Extracorporeal circulation through peripheral vascular successful rescue Abdominal Aortic Iatrogenic Injury During Total en bloc Spondylectomy for L4 Ewing’s sarcoma: A Case Report

Introduction: Abdominal aortic iatrogenic injury can result in massive hemorrhage and is a potentially fatal complication of total en-bloc spondylectomy surgery (TES) for primary malignant spinal tumors (PMST). Currently, there is no definite management for this complication. We report a case of a patient with abdominal aorta iatrogenic injury at the intervertebral disc of lumbar 3 (L3) to lumbar 4 (L4) level during TES performed via a posterior approach. Fortunately, our patient had a good outcome with prompt intervention. Patient concerns: A 16-year-old male was admitted to our department with a chief complaint of low lumbar pain, especially pain at night, since the past 6 months. Diagnosis: PMST at L4 (Ewing's sarcoma) with abdominal aorta iatrogenic injury at the L3 − L4 level that occurred during TES that was performed via a posterior approach. Interventions and outcomes: Multi-disciplinary treatment (MDT), including extracorporeal circulation (ECC) through the peripheral vasculature, was immediately performed to allow for the suturing of the abdominal aortic injury. After the abdominal aorta iatrogenic injury repair, the patient’s hemodynamic parameters stabilized. Two weeks later, TES was reattempted and successfully performed for L4 PMST. Conclusion Intraoperative vascular injury during posterior TES is rare; however, it cannot be avoided with surety since the anterior vertebral manipulation during TES is performed blindly. This complication is often lethal and not diagnosed. Consequently, surgeons must have a wide knowledge of the lumbar spine anatomy and its surrounding structures and conduct a detailed preoperative radiological assessment of the tumor and its surrounding structure. Furthermore, the surgeon should be aware of the risk of vascular injury and familiar with its clinical characteristics for prompt and effective diagnosis and intervention once an injury is suspected to avoid serious consequences. For abdominal aortic injury, the immediate establishment of ECC through peripheral vasculature to suture the vascular laceration may be a quick, safe, and effective management.