Strategies for prevention and operative treatment of aortic lesions related to spinal interventions.

Study Design. A retrospective analysis of a case series was performed. Objective. To give recommendations for the prevention and operative treatment of thoracic and thoracoabdominal aortic lesions in association with spinal interventions. Summary of Background Data. Aortic lesions after spinal interventions for traumatic vertebral fractures, segmental spondylodiscitis, or vertebral metastasis are fortunately rare, but associated with a high perioperative mortality rate and absolute numbers are unknown. Therefore, preventive strategies to avoid perioperative major vessel injuries and recommendations for the operative treatment of aortic lesions related to spinal surgery are required. Methods. The clinical course of 10 patients with an acute aortic hemorrhage or an increased intraoperative risk for aortic injuries in association with primary or secondary spinal interventions is reported. All patients were evaluated before surgery by orthopedic trauma surgeons, vascular surgeons, and diagnostic radiologists. Results. Five patients had preventive vascular interventions to avoid major aortic injuries during spinal reinterventions, and 5 patients were treated as an emergency for acute intraoperative hemorrhage related to spinal interventions. The operative treatment was performed by direct aortic sutures (n = 3), segmental alloplastic reconstructions (n = 2), or endovascular stent graft implantations (n = 3). Prophylactic banding of the thoracic aorta during thoracotomy or a femoral access for possible aortic balloon blockade was performed in patients with an estimated lower risk for an aortic laceration caused by malpositioned pedicle screws. No perioperative mortality was observed in patients treated by this interdisciplinary concept, but 1 patient treated under emergency condition for spondylodiscitis with an initially unrecognized aortic lesion died. Conclusion. In patients with complex spinal trauma, spondylodiscitis or difficult vertebral reinterventions, and an increased risk of major vessel injury, a preoperative interdisciplinary evaluation is recommended, even under emergency conditions. Endovascular stent graft technique is an additional option for prevention and treatment of suspected or acute aortic injuries of thoracic and infrarenal aortic lesions, whereas injuries to the visceral aortic segment still require advanced vascular reconstructions.