Iatrogenic arterial injuries of spine and orthopedicoperationsSachinder Singh Hans, MD,a,b Alexander D. Shepard, MD,a Pritham Reddy, MD,a,b Kumara Rama, MD,b
and William Romano, MD,c Detroit and Royal Oak, Mich
Objective: To describe the results of contemporary management of iatrogenic arterial injuries following spine andorthopedic operations.Methods: Patients with major arterial injuries following spine and orthopedic operations in four teaching hospitals (HenryFord Hospital, Detroit, Mich; Henry Ford Macomb Hospital, Clinton Township, Mich; St John Macomb Hospital,Warren, Mich; and St John Hospital, Detroit, Mich) over the last 10 years were studied. Data were collected on acontinuous basis from vascular registries and analyzed retrospectively.Results: Seventeen patients (8 spine, 9 orthopedic operations) had iatrogenic arterial injuries manifest as thrombosis orlaceration with bleeding, pseudoaneurysm, or arteriovenous fistula. The majority of arterial lacerations with bleeding andpseudoaneurysms were treated with open surgical repair while the majority of thromboses and arteriovenous fistulae weretreated with endovascular techniques. Fasciotomy was necessary in three of seven patients with arterial complications ofknee and hip operations. There was no mortality or limb loss. Significant morbidity in the form of foot drop (1), iliac veinthrombosis (2), delayed ambulation due to hematoma and swelling of the lower extremity (2), and ischemic myonecrosisof calf muscles (1) occurred. Two patients launched legal action.Conclusion: Arterial injuries following orthopedic and spine operations can be successfully managed by both open andendovascular techniques. Significant morbidity and increased length of stay is common. Patient dissatisfaction with thecomplication and need for ensuing treatment can have significant medicolegal consequences. ( J Vasc Surg 2011;53:
407-13.)
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Arthroplasty and spine procedures impart pain reliefand improve quality of life for patients affected by arthritisof the spine or major joints. These procedures are nowperformed in patients of advanced age with preexistingcomorbidities. Despite the increasing number of spine andorthopedic operations, iatrogenic arterial injuries are rela-tively uncommon.1-11 Delay in the diagnosis and manage-ment of such injuries can result in occasional mortality andsignificant morbidity including limb loss. Since the first casereport of arterial injury following hip arthroplasty, therehave been case reports, a few case series, and one multi-institutional study examining the incidence, predictors andmanagement of such injuries.1-11 Previously, publishedreports have focused on the vascular complications of kneeand hip arthroplasty and their management by open surgi-cal techniques.7-11 In this report, early and late outcome ofcontemporary repair of iatrogenic arterial injuries resultingfrom spine, upper, and lower extremity orthopedic proce-dures is reported.
From the Division of Vascular Surgery, Henry Ford Health Systems, De-troit;a St John Health Systems, Detroit;b and Interventional Radiology,William Beaumont Hospital, Royal Oak.c
Competition of interest: none.Presented at the 2010 Vascular Annual Meeting of the Society for Vascular
Surgery, June 10-13, 2010, Boston, Mass.Reprint requests: Sachinder Singh Hans, MD, Department of Surgery, St
John Macomb Hospital, 28411 Hoover, Warren, MI, 48093 (e-mail:[email protected]).
The editors and reviewers of this article have no relevant financial relationshipsto disclose per the JVS policy that requires reviewers to decline review of anymanuscript for which they may have a competition of interest.
Patients with major arterial injuries following orthope-ic and spine operations in four teaching hospitals were
ncluded: Henry Ford Hospital, Detroit, Mich (725 bedertiary care facility); Henry Ford Macomb Hospital inlinton Township (350 bed teaching hospital); St Johnospital and Medical Center, Detroit, Mich (550 bed
ertiary care medical center); and St John Macomb Hospi-al, Warren, Mich (350 bed teaching hospital). All fourarticipating hospitals have independent vascular registries.atients with arterial injuries were entered by residents,
ellows, and attending vascular surgeons. Data regardinghe number of orthopedic and spine procedures from eachospital were added for the denominator. Data were col-
ected on a continuing basis from vascular registries andnalyzed retrospectively from 1999 to 2009. There were aew patients with laceration of branch arteries (iliac, femo-al, popliteal) requiring assistance by vascular surgeons buthey were not included in this report.
Our approach regarding management of arterial inju-ies following spine/orthopedic procedures is described inclinical flow sheet (Fig 1).
ESULTS
Seventeen patients (ten male, seven female) had iatro-enic arterial complications (mean age 62.7 � 6.4 years).hirteen patients were Caucasian and four were African-merican. All patients undergoing hip and knee proceduresad spinal anesthesia and patients undergoing shoulder and
JOURNAL OF VASCULAR SURGERYFebruary 2011408 Hans et al
Spine operations
Five patients out of 560 anterior lumbar spinal fusionsdeveloped significant arterial complications (Table I). Twopatients developed thrombosis of the left iliac artery follow-ing attempted control of bleeding from tributaries of theleft iliac vein. In one patient, the venous tear extended toinvolve the confluence of the common iliac veins; duringcontrol of this bleeding, retraction of diseased commonand external iliac arteries led to a localized dissection withthrombosis of the left external iliac artery. This injury wastreated with a left iliofemoral graft. In the second patient,arterial occlusion was diagnosed when somatosensoryevoked potential showed loss of peripheral nerve conduc-tion (posterior tibial nerve) during/after an anterior spinalfusion procedure complicated by venous bleeding. Thepatient was noted to have an absent femoral pulse and was
Fig 1. Suggested management strategies for arter
Table I. Arterial injuries associated with spine operations
Incidence Presentatio
Anterior lumbarspinal fusion
5/560 (0.0089%) Iliac artery thrombo
Aortofemoral graft locclusion � 1
Left iliac artery thromiliac venous hemo
Thoracic spinefusion
1a Contained lower thorupture � 1
Thoracolumbarspine fusion
1a Thoracic aortic screwpenetration � 1
Lumbar discectomy 1/12,654 (0.0007%) Shock with abdomin
aInitial surgery performed at an outside institution.
treated with a left external iliac covered stent (Fluency Bard P
ascular, Tempe, Ariz) and thromboembolectomy of theeft femoral, popliteal, and infrapopliteal arteries.
One patient with a remote aortobifemoral graft devel-ped left graft limb thrombosis, presented to the vascularlinic 48 hours after anterior spinal fusion and underwentuccessful open thrombectomy of the graft. Another pa-ient was diagnosed with left iliac artery thrombosis 24ours post anterior spinal fusion and was treated with left
liac stenting. A final patient underwent a left iliac arteryhrombectomy followed by left external iliac artery stentingor left common and external iliac arterial thrombosis.
One patient developed abdominal pain and shock fol-owing microlumbar discectomy. Computed tomographyCT) scan of the abdomen showed a retroperitoneal hema-oma. Arteriography showed a left common iliac artery pseu-oaneurysm with common iliac ateriovenous (AV) fistula.
atient underwent a left common iliac artery interposition
Fig 3. Arteriogram showing placement of covered stent.
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JOURNAL OF VASCULAR SURGERYVolume 53, Number 2 Hans et al 409
graft with 10 mm polytetrafluoroethylene (PTFE) prosthesisand ligation of the iliac vein as profuse venous bleedingprecluded repair. Endograft (covered stent) was not availableat that time.
Two patients had pedicle screw injuries to the thoracicaorta noted late after primary thoracic spine operationsperformed at an outside hospital. One of these patients hadtwo injuries; one was an infected pseudoaneurysm and theother a simple screw penetration. Both patients underwentsuccessful thoracic aortic repair using atriofemoral bypassand have been previously reported.5
Orthopedic procedures
Knee arthroplasty. Three patients sustained popli-teal arterial lacerations during knee arthroplasty (TableII). Two patients were diagnosed by an orthopedistfollowing release of the tourniquet. One patient under-went repair of the popliteal artery with end-to-end anas-tomosis via medial approach. Two patients underwentrepair of the popliteal artery through the posterior ap-proach, one with end-to-end anastomosis and one withthe interposition of a short segment PTFE graft (W. L.
Fig 2. Arteriogram via contralateral femoral approach showinganeurysm popliteal artery.
Table II. Arterial injuries associated with knee arthroplast
JOURNAL OF VASCULAR SURGERYFebruary 2011410 Hans et al
presented 2 months following knee surgery with a pop-liteal artery pseudoaneurysm and was treated with place-ment of a covered stent (Viabahn; W. L. Gore andAssociates, Newark, Del) via a contralateral percutane-ous femoral artery approach (Figs 2-4). A final patientdeveloped popliteal artery thrombosis following a sec-ondary knee procedure. This injury was treated withthrombectomy and vein patch grafting via a posteriorapproach with concomitant fasciotomy. Vacuum assistedclosure therapy was used in two patients followingfasciotomy.
Hip procedures. An injury to the left lateral circum-flex femoral artery was treated with ligation and evacuationof hematoma (Table III) when the patient presented with acompression femoral neuropathy and pseudoaneurysm.
In one patient undergoing redo hip arthroplasty,thrombosis of the left common femoral artery secondary todissection occurred. Thromboendartectomy of the left fem-oral artery with embolectomy of the infrapopliteal arteries andfour compartment fasciotomies was performed. Patient hadischemic myonecrosis which required excision of much of theanterior and lateral compartment musculature.
Shoulder arthroplasty. One patient had laceration ofthe axillary artery and underwent repair with a 6 mm PTFEinterposition graft (Table IV) during a redo shoulder ar-throplasty. One patient developed an AV fistula 10 yearsfollowing biceps tendon repair and stapler fixation at thelevel of the humeral head at an out-of-state hospital. Heunderwent placement of a covered stent (Fluency Bard,Tempe, Ariz) in the left axillary artery using a femoralapproach as a first stage procedure followed by direct accessof the left brachial artery (at the elbow), left cephalic, andbasilic veins, using coaxial microcatheter system, coil em-bolization of the AV fistula was performed with satisfactoryoutcome as covered stent placement failed to completely
Table III. Arterial injuries associated with hip surgery
Incidence Presentation
Hip surgery 2/13,160 (0.0015%)Redo hip arthroplasty 1 Left femoral artery
thrombosis
Open reduction andinternal fixation
1 Left lateral circumfleartery pseudoaneuwith femoralneuropathy
Table IV. Arterial injuries associated with shoulder operat
aInitial surgery performed in outside institution.
obliterate the fistula at first stage (Figs 5-7). a
ength of stay and readmissions
The average length of stay for hip arthroplasty (openeduction and internal fixation) and knee arthroplasty washree days. Shoulder arthroplasty averaged 2 days, anteriorumbar fusion averaged 2 days, and posterior lumbar spineperations averaged two days in patients without arterial
njuries.Two patients out of 17 were treated as outpatients. Sec-
ndary admissions were necessary for three patients for arterialnjuries following thoracic spine operations (2) and left aorticraft limb occlusion (1). The remaining 12 patients with
Fig 5. Left axillary arteriogram showing arterial venous fistula.
Management Complications
Left femoral endarterectomy anddistal thromboembolectomywith fasciotomy
Ischemic myonecrosis ofanterior and lateralcompartments
Open repair of pseudoaneurysmand evacuation of hematoma
rterial injuries had an average stay of 10 � 3 days.
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JOURNAL OF VASCULAR SURGERYVolume 53, Number 2 Hans et al 411
Fasciotomy
We performed four compartment fasciotomies in three ofseven patients with arterial laceration/occlusion following hipand knee surgery. Indications for fasciotomy included: severepain in the lower extremity, which was out of proportion tothe physical findings; tense swelling and tenderness of the calfmuscles; limited dorsiflexion of the foot with sensory loss inthe first web space; intraoperative detection of swelling andischemic changes in the muscles of the calf.
Late follow-up
Patients were followed by clinical examination, Dopp-
Fig 6. Using coaxial microcatheter system, coil embolization ofthe arteriovenous (AV) fistula being performed through left bra-chial artery (elbow), left sephalic, and basilic veins.
Fig 7. Venogram showing complete obliteration of left axillaryarterial venous fistula.
ler arterial study (ankle-brachial indices), and duplex imag- A
ng of the repaired artery/interposition graft. Patients withnjury to the thoracic aorta underwent follow-up CT scanf the chest with IV contrast. One patient was lost toollow-up after 3 months. In the remaining 16 patients,ean follow-up was 60 � 18 months. One patient hadifficult ambulation due to foot drop and now uses an anklerace. Three patients use either a four prong cane and/or aalker for ambulation.
ISCUSSION
With the increasing popularity of spine surgery, thencidence of arterial injuries is increasing (vascular compli-ations 0%-0.8% following anterior spinal surgery). Suchomplications can compromise the outcome of these pro-edures. We have previously reported two patients withhoracic aortic injuries and a pseudoaneurysm caused by aedicle screw successfully repaired by open surgery.5 Inetrospect, one of these injuries could have been repairedith a thoracic aortic stent graft following removal of theedicle screw. An associated infected pseudoaneurysm pre-luded the use of prosthetic material in the second patient.uring posterior spinal surgery (disk removal), pituitary
ongeur can occasionally cause injury to the iliac artery orein manifesting as excessive bleeding, thrombosis, or de-ayed AV fistula. Because of abdominal pain and shock inhe patient with a left iliac artery and venous injury, openepair was undertaken; covered stents were not available athe time of this operation. At the present time, a commonliac artery-vein fistula is probably more appropriately man-ged with a covered stent. Vascular complications are morerequent during exposure of the lower lumbar spine fornterbody fusion.2,3,6 The majority of these are venousnjuries (iliolumbar vein or the tributaries of the left com-
on iliac vein). In some instances, attempts to controlenous bleeding can lead to excessive retraction of the iliacrtery causing a localized dissection with resulting throm-osis as occurred in two of our patients. Such patientsequire emergent reestablishment of arterial flow either byypass grafting or stent placement � distal thromboembo-
ectomy, depending on the extent of thrombosis and distalmbolism. Left iliac artery thrombosis may also occur sec-ndary to retraction for exposure of L3-L4 or L4-L5 diskpace.2,6 Diagnosis may be delayed as numbness in the footan be confused with nerve root injury and pallor of the skinay be difficult to assess in darker-skinned patients. Due to
he effects of inadvertent lumbar sympathectomy, the leftoot may remain warm.2 In this article, one patient withrior aortobifemoral grafting was not diagnosed with graftimb thrombosis until 48 hours following anterior spinalusion. This delay in diagnosis may have resulted fromaintenance of collateral flow to the extremity.
The incidence of acute arterial complication followingnee and hip procedures has been reported to be 0.08% to.25%.1,6,10 Abularrage et al analyzed preoperative andostoperative data from the National Surgical Quality Im-rovement Program of the Veterans’ Affairs Medical Cen-ers from 1996 to 2003 and identified redo procedures and
frican American race as risk factors for arterial injury with
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JOURNAL OF VASCULAR SURGERYFebruary 2011412 Hans et al
knee and hip procedures.11 In the current report of ninearterial injuries following orthopedic procedures (knee,hip, and shoulder), three had redo arthroplasties.
Arterial injury can cause arterial occlusion leading toischemia or arterial laceration leading to hemorrhage, pseu-doaneurysm, and/or AV fistula. Mechanisms of injury areboth direct (ie, instrument injury or protrusion of cementor screws, or heat injury from exothermic reaction gener-ated by cement polymerization) and indirect (ie, arterialstretch during retraction for exposure or during joint ma-nipulation).1,6,10 Previous studies have reported that allvascular injuries following total knee arthroplasty are theresult of indirect trauma, whereas all injuries occurringduring total hip arthroplasty are direct vessel injury.9 Incontrast, in the current series all three popliteal injuriesoccurring during knee arthroplasty were direct injuries.Recognizing acute arterial injury can be difficult in somepatients. Use of regional anesthesia affecting the neurolog-ical status of the limb can delay recognition of the patients’symptoms of arterial injury. Vascular checks in the recoveryroom by nursing and medical staff should be performedbefore transferring the patient to a postoperative unit.Careful assessment of the need for joint replacement inpatients with prior arterial bypass graft or significant lowerextremity arterial occlusive disease may be prudent. The useof tourniquet in patients undergoing lower extremity or-thopedic procedures with a history of arterial bypass graftshould be avoided.
Access for arteriography is best obtained from thecontralateral femoral artery, though iliac artery stentingmay be best performed through an ipsilateral retrogradefemoral approach. Because of spinal fusion hardware, steepoblique positioning of the fluoroscopic image intensifiermay be necessary for adequate visualization to diagnose andtreat arterial injuries. In patients with popliteal artery injury,we prefer a posterior approach unless the diagnosis is madeduring knee surgery with the patient already under anes-thesia, in which case a medial approach can be used as weperformed popliteal artery end-to-end repair in one of ourfour patients in whom the orthopedist encountered exces-sive bleeding after release of the tourniquet.
We performed four compartment fasciotomies in threeof seven patients with arterial laceration/occlusion follow-ing hip or knee surgery. Calligaro et al have reported anincreased need for fasciotomy if the arterial injury is iden-tified more than 24 hours postoperatively.1 The need forfasciotomy should be based on clinical findings as theliterature on compartment pressures is based on acutetrauma models and may not be applicable after joint re-placement.9 Patients with pseudoaneurysms and arterio-venous fistulae can be successfully treated with coveredstents and coil embolization. Associated hematoma mayrequire operative decompression, however, as in one pa-tient in this series with a lateral circumflex femoral arterypseudoaneurysm with a large hematoma causing a femoralneuropathy.
Careful assessment of arterial circulation prior to ortho-
pedic and spine surgery, careful operative planning, metic-
lous operative technique with satisfactory exposure andvoidance of excessive retraction of major vessels may helpn prevention of arterial complications. The use of intraop-rative neuromonitoring (somatosensory evoked potential)t the peripheral and central levels to detect nerve rootompression12 may also detect thrombotic occlusion of theliac artery, as was the case in one of our patients. This is
ainly performed in patients undergoing spine surgery atur institutions. Early diagnosis of arterial complicationollowed by emergency vascular surgical consultation canesult in a successful outcome in a majority of patients.
In the current series, there was no mortality or extrem-ty amputation, but there was significant morbidity in theorm of foot drop, delayed ambulation due to residualematoma in the knee/calf area, calf muscle necrosis, andostoperative venous thrombosis with persistent swellingf the lower extremity. Two of the 17 patients filed lawsuitsnd the majority of the patients expressed dissatisfactionith their outcomes. In a previously published report,early half of the patients elected to launch a legal suitgainst the operative surgeon following knee or hip arthro-lasty with an arterial complication.9 Patients at increasedisk of iatrogenic arterial injury (such as those with periph-ral arterial disease with or without prior arterial bypassraft) and patients undergoing redo joint arthroplasty mayenefit from vascular workup before planned orthopedic/pine surgery. Intraoperatively, precautions must be takenhen retracting major vessels. Awareness of arterial injury
nd familiarity with their manifestations will enhance earlyiagnosis, prompt operative repair, and improve results.8
ONCLUSIONS
It appears that, despite all efforts to minimize risk,rterial injuries after orthopedic and spine operations willontinue to occur. Patients undergoing spine and orthope-ic operations should have careful pre- and postoperativevaluation of distal pulses. Emergent consultation with aascular surgeon should be undertaken in patients sus-ected of arterial injury. Prompt recognition of arterialnjury following spine or orthopedic operations will gener-lly result in successful limb salvage, albeit with significantorbidity and increased length of stay.
UTHOR CONTRIBUTIONS
onception and design: SHnalysis and interpretation: SH, ASata collection: SH, AS, PR, KR, WRriting the article: SHritical revision of the article: SH, ASinal approval of the article: SHtatistical analysis: SHbtained funding: SHverall responsibility: SH
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