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Lumbar Arterial Venous Fistula and Pseudo Aneurysm with retroperitoneal hematoma-a rare complication 2005

Interventional Spine

Suresh C Patel, M.D.
Horia Marin , M.D., Non ASSR Member
Todd Aho , M.D., Non ASSR Member
Sanders William , M.D., Non ASSR Member

Excerpta

Lumbar Arterial Venous Fistula and Pseudo Aneurysm
With Retroperitoneal Hematoma-A Complication of L3-L4 Disk Space Biopsy Procedure

1. Purpose:

Vascular injury is a rare adverse event for common spinal interventional procedures. This case reports a possible mechanism of rare complication of development of an arterial aneurysm and A-V fistula following disc space aspiration and biopsy.

2. Materials and Methods:

A 56 year old male with a history of aortic valve endocarditis and aortic valve replacement had a magnetic resonance imaging finding of diskitis/osteomyelitis L3-L4 which progressed despite anti bacterial therapy with a larger phlegmon and abscess formation. Patient underwent a disk space aspiration and bone biopsy at L3-L4 with a coaxial system using an 18 gauge needle, which was non-diagnostic. Repeat bone biopsy was attempted using a 14 gauge coaxial system. After the introduction of the trocar, a "brisk pulsatile" arterial blood flow was encountered. Procedure was terminated. Patient was observed for the next five days which showed a gradual drop of hemoglobin from 10 to 6 grams. The CT scan of abdomen showed a large left sided retroperitoneal hematoma. Selective angiography identified a pseudo aneurysm of the left third lumbar vertebral artery and the arterial venous fistula. Both the pseudo aneurysm and arterial venous fistula were successfully treated with combination of coiling and glue. Patient hemoglobin subsequently stabilized at 9.4 grams.

3. Discussion:

Traumatic arterial venous fistula and pseudo aneurysm of the spinal vertebral arteries are rare and infrequent complication for diagnostic and therapeutic spinal procedures with incidence of 1-5% reported for lumbar disc surgery. Exact incidence of vascular injury from percutaneous lumbar spinal procedures is not known. We believe that this complication occurred from an anatomic variant of the left third lumbar artery being a common large trunk for the 3rd, 4th and 5th lumbar arteries and larger cutting end of the trocar introducer. The large caliber of the main trunk of the left third lumbar artery was susceptible to this vascular injury and complication. It is advisable to closely monitor patients with serial hemoglobin measurements, possible CT scan of abdomen and diagnostic angiogram if arterial blood is encountered during spinal interventional procedures.