Extracorporeal circulation through peripheral vascular successful rescue Abdominal Aortic Iatrogenic Injury During Total en bloc Spondylectomy for L4 Ewing’s sarcoma: A Case Report

doi:10.21203/rs.3.rs-3137325/v1

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Case Report

Extracorporeal circulation through peripheral vascular successful rescue Abdominal Aortic Iatrogenic Injury During Total en bloc Spondylectomy for L4 Ewing’s sarcoma: A Case Report

https://doi.org/10.21203/rs.3.rs-3137325/v1

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Introduction:

Abdominal aortic iatrogenic injury can result in massive hemorrhage and is a potentially fatal complication of total en-bloc spondylectomy surgery (TES) for primary malignant spinal tumors (PMST). Currently, there is no definite management for this complication. We report a case of a patient with abdominal aorta iatrogenic injury at the intervertebral disc of lumbar 3 (L3) to lumbar 4 (L4) level during TES performed via a posterior approach. Fortunately, our patient had a good outcome with prompt intervention.

Patient concerns:

A 16-year-old male was admitted to our department with a chief complaint of low lumbar pain, especially pain at night, since the past 6 months.

Diagnosis:

PMST at L4 (Ewing's sarcoma) with abdominal aorta iatrogenic injury at the L3 − L4 level that occurred during TES that was performed via a posterior approach.

Interventions and outcomes:

Multi-disciplinary treatment (MDT), including extracorporeal circulation (ECC) through the peripheral vasculature, was immediately performed to allow for the suturing of the abdominal aortic injury. After the abdominal aorta iatrogenic injury repair, the patient’s hemodynamic parameters stabilized. Two weeks later, TES was reattempted and successfully performed for L4 PMST.

Conclusion

Intraoperative vascular injury during posterior TES is rare; however, it cannot be avoided with surety since the anterior vertebral manipulation during TES is performed blindly. This complication is often lethal and not diagnosed. Consequently, surgeons must have a wide knowledge of the lumbar spine anatomy and its surrounding structures and conduct a detailed preoperative radiological assessment of the tumor and its surrounding structure. Furthermore, the surgeon should be aware of the risk of vascular injury and familiar with its clinical characteristics for prompt and effective diagnosis and intervention once an injury is suspected to avoid serious consequences. For abdominal aortic injury, the immediate establishment of ECC through peripheral vasculature to suture the vascular laceration may be a quick, safe, and effective management.

primary malignant spinal tumor

total en-bloc spondylectomy

abdominal aortic injury

multi-disciplinary treatment

extracorporeal circulation

Primary malignant spinal tumors (PMST) are rare and comprise < 10% of all spinal tumors; moreover, they are often diagnosed at an advanced stage and induce neurological deficits due to spinal canal invasion, thus requiring surgical intervention[1, 2]. Surgical intervention for the management of symptomatic spinal cord compression is crucial and. it is the first and paramount step in managing patients who present with motor deficits[3]. Spinal tumor resections are often referred to as “total en-bloc spondylectomy (TES),” “gross total,” or “intralesional,” and the latter two are intralesional resections[4]. TES is indicated for primary malignant bone tumors and aggressive benign tumors and infrequently for solitary metastatic lesions[5]. The advantages of TES include the achievement of a satisfactory surgical tumor boundary and complete tumor resection with clean margins. Moreover, successful en-bloc resection results in fewer local recurrences and improved prognoses in both primary and isolated spinal metastases[6]. However, the complex structures around the spine make TES in the lumbar spine region challenging and increase the risk of complications which in turn may impact the postoperative survival rate[7]. Acute vascular injury, although rare, is a life-threatening intraoperative complication that should be identified and treated timely [8, 9]. However, there is no consensus on the most appropriate management technique for intraoperative vascular injury. Herein, we report a case of abdominal aortic injury during TES for a primary malignant tumor of the L4. For multi-disciplinary treatment (MDT) we established extracorporeal circulation (ECC) through peripheral vasculature to allow for the repair of the abdominal aorta injury. Fortunately, due to timely detection and prompt intervention, no serious adverse events occurred. This report highlights the good outcome obtained with prompt treatment of intraoperative abdominal aortic injury.

2.1 Basic condition of the patient

Age

Sex

Symptoms

Auxiliary examination

Diagnosis

Therapeutic method

16 years

Male

Low lumbar pain, especially pain at night, since 6 months

X-ray

Magnetic resonance image (MRI) (Fig. 1A-C)

Computed tomography (CT) (Fig. 1D)

Preoperative pathological examination

Ewing's sarcoma

Abdominal aortic repair with ECC through peripheral vasculature

TES resection

2.2 Operative procedure

The patient was put under general anesthesia and placed in a prone position and a median posterior incision centered at L4 was given. Eight lumbar vertebral pedicle screws were implanted in L2 till S1. Owing to the large L4 vertebral body, the anterior vertebral tissue can not be reached by separating the fingers. Therefore, the lateral tissues of the vertebral body are separated with the fingers and anterior vertebral tissues are separated with the metal stripper during the operation. While separating the anterior vertebral, sudden hemorrhage was noted in the surgical area. Consequently, the patient's blood pressure dropped sharply and could not be normalized despite massive rehydration and transfusion. We immediately suspected a major vascular injury and undertook contingency plans, including MDT. We organized the MDT, immediately resutured the patient, placed the position in the supine position, and prepared for emergency laparotomy. Meanwhile, a balloon was placed in the abdominal aorta by the interventional team. Despite this, the patient’s blood pressure could not be maintained. Subsequently, we involved the general surgery team in the explorative laparotomy. A midline incision was made, the peritoneum was opened, and the intestines were retracted. A hematoma was evident deep in the retroperitoneum between L3 and L4; however, when the retroperitoneum was opened, a vascular break could not be identified due to the copious hemorrhage. Therefore, we used gauze pad packing pressure for temporary hemostasis. After consultation with the MDT team, ECC was established through the peripheral vasculature to stabilize the patient. Next, the MDT team continued the gauze pad pressed to stop the bleeding and walked along the abdominal aorta to expose the proximal part of the wound. The ECC output tube was inserted into the abdominal aorta at the L1 − L2, and the local femoral vein was exposed at the left groin region wherein the ECC input tube was inserted and the aspirator was connected to the ECC tube. Hence, we created an ECC device that bypassed the abdominal aortic rupture (Fig. 2A). When the ECC machine was switched on, the patient's blood pressure stabilized through continued blood infusion, and his vital signs normalized. Simultaneously, we began to look for vascular breaks by loosening the gauze mat once the local bleeding had significantly reduced. Using the aspirator, we were able to quickly expose the vascular rupture (Fig. 2B-C). Using a vascular clamp, the wound was sutured, following which, the abdominal incision was closed layer-by-layer. The patient was transferred to the intensive care unit (ICU) for further treatment. Moreover, the posterior TES for the primary malignant tumor of the L4 vertebral body was successfully performed after two weeks (Fig. 3A-E).

2.3 Postoperative course

Post the vascular repair, the patient was transferred to the cardiac ICU for continued treatment where he was intubated and placed on a ventilator. During the first three postoperative days, the patient’s hemoglobin showed a progressive decline, r. Rehydration, transfusion, and anti-infection treatment were continued. Simultaneously, the patient was temporarily prohibited from eating to avoid abdominal distension and flatulence. Three days after the vascular repair, the patient was extubated. On the 4th postoperative day, the patient was given enteral nutrition and his hemoglobin level was within the normal range; hence, we concluded that hemostasis had been achieved. One week postoperatively, the patient's condition stabilized, and he was transferred to the general orthopedics ward. Following this, two weeks later TES resection was performed after evaluation. After the posterior TES operation, the patient was transferred to the orthopedics ward. We closely monitored the patient for any change in the vital signs, and spinal cord function, including changes in sensation, movement, and limb muscle strength. Fortunately, the patient's vital signs remained stable and the patient's low lumbar pain was relieved and the muscle strength of both legs was normal. The patient was discharged with instructions to dress the wound regularly, avoid exercise, and take analgesia medication when needed.

TES has been increasingly accepted as a definitive treatment of spinal tumors, especially for primary malignant and solitary metastatic lesions in the thoracic and upper lumbar spine[10, 11]. Thorough knowledge of the lumbar spine anatomy and its surrounding structures is mandatory before performing a posterior TES[12]. A lumbar TES is even more challenging to perform due to the complex lumbar anatomy, particularly the lower lumbar region, and hence, numerous approaches have been described, which potentially increase the complication rates that may impact the postoperative survival rate [5, 7].The rate of complications following TES ranges between 34% and 77%[6, 13–15].

Aortic iatrogenic injury is a rare complication of TES and is underreported and underestimated during spine surgery [16]. Although it has a low incidence of 0.01–1%, it is a highly lethal complication with a mortality rate of 15–65%)[17]. Aortic injury has been reported during posterior pedicle screw placement in the thoracic spine, lumbar fusion surgery, disk removal, and TES for spinal tumors. Thoracic aortic injury was mostly reported during pedicle screw placement. Since the thoracic spine pedicles are smaller than the lumbar spine pedicles, an increased risk of screw misplacement is present in the thoracic region[18, 19]. Abdominal aortic injury was most commonly reported following lumbar fusion surgery, disk removal, and TES for spinal tumors. Vascular complications during lumbar posterior fusion surgery occur in 75% of cases at the L4 − L5 level[20]. The possible reason for arterial injury during disk removal is an anteriorly-situated osteophyte tethered to the blood vessel. One of the potential causes of arterial injury during TES is the presence of blood vessels adjacent to the tumor or adhesion, resulting in intraoperative injury. In our case, we could not manually separate the blood vessels in anterior to the large L4 vertebral body. Therefore, we used a metal stripper to assist in the separation of anterior vertebral vessels. However, there is a risk of vascular injury because this step is performed blindly. There are three main types of vascular injuries during spine surgeries, including fistula, laceration, and pseudoaneurysm, with incidences of 66%, 33%, and 3%, respectively[21, 22].Clinical manifestations associated vary with the type of vascular injury and are not always easily recognized, especially when the injury occurs during a posterior approach[23]. The clinical presentations of fistula and pseudoaneurysm can be chronic and remain undiagnosed for months or years postoperatively and treated in an elective setting. Contrarily, most symptoms of vascular laceration may present intraoperatively and should be addressed immediately[24]. Direct arterial laceration generally causes acute retroperitoneal hemorrhage with abdominal distention, hypotension, and hematocrit decline[17]. In the present case, a large tear of the abdominal aorta (Fig. 2C) caused massive bleeding (Fig. 2B) during posterior TES.

Computed tomography (CT), CT angiography (CTA), and digital subtraction angiography (DSA) were reported to be the most commonly ordered imaging modalities in cases of suspected aortic injuries[25]. Angiography is the gold standard for the diagnosis of vascular injury and can accurately and specifically reflect vascular alignment and the site of injury[26]. Moreover, a significant portion of vascular injury requires direct diagnosis intraoperatively[17]. Early diagnosis is critical for the management of vascular injury. When unexplained intervertebral hemorrhage suddenly occurs intraoperatively or when vascular wall tissue is found within the nucleus pulposus, it is suggestive of vascular injury[27, 28]. In our case, we were able to promptly diagnose the patient with abdominal aortic injury due to the profuse intraoperative local hemorrhage and sudden changes in the patient's vital signs.

Once the vascular injury is confirmed, emergency treatment measures and blood and fluid transfusions should be actively administered to simultaneously maintain hemodynamic stability. In the present case, we performed an open exploration by filling the posterior incision, quickly closing the surgical site, turning over the patient over, and resterilizing the sheet after we confirmed the aortic injury. We placed a midline abdominal incision large enough to enter via the peritoneum and not retroperitoneally. The first reason is that the retroperitoneum exerts some pressure on the hematoma, thus controlling bleeding and maintaining blood pressure to some extent. Secondly, abdominal distention is a serious issue and a direct push on the can decompress the hematoma, leading to fatal hemorrhage. Therefore, we suggested that the patient should be placed on ECC before opening the retroperitoneum. Repair of such vascular injuries can be done via an open approach or endovascularly, and in select cases, a combination of both may be needed. Open surgery enables control of acute bleeding and has been traditionally recommended for repairing such lacerations. A small tear of the vessel can be repaired by lateral suturing; however, a large tear is extremely difficult to repair directly due to the massive bleeding. Selective vascular embolization and interventions have become the treatment of choice for vascular injuries as they are minimally invasive and rapidly effective[27, 29]. Wang et al.[9] reported a case of abdominal aorta injury during lumbar fusion surgery via a posterior approach and successfully performed transluminal angioplasty with stent placement to cease the bleeding. However, endo leaks are known to be the most common complications following endovascular repair[30]. Pacini reported in one study that endovascular therapy converted to open surgery in 16 − 18% of patients at 2.5 years, resulting in a mortality rate of 13%[31]. Phani reported a case of aortic rupture with vascular repair assisted by vascular surgery during the surgical treatment of tuberculous discitis; however, unfortunately, the patient died on the second postoperative day[32]. Therefore, despite the recent rapid development of endovascular therapy, many cases require open repair. A large laceration still requires suturing for a successful rescue. Moreover, MDT is often employed involving a neurosurgeon, a general surgeon, a vascular surgeon, an interventional radiologist, and an anesthesiologist.

Traditionally, ECC is known as cardiopulmonary bypass (CPB). CPB is a life-support technique that uses a series of special artificial devices that circulate blood from the body to outside of the body. CPB is often used in open heart surgery wherein a CPB temporarily replaces the human heart and lung by an external circuit consisting of pumps and an oxygenation membrane and arterial/venous cannulation is the first step to initiate CPB[33, 34]. CPB involves a highly technical process that is executed carefully through complex interactions between a surgeon, an anesthesiologist, and a cardiovascular perfusionist[35]. The application of CPB has been reported in the management of aortic arch injury. Kim accidentally punctured the aortic arch intraoperatively while removing a tumor of the thoracic spine (T3) and successfully performed open vascular repair with the establishment of CPB assisted by thoracic surgery, which yielded positive outcomes[36]. However, for the management of abdominal aortic injury, the application of CPB has obvious disadvantages, such as the need to open the patient’s chest with greater collateral damage and other results. In our case, we established ECC through the peripheral vasculature creatively. To the best of our knowledge, this is the first case to report an intraoperative injury of the abdominal aorta that was sutured directly with the aid of ECC which was established through the peripheral vasculature. ECC provides optimal conditions for a successful suture of the ruptured blood vessel without untoward side effects, and the intraoperative drainage device reduces blood loss greatly, which ensures that the required blood levels reach the brain throughout the procedure, avoiding any neurological sequelae. In our experience, ECC has the following advantages. First, its application is rapid and usually takes 20 − 30 minutes from preparation to completion, making it suitable for first aid applications. Second, once ECC is established, no more blood loss occurs, thus greatly reducing the need for transfusions, and is ideal for patients who are underprepared for blood or have already had large transfusions. Moreover, because there is no further blood loss, the surgery can be performed at ease and more effectively and, can be more orderly and careful. Third, compared with traditional thoracic aortic cross-clamping, ECC is significantly less invasive and can be performed via the original abdominal incision, saves time, and does not require the patient to be placed in the supine position. Finally, ECC can not only control the amount of blood loss but also monitor and adjust the internal environment and blood gas levels through the host computer, which is more accurate and rapid than that achieved by adjustment of peripheral vascular medication, and can stabilize vital signs more quickly and safely.

Vascular injury is an unavoidable complication in spinal surgery. Although its incidence during TES is rare, it is often very tricky and even disastrous once it happens. Physicians must have a broad knowledge of spinal anatomy, which is important in preventing this injury. Meanwhile, physicians should always be alert to the risk of vascular injury and be familiar with its clinical characteristics. Once an injury is suspected, a prompt diagnosis, adequate intraoperative management, and early repair are paramount and may prevent fatal outcomes. We believe that rapid organization of the MDT is helpful for swift diagnosis and treatment. The establishment of ECC through peripheral vasculature can provide sufficient conditions for direct and effective repair of the large abdominal aortic laceration to improve the success rate and reduce mortality. ECC through peripheral vasculature can be used as an first-aid auxiliary treatment strategy for intraoperative abdominal aortic injury.

Ethics approval and consent to participate

We have the consent of the patient's guardian and the Ethics Committee of the Second Hospital of Shanxi Medical University.

Consent for publication

The parents of this patient consented to the publication of the case and any accompanying images with written informed consent.

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that there was no potential conflict of interest.

Funding

This work was supported by the Natural Science Foundation of Shanxi Province [20210302124410; 201901D111373; 201903D321156], The Second Hospital of Shanxi Medical University, and four research funding projects within the hospital [2020001-10].

Authors' contributions

YF, ZL, ZT, JL and JB contributed to the implementation of the operation. GG, SS, SY, QL and XL participated in MDT diagnosis and treatment. WQ administered the anesthesia. XQ, KZ and LY collected the case data. XQ drafted the manuscript. ZT, YF, and ZL revised the manuscript. All authors contributed to the manuscript and approved the final version.

Acknowledgement

We thank Bullet Edits Limited for the linguistic editing and proofreading of the manuscript.

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No competing interests reported.

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You are reading this latest preprint version

Extracorporeal circulation through peripheral vascular successful rescue Abdominal Aortic Iatrogenic Injury During Total en bloc Spondylectomy for L4 Ewing’s sarcoma: A Case Report

Status:

Version 1

Abstract

Introduction:

Patient concerns:

Diagnosis:

Interventions and outcomes:

Conclusion

Figures

1. Introduction

2. Case presentation

2.1 Basic condition of the patient

2.2 Operative procedure

2.3 Postoperative course

3. Discussion

4. Conclusion

Declarations

References

Additional Declarations

Status:

Version 1