Endovascular occlusion of iatrogenic lumbar artery pseudoane
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A case of iatrogenic pseudoaneurysm of the fourth lumbar artery as a complication after transpedicular screw fixation in the lumbar spine was reported. The lesion was succesfully occluded with endovascular liquid embolic agent infusion and the patient was fully recovered.

A 72-year-old male patient treated with oral anticoagulant for prosthetic heart valve presented long-term lower back pain and neurogenic intermittent claudication. Lumbar spine magnetic resonance (MR) image revealed severe lumbar scoliosis and L3-S1 spinal stenosis due to adjacent segment degeneration. The patient underwent T12–S1 posterior lumbar fusion with instrumentation. Oral anticoagulation was discontinued 5 days before surgery and replaced with low-molecular-weight-heparin (LMWH). The patient made an uneventful postoperative recovery and LMWH was initiated 24 hours after surgery.

Three days after surgery, the patient presented with acute onset monoplegia affecting the left lower limb, general discomfort with abdominal pain and sweating. Low hemoglobin level (6.4 g/dl) was observed on blood test. A CT scan revealed a large posterior epidural and paravertebral hematoma and an acute hematoma in the left psoas muscle suggesting pseudoaneurysm. LMWH was discontinued. A diagnostic spinal angiogram was performed via right common femoral artery. Selective second left lumbar injection demonstrated two pseudoaneurysms in the left paravertebral space.

It was decided to treat the pseudoaneurysms with selective embolization. A total of 4ml of high-density liquid embolic agent were injected through the microcatheter in the proximal pseudoaneurysm, and both pseudoaneurysms were succesfully occluded in the final control angiogram.

The patient was then re-operated and the posterior paravertebral and epidural hematoma was drained. On the first day after surgery, the patient was mobile and he reported significant pain relief. He was hemodynamically stable. LWMH was then initiated and replaced with oral anticoagulation after 24hours. After a few days, the patient's overall condition improved significantly and he was discharged two weeks after hematoma evacuation.

Lumbar artery pseudoaneurysm is an uncommon but potentially life-threatening complication of lumbar screw fixation and should be considered in patients that present with flank pain and hemodynamic instability following surgery.

source: https://www.sciencedirect.com/science/article/pii/S2352644020300765?dgcid=rss_sd_all
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