms such as leg swelling or cardiac failure.[1] The anatomic relationship between the lumbar discs and the anterior abdominal vasculature provides a potential for life-threatening complications when the anterior longitudinal ligament is penetrated during a retroperitoneal surgical approach by a pituitary rongeur.[2] The common iliac arteries, which are immediately anterior to the L4/5 lumbar-disc space, are the most commonly injured vessels (right CIA 43%; left CIA 29%). Other reported vascular injuries have included the aorta, the inferior vena cava, iliac veins, and branches of the iliac vessels. Preexisting degenerative disc surgery, retroperitoneal inflammatory processes, aggressive discectomy, and possibly increased intra-abdominal pressure are some of the proposed risk factors of vascular injury during lumbar disc surgery.[2],[3] AV fistulas may be formed immediately when the laceration includes both arterial and venous tear. Arterial hemorrhage evacuates through the venous defect leading to small or absent trauma bleeding or retroperitoneal hematoma. This is also a reason why hypotension may be absent as very minimal blood loss is present and thus, these injuries are recognized after a long time interval.[4]

The most common clinical symptom in a patient with AVF is dyspnea on exertion and a holosystolic machinery murmur in the lower abdomen or the back. The presence of leg edema, ascites, hepatomegaly, and anuria indicate severe cardiac decompensation. The development of high-output cardiac failure in a young patient, who has recently undergone lumbar discectomy, is almost diagnostic of traumatic AVF. Almost 25% of these cases go undetected for up to a year due to mild symptoms, treatment of congestive symptoms with diuretics, misdiagnosis, and ignorance of this condition. The diagnosis of this condition is made by imaging, usually CTA or DSA.[5],[6]

Surgery is associated with high mortality and morbidity rates. In spite of recent advances, surgery of chronic fistulas is still associated with a high mortality rate of 5%–10%. In an effort to avoid the morbidity and mortality associated with an open approach to traumatic AVF, the focus has shifted to endovascular techniques wherever feasible. They are associated with shorter hospital stay, lesser mortality and morbidity and can be performed under local anesthesia, especially in high-risk patients.[2]


  Conclusion Top


Iatrogenic AVFs following lumbar disc surgery usually have an insidious presentation due to their nonspecific presentation. Their presence of cardiac failure symptoms, unilateral leg edema, and past history of lumbar disc surgery should alert us to this condition. The treatment can be open surgery, although the endovascular approach is associated with excellent results with the minimum mortality and morbidity.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ocal O, Peynircioglu B, Eldem G, Akpinar E, Onur MR, Kabakci G, et al. Iliac arteriovenous fistulas after lumbar spinal surgery. Turk J Emerg Med 2017;17:109-11.  Back to cited text no. 1
    
2.
Canaud L, Hireche K, Joyeux F, D'Annoville T, Berthet JP, Marty-Ané C, et al. Endovascular repair of aorto-iliac artery injuries after lumbar-spine surgery. Eur J Vasc Endovasc Surg 2011;42:167-71.  Back to cited text no. 2
    
3.
Szolar DH, Preidler KW, Steiner H, Riepl T, Flaschka G, Stiskal M, et al. Vascular complications in lumbar disk surgery: Report of four cases. Neuroradiology 1996;38:521-5.  Back to cited text no. 3
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4.
Papadoulas S, Konstantinou D, Kourea HP, Kritikos N, Haftouras N, Tsolakis JA, et al. Vascular injury complicating lumbar disc surgery. A systematic review. Eur J Vasc Endovasc Surg 2002;24:189-95.  Back to cited text no. 4
    
5.
Noland S, Espinoza CA, Dvorak JD, Rose JD, Powell CS. Endovascular repair of iatrogenic iliocaval fistula causing high-output cardiac failure after spine fusion. Ann Vasc Surg 2017;45:262.e1.  Back to cited text no. 5
    
6.
Akpinar B, Peynircioǧlu B, Cil B, Daǧlioǧlu E, Cekirge S. Iliac vascular complication after spinal surgery: Immediate endovascular repair following CT angiographic diagnosis. Diagn Interv Radiol 2009;15:303-5.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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