Vascular injuries and complications in anterior lumbar interbody fusion: an up-to-date review.

Vascular injuries during anterior lumbar interbody fusion (ALIF) are reported in the existing literature with an incidence rate ranging from 1% to 24%, predominantly venous lacerations owing to branch vessel avulsions during mobilization and retraction. Arterial injuries, although less frequent, occur at an incidence of 0.45% to 1.5% and are mainly characterized by thromboses; aortic lacerations remain exceptionally rare. L4-L5 and L5-S1 are the two levels associated with the majority of vascular complications. Preoperative 3D CT angiography is paramount and a gold standard, as it illustrates the anatomic variations of the iliolumbar vein, the aorta, and the vena cava bifurcation, providing the surgeon with valuable information regarding operative trajectories. Regarding preventive measures, venous laceration, the most common vascular injury, occurs less frequently when employing nonthreaded interbody grafts such as iliac crest autograft or femoral ring allograft. Also, left iliac artery thrombosis can be decreased intraoperatively by intermittent release of retraction. Managing vascular complications includes compression for bleeding control, Trendeleburg positioning of the patient and venorrhaphy, and the employment of topical clot-forming enhancement and/or hemostatic agents. Although postoperative lower limb duplex ultrasonography can be an effective tool, magnetic resonance venography (MRV) and intravenous catheterization (IVC) remain the gold standards for diagnosing postoperative pelvic vein thrombosis in cases of iliac vein repair after anterior spine surgery. This paper aimed to highlight the incidence of major vascular injury during ALIF surgery, describe predisposing risk factors, and discuss management techniques while highlighting the requirement for more sensitive and factor-specific studies to attain a more profound understanding of the mechanism of vasculature complications during ALIF procedures.