Subacute Course of Common Iliac Arterial Laceration in Lumbar Disc Surgery
A 20-yr-old man, 173 cm in height and 58 kg in weight, underwent a microdiscectomy for a symptomatic right-sided disc herniation at the intervertebral space, confirmed by magnetic resonance imaging in 2002. Routine laboratory studies were unremarkable with a hemoglobin (Hb) level of 14.1 g/dL and hematocrit (Hct) of 41.6%. Anesthesia was induced with 250 mg thiopental, 100 mg succinylcholine, 25 mg atracurium and maintained with 1.5% isoflurane in 50% oxygen and 50% nitrous oxide with a fresh gas flow 2 L/min. A routine microdiscectomy was carried out in the prone position on Wilson's frame under general anesthesia. During operation the discectomy the surgeon felt some momentary downward slippage of the pituitary rongeur into the deep intervertebral space. At that moment unexplained profuse bleeding occurred in the disc space. Shortly after this event blood pressure (BP) suddenly decreased from 110/80 mmHg to 80/60 mmHg. It became normalized soon after the injection of ephedrine 10 mg and atropine 0.5 mg and the bleeding stopped spontaneously. In the recovery room, the patient experienced transient hypotension (90/60 mmHg) and tachycardia (95 bpm/min) which again responded well to volume replacement. On the first day after the surgery operation the patient complained of abdominal discomfort and wound pain. BP was 100/70 mmHg, HR 92 bpm/min and body temperature 38.4℃. Hb and Hct was 11 g/dL and 32% respectively. Neurologic examination revealed normal motor tone in his lower extremities. Physically, the abdomen was mildly distended with tenderness in the left lower quadrant of the abdomen on a physical examination. Bowel sounds were decreased. Apparently he was stabilized with volume expansion.\nOn the second day after the operation he started to complain of increasing abdominal pain in the left quadrant with dizziness and became restless and very pale. At that time BP was 100/60 mmHg, HR 100 b/min and body temperature 38.5℃. Hb was 9.2 g/dL and Hct was 26.9%. Abdominal examination revealed decreased bowel sounds and the left femoral and deep peroneal artery pulsation was absent on palpation. Three hours later, Hb became 6.8 g/dL and Hct was 19.7%. Four units of blood were transfused for stabilization. An urgent Doppler sonogram showed no flow in the common iliac artery suggesting segmental obstruction. Contrast-enhanced CT also revealed a low attenuation perfusion defect in the common iliac artery at the level of L4-5 with a moderate amount of retroperitoneal hematoma (). There was no leakage of contrast but a few small air densities were present around the obstructed artery probably coming out from the perforated anterior spinal ligaments. Angiography of the abdomen demonstrated a complete obstruction of the left common iliac artery, located about 2 cm distal to the aortic bifurcation (). The distal portion of the obstructed artery was filled with contrast material by collateral circulation through the internal and external iliac arteries. Fifty five hours after the L4-5 discectomy, an emergent laparotomy was performed. Anesthesia was induced with 250 mg thiopental, 100 mg succinylcholine, 25 mg atracurium and maintained with 1.5% isoflurane in 50% oxygen and 50% nitrous oxide with a fresh gas flow 2 L/min. During the operation, BP and HR were stable and the surgical field revealed a moderate retroperitoneal hematoma. There was no active bleeding. A small defect was observed in the anterior longitudinal ligament overlying the right side of the L4-5 disc space. The laceration was located at the posterior aspect of the left common iliac artery, made by a partial puncture with a pituitary rongeur. It was packed with thrombus and adhered densely to the punctured anterior longitudinal ligament at the surgical level so that it was spontaneously sealed. The arterial injury was repaired by the excision and interposition of an 8 mm polytetrafluoroethylene graft with the removal of the retroperitoneal hematoma. The postoperative course was uneventful and the patient remains in good condition over 10 yr later.