Iliac Venous Injury Complicating Anterior Spinal Surgery: Incidence, Predisposing Factors and Management

Methods: Ten major vascular injuries in 349 anterior spinal procedures by a single access surgeon were identified. Operative reports and charts were reviewed.

Results: The incidence of major vascular injuries was 2.9%, with one aortic injury, nine CIV injuries (six left and three right) and no deaths. Mean EBL was 1,410 ml. Predisposing factors were: scoliosis (2), osteomyelitis (2), spondylolisthesis (2), osteophyte at L5-S1(1), revision ALIF (1), migrated PLIF cage (1). Initial control of bleeding was obtained with spongestick compression, avoiding suction. Vascular clamps were not applied. Trendelenburg's position was utilized and definitive repair was attempted after preparations for volume resuscitation/ transfusion. In eight venous cases, lateral venorrhaphy was performed, reinforced by topical hemostatic agents. In one venous case, a 10 mm defect was repaired using vascular clips and fibrin glue. A single terminal aortal injury in the setting of previous osteomyelitis and a bridging osteophyte occurred at L3-L4. Lateral aortorraphy with single figure-of-eight suture was successful. Magnetic resonance venogram (MRV) was obtained in six patients with CIV injuries, demonstrating venous patency in five - an IVC filter was placed in the latter patient.

Conclusion: Careful handling of the iliac vein and topical hemostatic agents can lead to successful outcome and preserve venous patency. Spinal deformity, osteomyelitis, spondylolisthesis and osteophyte formation point to increased risk of vascular injury. Postoperative screening for DVT with MRV and extremity venous duplex scanning, is recommended in the setting of iliac vein repair.