Rare iatrogenic iliac artery injury during lumbar disc surgery - a case report.

Damage to large abdominal vessels during lumbar discectomy surgery is a rare but life-threatening complication. A CASE REPORT: The authors present the case of a 57-year-old patient who received surgery for critical degenerative lumbal spinal stenosis on the L4-L5 level. The diagnosis was based on strong right sciatica and neurogenic claudication. A bilateral laminotomy from the right and a microdiscectomy were performed. During surgery, no bleeding from the intervertebral space was observed and blood pressure was low but stable from the beginning. After surgery, the patient was in good general and neurological condition, without preoperative right-sided sciatica. Within a few hours after the operation, the circulatory and respiratory systems were stable with normal saturation and the patient did not report shortness of breath. Paleness of the skin and mucous membranes was observed. Follow-up morphology tests performed at 6 and 10.5 hours after surgery showed a decrease in the level of erythrocytes. The patient had palpable tenderness in the left hypochondriac region. Suspicion of bleeding into the abdominal cavity from arteries or iliac veins was stated. Immediately, an angio-computed tomography (CT) of the abdominal cavity was performed, which confirmed the presence of a hematoma in the peritoneal space and a pseudoaneurysm of the left iliac artery. The patient was urgently transported to the Vascular Surgery Clinic, where a Y-type covered stent was implanted percutaneously into both iliac arteries. After the procedure, there were symptoms of ischaemia in the left lower extremity and intermittent claudication. A Doppler study showed signs of narrowing at the stent level on the left side. The patient was reoperated after a CT check-up and a second stent was implanted into the left iliac artery, which allowed vasodilation and true flow in the artery. CONCLUSIONS: The authors suggest that both the neurosurgeon and anaesthesiologist should have been aware of the possibility of such a rare but life-threatening complication as iliac vessel damage during lumbar discectomy surgery. A quick diagnosis and implementation of a proper procedure reduces the high mortality rate caused by this complication. In cases of a sudden unjustified drop in blood pressure during lumbar discectomy, an immediate laparotomy should be performed to find and repair the site of laceration of a vessel. In patients who are stable hemodynamically, performing an angio-CT function of the abdominal cavity is suggested and the damaged artery should be treated with a covered stent.

Postmortem computed tomography with the use of air for blood vessel enhancement--Early experience.

Postmortem computed tomography (PMCT) is gaining popularity in forensic medicine. Computed tomography routinely performed in clinical medicine involves intravenous contrast administration. Unfortunately, postmortem examinations are typically limited to uncontrasted CT scans, where blood vessels and their potential injury sites are invisible. One serious problem is the fact that due to the process of decomposition, contrast agents used for vessel visualization in the living cannot be used in cadavers. Therefore, a special contrast agent designed for cadavers has been developed. This contrast agent has a high density and is lipophilic. Its use ensures very good visualization of blood vessels it is, however, associated with high costs and may alter findings of a later histopathological examination. This study presents early experience with the air as negative contrast agent to enhance all blood vessels in the body. The carbon dioxide (CO2) gas has been used as a contrast agent in live individuals with contraindications against the use of iodinated contrast. In corpses with advanced postmortem changes, putrefaction gases also considerably enhance the visibility of blood vessels and organs they fill. There have also been some positive effects with the use of gas in postmortem angiography of coronary vessels. These findings encouraged us to attempt air administration via catheters introduced into the femoral artery or a central venous access site in the superior vena cava. The gas distributed easily throughout the body and surprisingly well contrasted both arteries and veins of various caliber. The presence of the air administered into vessels did not cause any apparent, significant alterations in autopsy findings. Although optimization of the gas administration technique requires further studies, we can already say that this is a promising direction in postmortem angiography.

Improving the results of transarterial embolization of type 2 endoleaks with the embolic polymer Onyx.

INTRODUCTION: Type 2 endoleaks (T2E) occur in 10 to 20% of patients after endovascular abdominal aortic aneurysm repair (EVAR) and remain a significant clinical issue. AIM: To evaluate the efficacy and clinical outcomes of transarterial treatment of persistent type II endoleaks after EVAR using the liquid embolic Onyx. MATERIAL AND METHODS: From February 2012 to August 2015 transarterial T2E embolization was attempted in 22 patients (21 men, median age: 73, range: 62-88 years). Indications for treatment included an increase in the diameter of the aneurysm sac above 5 mm and a persistent endoleak observed for more than 6 months. Mean time from EVAR to endoleak treatment was 43 months (range: 2-125 months). RESULTS: Primary technical success was achieved in 17 (77.3%) patients and secondary technical success in 81.8%, with 0% in-hospital mortality. The mean procedure time was 95 ±48 min, with an average fluoroscopy time of 54 ±25 min. The mean amount of Onyx used was 7.5 ±6.6 ml. Clinical success was seen in 17/21 patients with follow-up imaging (80.9%). Mean follow-up time was 17 months (range: 3-38 months). CONCLUSIONS: Onyx has been shown to effectively stabilize previous aneurysm growth as a result of the T2E in the majority of our patients. Transarterial embolization of T2E can be significantly improved as compared to previously reported results by using liquid embolic polymers such as Onyx.

The use of 3D computed tomography reconstruction in medico-legal testimony regarding injuries in living victims - Risks and benefits.

Forensic pathologists are often called upon to determine the mechanism and severity of injuries in living individuals. Such expert testimony is often based solely on hand-written clinical notes. The victims' injuries may also be visualized via three-dimensional (3D) reconstruction of computed tomography (CT) images. This method has certain benefits but is not free from limitations. This paper presents two case reports. The first case is that of a female who was brought to the hospital with a knife thrust into her body. The prosecutor's questions focused on the wound channel. The information obtained from the patient's medical records was very general with many contradictory statements. A re-evaluation of the available CT scan data and a subsequent 3D reconstruction helped determine the exact course of the wound channel. The other case was that of a young male, hospitalized based on CT evidence of bilateral rib fractions, who claimed to have been assaulted by police officers. Court expert witnesses were already in possession of a 3D reconstruction showing symmetrical fractures of the patient's lower ribs with bone fragment displacement. An expert witness in radiology definitively excluded the presence of any actual fractures, and explained their apparent visibility in the three-dimensionally reconstructed image as a motion artifact. These two cases suggest that a professionally conducted 3D CT reconstruction is a very useful tool in providing expert testimony on injuries in living victims. However, the deceptive simplicity of conducting such a reconstruction may encourage inexperienced individuals to undertake it, and thus lead to erroneous conclusions.

Endovascular repair of traumatic thoracic aortic rupture: a single centre experience.

BACKGROUND: Thoracic aortic rupture is usually the result of a sudden deceleration caused by a traffic accident, fall or some other misfortune. Before the endovascular era, there was only one treatment option: open repair, burdened by high morbidity and significant mortality. Now, we have the ability to treat it with a stent graft. The advantages of this method include avoiding a thoracotomy or aorta cross-clamping and their associated complications. AIM: To present our experience and results of endovascular treatment of thoracic aortic ruptures. METHODS: Since 1998, we have performed endovascular treatment for aortic lesions in 1,598 patients. From this group, the indication for stent graft implantation in 31 patients was a traumatic aortic rupture or pseudoaneurysm caused by an injury. All patients had a history of blunt chest trauma. The sequence of injury treatment depended on the severity of each. In all but two patients, the first was an aortic stent graft implantation. The length of thoracic aorta covered ranged from 100-200 mm (mean 123 mm). We did not use any method of spinal cord ischaemia protection. Final angiography showed complete exclusion of the aortic disruption in all patients. RESULTS: All but one operation was successful. One patient died intraoperatively due to concomitant injuries. After the operation, none of the patients had signs of spinal cord ischaemia or any other complications through a follow-up period ranging from 12 to 96 months (mean 40 months). CONCLUSIONS: Our experience with traumatic thoracic aortic ruptures suggests that endovascular treatment should be the method of choice, especially in unstable multi-trauma patients. However, long-term studies are required to assess the durability of this technique after many years.

Influence of atheromatous lesions in the ilio-femoral segment on the occurrence of stentgraft thrombosis after endovascular treatment of an abdominal aortic aneurysm.

UNLABELLED: Limb graft thrombosis (LGT) is one of the most frequent severe complications after endovascular repair of abdominal aortic aneurysms. The aim of the study was to assess the influence of atherosclerosis in ileo-femoral segment on the incidence of LGT as well as to analyze the methods of treatment of LGT. MATERIAL AND METHODS: The medical records of 564 consecutive patients operated endovascularly for abdominal aortic aneurysm by means of bifurcated stentgrafts in the Department of General, Vascular and Transplantat Surgery of Medical University of Warsaw were analyzed. The minimal observation time after surgery was one year. Patients with inflammatory, ruptured and falls aneurysms as well as those with the observation period below 12 months were excluded from the study. Patients were divided into two groups: test (B) and control (K) depending on the progression of atherosclerosis in the iliac arteries. Group B included 184 patients (13 women and 171 men), with advanced atherosclerotic lesions of ilio-femoral segment, corresponding to the A - C class in the TASC classification. The remaining 380 patients (25 women and 355 men) without significant blood flow disorders in the iliac arteries, constituted the group K. The computed tomography was done in all patients with acute limb ischemia. RESULTS: During the observation time up to 114 month, the LGT occurred in 43 (7.6%) cases: [group B - 34/184 (18.5%), group K - 9/380 (2.4%)]. The treatment of LGT included an attempt of patency restoring of the prosthesis by means of thrombolysis or thrombectomy combined with stenting. In case of failure the cross-over femoro-femoral bypass was implanted. Thrombectomy was successful in 21 of 40 cases (52.5%), the local thrombolysis was done in 5 patients and it was successful in three cases and in the remaining two patients the thrombectomy was done. In 16 of 24 patients after patency restoring of the prosthesis the angioplastics and stenting was done. In 17 cases the femoro-femoral bypass was implanted. CONCLUSIONS: The atherosclerosis in ileo-femoral segment significantly increases the risk of LGT. An attempt of patency restoring (thrombectomia or thrombolysis) combined with stenting and cross-over femoro- femoral bypass implantation in case of failure seems to be the successful method of LGT treatment.