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. 2023 Aug 14;6(7):CASE23272.
doi: 10.3171/CASE23272. Print 2023 Aug 14.

Intravascular ultrasound to aid in the diagnosis and revision of an intra-aortic pedicle screw: illustrative case

Landon D Ehlers  1 , Patrick J Opperman  1 , Jack E Mordeson  1 , Jonathan R Thompson  2 , Daniel L Surdell  1
Affiliations

Intravascular ultrasound to aid in the diagnosis and revision of an intra-aortic pedicle screw: illustrative case

Landon D Ehlers et al. J Neurosurg Case Lessons. .

Abstract

Background: Pedicle screw impingement on vessel walls has the potential for complications due to pulsatile effects and wall erosion. Artifacts from spinal instrumentation create difficulty in accurately evaluating this interface. The authors present the first case of intravascular ultrasound (IVUS) used to characterize a pedicle screw breach into the aortic lumen.

Observations: A 21-year-old female with surgically corrected scoliosis underwent computed tomography angiography (CTA) 3 years postoperatively, which revealed a pedicle screw within the thoracic aorta lumen. Metal artifact distorted the CTA images, which prompted the decision to use intraoperative IVUS. The IVUS confirmed the noninvasive imaging findings and guided final decisions regarding aortic endograft size and location during spine hardware revision.

Lessons: For asymptomatic patients presenting with pedicle screws malpositioned in or near the aorta, treatment decisions revolve around the extent of vessel wall penetration. Intraluminal depth can be obscured by artifact on computed tomography or magnetic resonance imaging or inadequately evaluated by a transesophageal echocardiogram. In our intraoperative experience, IVUS confirmed the depth of vessel lumen violation by a single pedicle screw and no wall penetration by two additional screws of concern. This was useful in deciding on thoracic endovascular aortic repair graft size and landing zone and facilitated safe spinal instrumentation removal and revision.

Keywords: aorta; case report; intravascular ultrasound; pedicle screw; revision.

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Conflict of interest statement

Disclosures Dr. Thompson is the program director for the vascular surgery fellowship, which receives an annual educational grant from Gore Medical for simulation-based training.

Figures

FIG. 1.
FIG. 1.
Preoperative CTA. Left: Axial view at the T5 level of the left T5 pedicle screw laterally breached and violating the aortic wall (white arrow). Right: Corresponding sagittal view of the left T5 pedicle screw.
FIG. 2.
FIG. 2.
Intraoperative IVUS image confirming erosion of the T5 pedicle screw (white arrow) through the aortic wall. Intraoperative measurement estimated the screw depth to be 8 mm within the aortic lumen.
FIG. 3.
FIG. 3.
Intraoperative fluoroscopy showing partial deployment of the TEVAR graft starting distal to the left subclavian artery and centered over the T5 pedicle screw. Driver is seen to be engaged in the screw head to allow tandem removal while the remainder of the graft is deployed.
FIG. 4.
FIG. 4.
Completion angiography after TEVAR graft deployment showing good wall apposition and no evidence of endoleak or extravasation.
FIG. 5.
FIG. 5.
Follow-up CTA at 1 month showing revised spinal hardware at T5 and stable vascular graft wall apposition without evidence of endoleak or pseudoaneurysm development.
See this image and copyright information in PMC

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