Shock emorragico da lesione iatrogena aorto-caval. Case report

Abstract

INTRODUCTION: Vascular injuries during lumbar disc surgery vary between 1 and 5 per 10.000 disc operations and usually represent life- threatening events.

MATERIAL AND METHODS: The authors present a case of aorto-iliac and ICV laceration during lumbar disc hernia repair, successfully treated with immediate damage control and direct suture, followed by endovascular procedure.

CASE REPORT: A 34-year-old lady was operated on for a symptomatic disc herniation at L4-L5. Shortly after this procedure, an ipovolemic shock (IV degree) suddenly occurred with an evident abdominal distension. An emergent laparotomy in the same neurosurgery OR was then performed and revealed an active haemorrhage arising from an expansive retroperitoneal bleeding at the level of aorto-iliac bifurcation. After a proximal and distal damage control (manual compression plus aortic clamping) aortic and caval lacerations were repaired. An abdominal packing completed the procedure, due to the concomitant coagulopathy applied. At the second surgical look, carried out 24 hours after the first procedure, no active bleeding or vascular impairment were detected but an intraoperative US examination revealed a 3,5 cm wide right iliac pseudoaneurism confirmed by angioCT scan. This pseudoaneurism was later successfully treated with a double endovascular stenting.

Postoperative outcome was uneventful and the patient was then discharged 11 days after the discectomy. Follow up study at 2 years did not demonstrate significant sequels.

CONCLUSION: Although rare, vascular injuries during lumbar disc hernia surgery, are extremely severe complications, leading to high morbidity and mortality rates. In case of massive bleeding the presence of an “intrahospital” trauma team is a crucial factor for life-saving.