Incidence and Management of Vascular Injury and Thromboembolism in Patients Undergoing Anterior Lumbar Interbody Fusion

Introduction: Anterior lumbar interbody fusion (ALIF) facilitates more efficient discectomy, larger cage placement, and greater lordosis compared to posterior approaches. However, the literature characterizing its risk of vascular injury is sparse.

Methods: A retrospective single-center consecutive cohort study of adult ALIF patients from 2018-2022 was performed. Demographics, surgical characteristics, intraoperative vascular complications, and postoperative A/VTE (deep venous thrombosis [DVT] and pulmonary embolism [PE]) were recorded.

Results: Cohort included 352 patients with a mean age of 56.5 years and 49.2% were male. Distribution of treated levels was 45.5% 1-level, 36.6% 2-level, 13.4% 3-level, 4.3% 4-level, 0.3% 5-level. Mean estimated blood loss (EBL) was 386.0 ml. Intraoperative major and minor vascular injuries were encountered in 0.9% and 6.0% cases with mean EBL of 2416.7 ml and 662.5 ml, respectively. 0/3 patients with major vascular injuries and 4/21 (19.0%) with minor injuries had prior abdominal surgery, compared to 141/352 (40%) in the overall cohort. Major vascular injuries included 2 left common iliac vein lacerations (both repaired with suture, 1 resulted in case abortion) and 1 left common iliac artery dissection (with arterial thrombus and critical limb ischemia requiring stenting). These occurred in patients undergoing 5-level ALIF (arterial dissection with thrombus) and 3-level ALIF (left common iliac vein injuries at the L5 level). Overall A/VTE incidence was 3.1%; the incidence of A/VTE for major and minor vascular injury was 100.0% and 23.8% of cases, respectively. This included 5 patients with DVT/PE, 4 with DVT, 2 with PE, and 1 with ATE (6 received inferior vena cava filters and 11 received therapeutic AC). Left common iliac vein injuries resulted in 100% incidence of DVT.

Conclusion : ALIF may not be as low risk as previously thought with 6.9% incidence of vascular injury with 0.9% being major. A/VTE is the major sequala requiring medical management via AC.