An Endovascular Technique for Treatment of High-Risk Iatrogenic Aortic Pseudoaneurysms with the Ethylene Vinyl Alcohol Copolymer Onyx and Aortic Stent Grafting

Introduction

Iatrogenic injury of major vascular structures is a recognized complication of spinal surgery. Trauma of major retroperitoneal vessels can lead to acute perforation, which results in severe hemorrhage and possible hemodynamic instability. Screws or plates can chronically impinge on the aorta, causing formation of a pseudoaneurysm (PA) due to the constant pulsation of the aorta against the hardware. These iatrogenic aortic PAs bear the risk of secondary rupture. Acute and chronic injuries to the aorta can carry a mortality rate as high as 61 % (Bicknell CD et al. Eur J Vasc Endovasc Surg 2009; 37: 175). Especially in cases of chronic aortic impingement with the formation of iatrogenic PA, surgical correction with removal of the PA-inducing hardware is obligatory, but also bears a high risk for aortic rupture during removal procedure. Consequently, measures to avoid aortic perforation and severe bleeding complications are required prior to surgical removal. We describe a safe and minimally invasive treatment option of a high-risk iatrogenic PA with an insufficient landing zone for stent-grafting. The endovascular technique combined transbrachial embolization of the aortic PA with the liquid ethylene vinyl alcohol copolymer Onyx and simultaneous aortic stent-grafting. It resulted in immediate and complete occlusion of the PA, allowing for safe spinal surgery and removal of the PA-inducing material within the same session.