54 year old male with a history on physical exam and imaging studies consistent with lumbar neuroforaminal stenosis L4/5 and L5/S1 status post prior laminectomy with progressive severe degenerative disc disease. Patient was scheduled for L4/5 L5/S1 Fusion Lumbar Anterior 2 Level with Pedicle Screw Instrumentation and L4/5 L5/S1 Fusion Lumbar Posterior 2 Level with Instrumentation at Hospital for Special Surgery.
On 8/30/19 surgery was performed by an Orthopedic and Vascular Surgeon. According to the Orthopedic Surgeon’s operative report the vascular surgeon “provided exposure to the anterior lumbar spine at L4-5 and L5-S1 level” “During the vascular surgeon’s placement of the retractors at the L4/5 level a tear was made in the common iliac vein.” The operative report of the vascular surgeon states: “We mobilized the lumbar vessels to the left of the iliac vessels and divided them. We mobilized the vessels then over towards the patient’s right and placed a self-retaining retractor exposing L4- disc space. A discectomy and fusion was performed by {the orthopedic surgeon]. Once that was completed, we shifted the retractors and exposed the L5-S1 disc space by dividing the middle sacral vessels. The discectomy and fusion was performed by the orthopedic surgeon” The vascular surgeon’s report continues: “Upon removing the retractors from behind the vessels in the L5-S1 disc space, there was noted to be diffuse bleeding from the iliac vein confluence. We ultimately were able to clamp the common iliac vein to identify where the bleeding was. There were two areas. One was at the confluence of the iliac veins. One was on the undersurface of the vena cava just at the insertion of the left common iliac vein. We repaired both the bleeders with 5-0 Prolene suture. Once we complete the repair, there was noted to be some mild narrowing but the vein appeared patent and was hemostatic.
Because of the extensive blood loss which required transfusions, the surgeons decided to stop the surgery at that point and not proceed with the posterior fusion.
The patient will need to have the posterior fusion to stabilize the instrumentation as was the plan but for the complication and it is anticipated that it will be within one year of this initial surgery.
Is this an inherent and acceptable risk of this procedure or was it caused by the vascular surgeon’s negligence. There were two tears: one to the iliac vein and one to the vena cava. This does seem to be unusual.
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Do you believe there might have been medical error?
Iliac vein injury is an infrequent but known complication for anterior spine exposure. In 8 published series, the rate of major venous injury ranges 1.4-3.7% (Fantini GA, Pawan AY. Access related complications during anterior exposure of the lumbar spine. World J Orthop 2013 Jan 18; 4(1): 19-23). Therefore, the injury itself is not negligent per se. However, it is generally recommended to avoid clamping the iliac vein because the vein is fragile and clamping may exacerbate or extend the tear. A tear at the confluence of the IVC is a feared injury and can be difficult to fix. This is due to a narrow deep field making visualization difficult. It is easy to extend the tear or cause further tears during attempts to repair. Instead of attempting to clamp or encircle the vein for proximal and distal control, it is generally recommended to use Kitner peanut dissectors or sponge-sticks to apply gentle pressure proximal and distal to the injury in order to achieve adequate visualization to enable repair.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The complication itself is not negligent. However, the approach to repair it by clamping the iliac vein may not have been optimal and may have exacerbated the tear or resulted in large volume blood loss. It is unclear to me whether there was an injury aside from requiring large volume transfusion. Would need more details on the patient's outcome.
What makes you a good expert for this case?
I am a board-certified vascular surgeon. I have been called emergently twice in the past 7 years to repair this type of injury - i.e. iliac vein injury during anterior spine exposure for lumbar fusion. I successfully repair both injuries and understand the issues involved.
How often do you encounter cases similar to this one in your practice?
I have been called emergently twice in the past 7 years to repair this type of injury - i.e. iliac vein injury during anterior spine exposure for lumbar fusion. The most recent case was in June 2018. This is a rare but recognized complication from anterior spine exposure.
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