© Turkish Society of Radiology 2009
laceration or rupture of the retroperitoneal large vessels. Late complica-
tions include development of pseudoaneurysm and arteriovenous fistula
(AVF), presenting with back pain, leg edema, and high output cardiac
Although AVFs are generally described as late complications, this re-
flects late diagnosis (2). When associated with significant bleeding, it
can be recognized earlier. Endovascular treatment has been an increas-
ingly important option for treatment of vascular injuries in recent years;
this treatment is less invasive than surgery and is particularly useful in
patients with existing comorbidities.
We present a case of iatrogenic iliac AVF with massive retroperitoneal
bleeding. The ilio-iliac fistula and associated pseudoaneurysm were ini-
tially located by computed tomographic angiography (CTA); the fistula
and pseudoaneurysm were then repaired by endovascular stent graft
placement. Six-month clinical and CTA follow-up are also presented.
ajor vascular injuries are rare but life-threatening complica-
tions that may occur during spinal surgery. Early presentation
is acute massive hemorrhage and subsequent shock caused by
A 36-year-old woman underwent a lumbar disc surgery at the levels of
L4-5 and L5-S1. Sudden arterial bleeding occurred during the laminec-
tomy, which was thought to be controlled during the rest of the surgical
procedure. Postoperative imaging studies were performed because the
patient’s hemoglobin dropped from 13 g/dL preoperatively to 8 g/dL
postoperatively. Ultrasound (US) revealed retroperitoneal hemorrhage.
Hypotension, tachycardia, and an abdominal bruit were noted the day
following surgery. Subsequent CTA with 16-row multidetector comput-
ed tomography (MDCT) showed retroperitoneal hemorrhage and pseu-
doaneurysm around the infrarenal aorta and inferior vena cava (IVC).
In addition, there was contrast enhancement of the IVC and iliac veins
on the arterial phase dilatation of iliac veins; these findings plus the
abdominal bruit suggested an AVF (Fig. 1). The source of the arterial
injury appeared to be the right common iliac artery, since there was no
hemorrhage density or soft tissue density between the right common
iliac artery and the extraluminal contrast agent.
The patient was then brought to the angiography suite. An abdomi-
nal aortogram was performed via the right iliac artery which revealed
an iliac pseudoaneurysm and AVF between the right common iliac
artery and left common iliac vein (Fig. 2). A 10 × 40 mm endovascu-
lar stent graft (Fluency® Plus, Bard Peripheral Vascular Inc., Tempe,
Arizona, USA) was placed across the injury at the right common iliac
artery following accurate localization of the arterial injury with differ-
ent projections, protecting the ipsilateral internal iliac artery. Control
Diagn Interv Radiol DOI 10.4261/1305-3825.DIR.1018-07.4
Iliac vascular complication after spinal surgery: immediate
endovascular repair following CT angiographic diagnosis
Burcu Akpınar, Bora Peynircioğlu, Barbaros Çil, Ergun Dağlıoğlu, Saruhan Çekirge
From the Department of Radiology (B.A. burcu_akpinar@
yahoo.com, B.P., B.Ç., S.Ç.), Hacettepe University School of
Medicine, Ankara, Turkey; and the Department of Neurosurgery
(E.D.), Ankara Numune Education and Research Hospital, Ankara,
Received 4 May 2007; revision requested 8 August 2007; revision received
23 October 2007; accepted 27 October 2007.
Published online 27 October 2009
Iliac arterial injuries are rare but important complications that
can develop after spinal surgery. The presentation of these
injuries is usually late, with symptoms such as leg swelling or
cardiac failure. However, acute massive bleeding may be a
sign of early presentation as in our patient. Herein, we present
a case of life-threatening bleeding with early computed tom-
ography angiographic diagnosis of common iliac artery pseu-
doaneurysm and iliac arteriovenous fistula secondary to spinal
surgery which was successfully managed by endovascular
stent graft treatment.
Key words: • arteriovenous fistula • spinal surgery
• endovascular repair • stent graft • computerized tomography
Akpınar et al.
ii • Diagnostic and Interventional Radiology
US revealed patent stent graft with
normal flow in distal iliac and femo-
ral arteries, as well as normal venous
flow in iliac veins and IVC. The pa-
tient did well for the next six months,
and six-month follow-up CTA showed
a patent stent graft with completely
resolved retroperitoneal hemorrhage
and pseudoaneurysm (Fig. 4).
Early symptoms of vascular injuries
wide pulse pressure, and abdominal
distension secondary to hypovolemia
(1). Symptoms of retroperitoneal he-
morrhage may be useful for early de-
tection of vascular injuries after spinal
surgery. Most of the time, the diag-
nosis is made weeks or years after the
surgery because of the asymptomatic
development of a pseudoaneurysm or
an AVF. The most common late pres-
entation of asymptomatic vascular in-
juries is AVF (3). High-output cardiac
failure, leg edema, dyspnea, and back
pain develop in the late phase as a re-
sult of high-flow AVF (1).
angiograms showed closure of the fis-
tula and no evidence of filling of the
pseudoaneurysm (Fig. 3). The right
common femoral artery puncture was
closed with a vascular closure device
(Angio-Seal™, St. Jude Medical, Minne-
tonka, Minnesota, USA). The patient
was kept in the intensive care unit for
24 hours and then discharged. She was
put on 75 mg clopidogrel per day for
3 months (after a 300 mg loading dose
the day of the procedure) and 100
mg acetylsalicylic acid per day indefi-
nitely. One-week follow-up Doppler
Figure 1. Reconstructed CT angiography image
revealing pseudoaneurysm (*) and arteriovenous
fistula to the left common iliac vein (arrow) with
early opacification of inferior vena cava (arrowhead).
Figure 2. Pelvic arteriogram via introduced pigtail catheter advanced through the right
common femoral artery. The site of the arterial injury (arrow), pseudoaneurysm, and
arteriovenous fistula is seen. Dilated left iliac vein with early opacification of the inferior
vena cava is also seen.
Figure 3. Post-stent pelvic arteriogram showing patent
stent-graft across the right common iliac artery with no
evidence of filling of the fistula and pseudoaneurysm.
Figure 4. Six-month follow-up CT angiography image shows patent stent graft
with no residual/recurrent fistula or pseudoaneurysm.
Iliac vascular complication after spinal surgery • iii Download full-text
Among patients with vascular in-
juries during laminectomy, external
bleeding occurs in only 25% of cases
(3). Bleeding may be tamponaded
within the retroperitoneal space, and
unexplained anemia may be the only
clue to the injury. AVF may occur if
the arterial and venous lacerations
were formed together. In our case,
AVF may occur after penetration of
the anterior longitudinal ligament
with aortic, iliac arterial and venous
(IVC or iliac) injuries (4). The most
commonly injured artery reported in
the literature is the left common iliac
artery, which lies anterior to the L4-L5
vertebral disc (5).
giography is accepted to be the gold
standard modality for the diagnosis
and guidance of the treatment. US
is generally preferred as the first-line
diagnostic tool for detecting the ret-
roperitoneal hemorrhage because of
cost and availability for bedside evalu-
ation. In our case, US was the initial
imaging modality, followed by 16 de-
tector-CTA, which demonstrated the
extent of the injury.
The mortality of surgical treatment of
the vascular injuries has been reported
to be between 10% and 66%, even in
hemodynamically stable patients (6).
Mortality is related to the size of the
injured vessel, the size and location of
the laceration, and the time required
to control the bleeding (5). Today, en-
dovascular approaches provide alter-
natives to surgical repair. Endovascular
approaches are associated with shorter
duration of hospitalization and are less
invasive than surgery, which is espe-
cially important for high-risk surgical
patients (7). Endovascular methods are
well tolerated by the patients with only
There are few reports in the litera-
ture about the treatment of iliac AVF
following spinal surgery (8, 9). Stent
graft placement was first reported by
McCarter et al. in 1996 that described
endoluminal stent graft treatment of
an ilio-iliac fistula after disc surgery
(10). Although use of stent grafts has
increased in the peripheral arteries in
recent years; stent occlusion, deforma-
tion, intimal hyperplasia, and stenosis
are common concerns for long-term
CTA is a valuable noninvasive tool
in diagnosis of peripheral arterial le-
sions (11). There are studies in the
literature showing an excellent con-
cordance between the multislice CT
and digital subtraction angiography
(11–13). In our experience, CTA is a
particularly useful initial diagnos-
tic tool in iatrogenic complications,
particularly in identifying the site of
arterial injuries in patients with retro-
peritoneal hemorrhages. Despite the
established role of CTA in follow-up of
patients after endovascular aortic an-
eurysm repair, experience in periph-
eral stent graft follow-up with CTA is
rather limited in the literature (14). In
our experience, as a noninvasive tool,
CTA provides information on the to-
tal occlusion of the aneurysm, fistula,
and vessel patency after stent grafting.
Commenting on the in-stent stenosis
as a result of intimal hyperplasia by
CTA follow-up is, however, still dif-
ficult, particularly in small-caliber ar-
teries. In cases with clinical or other
signs (e.g., US, CTA) of stent stenosis
during follow-up, angiography should
be obtained for further diagnosis and
CTA has evolved in the last decade.
By using MDCT equipment, the qual-
ity of angiography has increased dra-
matically. We believe that it is crucial
to evaluate the possibility of such vas-
cular complications after spinal sur-
gery. In case of hemodynamic instabil-
ity in a high-risk surgical patient, en-
dovascular treatment should be kept
in mind. CTA can provide valuable
information for tailoring the manage-
ment, as in our case when it helped
us localize the injury. It was difficult
to determine the point of injury solely
by angiography in our case because
of high-flow AVF. Of note, long-term
durability of stent grafts even in iliac
arteries is a concern; therefore, stent
grafting should be reserved for high-
risk surgical patients, particularly
young patients, because of the lack of
randomized long-term trials.
1. Papadoulas S, Konstantinou D, Kourea
HP, Kritikos N, Haftouras N, Tsolakis JA.
Vascular injury complicating lumbar disc
surgery. A systemic review. Eur J Endovasc
Surg 2002; 24:189–195.
2. Franzini M, Atlana P, Annessi V, Lodini V.
Iatrogenic vascular injuries following lum-
bar disc surgery. Case report and review
of the literature. J Cardiovascular Surg
(Torino) 1987; 28:727–730.
3. Zhou W, Bush RL, Terramani TT, Lin PH,
Lumsden AB. Treatment options of iatro-
genic pelvic vein injuries: Conventional
operative versus endovascular approach.
Vasc Endovasc Surg 2004; 38:569–573.
4. Baker WH, Mansour MA. In: Rutherford RB,
ed. Vascular surgery. Arteriovenous fistula
of the aorta and its major branches. 5th ed.
Philadelphia: Saunders, 2000; 1440–1445.
5. Goodkin R, Laska LL. Vascular and vis-
ceral injuries associated with lumbar disk
surgery: medicolegal implications. Surg
Neurol 1998; 49:358–372.
6. Davidovic LB, Kostic DM, Cvetkovic SD,
et al. Aortocaval fistulas. Cardiovasc Surg
7. Baltacioglu F, Çimşit NÇ, Çil B, Çekirge S,
Ispir S. Endovascular stent-graft applications
in iatrogenic vascular injuries. Cardiovasc
Intervent Radiol 2003; 26:434–439.
8. Bierdrager E, Rooij WJ, Sluzewski M.
Emergency stenting to control massive
bleeding of injured iliac artery following
lumbar disk surgery. Neuroradiology 2004;
9. Burger T, Meyer F, Tautenhahn J, Halloul Z,
Fahlke J. Percutaneous treatment of rare ia-
trogenic arteriovenous fistulas of the lower
limbs. Int Surg 1998; 83:198–201.
10. McCarter DH, Johnstone RD, McInnes GC,
Reid DB, Pollock JG, Reid AW. Iliac arterio-
venous fistula following lumbar disk sur-
gery treated by percutaneous endoluminal
stent grafting. Br J Surg 1996; 83:796–797.
11. Iezzi R, Cotroneo AR, Pascali D, Merlino
B, Storto ML. Multi-slice CT (MSCT) an-
giography for assessment of traumatic le-
sions of lower limbs peripheral arteries.
Emerg Radiol 2007; 14:389–394.
12. Ofer A, Nitecki S, Linn S, et al. Multidetector
CT angiography of peripheral vascular dis-
ease: a prospective comparison with in-
traarterial digital subtraction angiography.
AJR Am J Roentgenol 2003; 180:719–724.
13. Catalano C, Fraioli F, Laghi A, et al.
Infrarenal aortic and lower-extremity ar-
terial disease: diagnostic performance
of multidetector row CT angiography.
Radiology 2004; 231:555–563.
14. Herzog C, Grebe C, Mahnken A, et al.
Peripheral artery stent visualization and
in-stent stenosis analysis in 16-row com-
puted tomography: an in-vitro evaluation.
Eur Radiol 2005; 15:2276–2283.