title: A shift toward endovascular repair for vascular complications in lumbar disc surgery during the last decade.
abstract: BACKGROUND
  The purpose of this study is to evaluate 2 patients who underwent endovascular repair directly after acute life-threatening vascular injury complicating lumbar disc surgery, and to update an overview of the literature from 2002 to gain insights into characteristics, diagnosis, treatment, and outcomes of this rare, life-threatening complication.
  
  
  METHODS
  PubMed was searched for English language studies on vascular injury (lacerations, arteriovenous fistulas, and pseudoaneurysms) complicating lumbar disc surgery by a posterior approach published from 2002. Two cases from the authors' institute were added to the review. Information on patient characteristics, diagnosis, treatment strategies, and outcomes were extracted by 2 independent reviewers.
  
  
  METHODS
  The first case describes a 54-year-old man who underwent lumbar disc surgery through a posterior approach (L5-S1) and became hypotensive intraoperatively. Angiography revealed an injury of the right internal iliac artery. Bleeding was successfully repaired by endovascular repair (acute balloon occlusion followed by coiling). The second case describes a 51-year-old women who suddenly became hypotensive during L4 through L5 discectomy caused by bleeding from a laceration in the right common iliac artery. Angiography confirmed the diagnosis, and the bleeding was successfully treated through endovascular repair with a covered stent.
  
  
  RESULTS
  A total of 56 cases from 34 articles were found in the literature since 2002, including lacerations, arteriovenous fistulas, and pseudoaneurysms. Two cases from the authors' institute were added to the review. Vascular injury was recognized intraoperatively in 36%, and within 24 hours postsurgery in 28%. The common iliac artery was most frequently affected (51%), followed by the iliac vein (23%). All lacerations were detected during surgery, whereas most arteriovenous fistulas and pseudoaneurysms were detected in the long term. Treatment consisted of open surgical repair (57%) or endovascular repair (43%). All patients survived surgery.
  
  
  CONCLUSIONS
  Publication bias might play a role in the literature of this area because all cases survived surgery, whereas mortality rates for this condition are high. However, early recognition, diagnosis, and prompt surgical repair are essential to prevent fatal outcomes in vascular injuries complicating lumbar disc surgery. Endovascular repair is a minimally invasive, fast, and efficient treatment modality that is increasingly and preferably used because of its low morbidity and mortality.
authors.affiliation: Department of Vascular Surgery, St. Elisabeth Hospital, Tilburg, The Netherlands. m.v.zitteren@elisabeth.nl
authors.forename: Moniek
authors.initials: M
authors.lastname: van Zitteren
authors.forename: Boxing
authors.initials: B
authors.lastname: Fan
authors.forename: Paul N
authors.initials: PN
authors.lastname: Lohle
authors.forename: J Cees
authors.initials: JC
authors.lastname: de Nie
authors.forename: Jan
authors.initials: J
authors.lastname: de Waal Malefijt
authors.forename: Patrick W
authors.initials: PW
authors.lastname: Vriens
authors.forename: Jan M
authors.initials: JM
authors.lastname: Heyligers
mesh_terms: D000792:Angiography; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007083:Iliac Artery / Q000000981:diagnostic imaging / Q000293:injuries* / Q000601:surgery; D007405:Intervertebral Disc Displacement / Q000601:surgery*; D007796:Laminectomy / Q000009:adverse effects*; D008159:Lumbar Vertebrae; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D015607:Stents; D057772:Vascular System Injuries / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*