title: Anterior Retroperitoneal Spine Exposure following Prior Endovascular Aortic Aneurysm Repair.
abstract: BACKGROUND
  We describe successful anterior retroperitoneal spine exposure to facilitate anterior lumbar interbody fusion (ALIF) in a patient with a prior endovascular aneurysm repair (EVAR).
  
  
  METHODS
  A 74-year-old male with an extensive spine surgical history presented with progressive neurogenic claudication and paresthesia involving both feet. In addition, his surgical history was notable for an EVAR performed elsewhere 5 years earlier, with subsequent right renal stent placement for encroachment of the right renal artery. Diagnostic evaluation identified severe L3-4 and L4-5 canal stenosis, and a 48 × 36-mm aneurysm sac with a type II endoleak. Revision L3-L5 fusion from an anterior approach with vascular surgery assistance was recommended.
  
  
  RESULTS
  The retroperitoneum was accessed through a left paramedian abdominal incision. The abdominal aortic aneurysm sac was visualized and noted to be nonpulsatile. The distal aorta and left iliac vessels were dissected and retracted medially to facilitate anterior exposure of the L3-4 and L4-5 disk spaces. Successful ALIF of the L3-5 vertebrae was then performed. Retractors were removed and the aortoiliac vessels were carefully returned to anatomic position. The aneurysm sac remained nonpulsatile, with normal pulses in the iliac arteries. Postoperative imaging demonstrated stable appearance of aortic stent graft. At 1-year follow-up, the patient reports complete resolution of symptoms and imaging demonstrates a patent aortic stent graft with a stable type II endoleak.
  
  
  CONCLUSIONS
  Widespread application of ALIF will inevitably include an increasing subgroup of patients with previous EVAR. Such patients require thorough clinical and radiographic perioperative considerations for the access surgeon.
authors.affiliation: Division of Vascular Surgery, Stanford University, Stanford, CA.
authors.forename: Brant W
authors.initials: BW
authors.lastname: Ullery
authors.affiliation: Division of Vascular Surgery, Stanford University, Stanford, CA.
authors.forename: Patrick
authors.initials: P
authors.lastname: Thompson
authors.affiliation: Division of Vascular Surgery, Stanford University, Stanford, CA. Electronic address: mwmell@stanford.edu.
authors.forename: Matthew W
authors.initials: MW
authors.lastname: Mell
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation; D000072226:Computed Tomography Angiography; D057867:Endoleak / Q000000981:diagnostic imaging / Q000209:etiology; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation; D006801:Humans; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D012720:Severity of Illness Index; D013123:Spinal Fusion / Q000379:methods*; D013130:Spinal Stenosis / Q000000981:diagnostic imaging / Q000601:surgery*; D015607:Stents; D016896:Treatment Outcome