Center for Vein Restoration, Greenbelt, Md; Center for Vascular Medicine, Greenbelt, Md.
Center for Vascular Medicine, Greenbelt, Md.
J Vasc Surg Venous Lymphat Disord. 2020 May;8(3):405-411. doi: 10.1016/j.jvsv.2019.08.018. Epub 2020 Feb 6.
Open lumbar spine stabilization surgery often requires mobilization of the left and right common iliac veins (CIVs) and the placement of plates and screws that can impinge on them. We reviewed our venography experience of the past 3 years to determine whether there is an association between spine stabilization surgery and the development of symptomatic iliac vein outflow lesions.
A retrospective chart review of prospectively collected data from our electronic medical record system was performed to identify patients who underwent venography with or without venous stenting and had a history of previous lumbar spine stabilization. Patients' demographics, medical comorbidities, venograms, and intravascular ultrasound (IVUS) data were collected and analyzed. The senior author reviewed all venograms and IVUS images of patients with previous spine stabilization procedures.
From January 2014 to April 2018, venography was performed in 1713 limbs in 1245 patients at the Center for Vascular Medicine. Of the 1245 patients, 18 patients had a history of lumbar spine stabilization procedures: five anterior-posterior and 13 posterior. Nine had single-level and eight had two- or three-level fusions. All 18 patients demonstrated pelvic lesions. These included 1 left CIV aneurysm, 5 left CIV stenoses, 3 bilateral CIV stenoses, 2 left CIV and inferior vena cava occlusions, and 2 external iliac vein stenoses. The aneurysm patient was treated with anticoagulation, 8 patients underwent stenting, 1 patient refused stenting because of relocation to another country, 1 inferior vena cava-CIV occlusion could not be crossed, fear of dislodging a thrombus and the proximity to a protruding posteriorly placed screw prevented stenting in 2 patients, and 4 patients had a venoplasty alone because of undersizing of a stenosis or missed lesions with IVUS after review by a blinded reviewer. Lesions in anterior lumbar interbody fusion patients were extremely stenotic, required predilation, and resulted in a residual stenosis requiring venoplasty at a second setting in one patient.
Lumbar spine stabilization surgery may be a risk factor for development of symptomatic venous outflow obstruction lesions. During venography and stenting in patients with anterior lumbar interbody fusion approaches, significant scarring may be encountered, resulting in a residual stenosis after stent placement. Predilation venoplasty, before stent deployment, is recommended to prevent stent migration. Furthermore, a history of spine stabilization surgery in patients presenting with pelvic symptoms, lower extremity pain or swelling, or post-thrombotic symptoms should prompt consideration of a pelvic venous duplex ultrasound examination to determine whether an iliac venous outflow lesion is present.
开放式腰椎稳定手术通常需要移动左右髂总静脉 (CIV) 并放置可能会压迫到它们的钢板和螺钉。我们回顾了过去 3 年的静脉造影经验，以确定脊柱稳定手术与症状性髂静脉流出病变的发展之间是否存在关联。
对我们电子病历系统中前瞻性收集的数据进行回顾性图表审查，以确定接受静脉造影和/或静脉支架置入且有既往腰椎稳定病史的患者。收集并分析患者的人口统计学、合并症、静脉造影和血管内超声 (IVUS) 数据。资深作者回顾了所有有既往脊柱稳定手术的患者的静脉造影和 IVUS 图像。
2014 年 1 月至 2018 年 4 月，在血管医学中心对 1245 名患者的 1713 条肢体进行了静脉造影。在 1245 名患者中，有 18 名患者有腰椎稳定手术史：5 例前路，13 例后路。9 例为单节段融合，8 例为 2 节段或 3 节段融合。所有 18 名患者均存在盆腔病变。包括 1 例左侧髂总静脉动脉瘤、5 例左侧髂总静脉狭窄、3 例双侧髂总静脉狭窄、2 例左侧髂总静脉和下腔静脉闭塞、2 例髂外静脉狭窄。动脉瘤患者接受抗凝治疗，8 例患者接受支架置入，1 例患者因移居另一个国家而拒绝支架置入，1 例下腔静脉-髂总静脉闭塞无法通过，担心血栓脱落和 2 例患者因紧贴突出的后路放置的螺钉而阻碍支架置入，4 例患者因狭窄或 IVUS 检查漏诊而进行单纯血管成形术。前路腰椎间融合术患者的病变极为狭窄，需要预扩张，导致 1 例患者在第二次设置时需要血管成形术来解决残余狭窄。
腰椎稳定手术可能是发生症状性静脉流出阻塞病变的危险因素。在前路腰椎间融合术入路的患者进行静脉造影和支架置入时，可能会遇到严重的瘢痕形成，导致支架放置后残留狭窄。建议在支架植入前进行预扩张血管成形术，以防止支架移位。此外，对于出现盆腔症状、下肢疼痛或肿胀或血栓后症状的脊柱稳定手术史患者，应考虑进行盆腔静脉双功能超声检查，以确定是否存在髂静脉流出病变。
