Abdominal aortic pseudoaneurysm as a complication of percutaneous vertebroplasty: A case report

Abstract

BACKGROUND

Percutaneous vertebroplasty is a widely used treatment for painful vertebral compression fractures. Cement leakage and infection are the most common complications, whereas vascular injury, particularly aortic puncture, is exceedingly rare but potentially fatal. Reports of major vascular injury during vertebroplasty remain scarce, and awareness of this complication remains limited among proceduralists. This case report describes an aortic pseudoaneurysm caused by inadvertent needle puncture during vertebroplasty, highlighting the recognition, endovascular management, and prevention of this complication.

CASE SUMMARY

A 74-year-old female with severe osteoporosis and prior vertebral compression fractures (L3 and L4) underwent percutaneous vertebroplasty for back pain refractory to conservative therapy. During needle advancement at L3, the needle inadvertently traversed the vertebral body, and retrograde blood flow through the needle prompted reflexive withdrawal. Cement injection was subsequently performed at the same level, and anterior cement extravasation was observed on lateral fluoroscopy during injection. Computed tomography angiography revealed a pseudoaneurysm of the infrarenal abdominal aorta with an associated retroperitoneal hematoma, and the hemoglobin level decreased from 12.8 g/dL to 9.6 g/dL. Urgent aortic angiography confirmed the pseudoaneurysm, which was successfully excluded with an endovascular stent-graft. The patient recovered uneventfully, and 6-month computed tomography angiography confirmed stable stent positioning without endoleak, thrombosis, or migration.

CONCLUSION

Aortic injury is a rare but life-threatening complication of vertebroplasty requiring continuous fluoroscopic monitoring throughout the procedure and prompt management.

Key Words: Vertebroplasty; Aortic puncture; Pseudoaneurysm; Polymethylmethacrylate; Endovascular repair; Iatrogenic vascular injury; Case report

Core Tip: Aortic injury during percutaneous vertebroplasty is an extremely rare but potentially fatal complication. We report a case of inadvertent anterior cortical breach during needle advancement, resulting in infrarenal aortic puncture, pseudoaneurysm formation, and retroperitoneal hematoma. This complication was recognized by retrograde blood flow through the needle and confirmed by computed tomography angiography. Endovascular stent-graft placement successfully achieved complete exclusion of the pseudoaneurysm, with stable findings at 6-month follow-up. This case highlights the importance of continuous fluoroscopic depth monitoring, maintaining a strict midline needle trajectory, and ensuring immediate access to vascular intervention, particularly in patients with severe osteoporosis.

INTRODUCTION

Percutaneous vertebroplasty is a widely used and effective treatment for painful vertebral compression fractures, which are most commonly associated with osteoporosis, malignancy, or trauma[1]. The procedure involves the injection of polymethylmethacrylate (PMMA) into the fractured vertebra to stabilize the spine and relieve pain. Although complication rates are low, the most frequently reported complications include cement leakage and infection[2]. Among these, aortic puncture is an extremely rare but potentially fatal event, underscoring the importance of careful technique and vigilant intraprocedural monitoring.

Herein, we report a case of intraprocedural aortic puncture during vertebroplasty, review the likely mechanism and management of this rare complication, and summarize previously reported cases of major vessel injury associated with vertebroplasty.

CASE PRESENTATION

Chief complaints

The patient, a 74-year-old female, presented with lower back pain that had been refractory to conservative therapy for 4 weeks.

History of present illness

The patient’s back pain had persisted despite conservative management, including analgesics and a thoracolumbosacral brace. Her pain intensity was self-rated as 8/10 on a visual analogue scale. Given the severity and refractory nature of her symptoms, percutaneous vertebroplasty was planned to relieve pain and stabilize the affected vertebrae.

History of past illness

The patient had severe osteoporosis (T-score -3.3) with prior vertebral compression fractures involving L3 and L4.

Personal and family history

The patient reported no family history of aneurysmal disease or connective tissue disorders.

Physical examination

Physical examination upon admission revealed normal vital signs, localized tenderness over L3 and L4, and no neurological deficits.

Laboratory examinations

The patient’s coagulation profile and renal function markers were within normal limits. The preprocedural hemoglobin level was 12.8 g/dL.

Imaging examinations

Preprocedural imaging demonstrated moderate compression of L3 and L4 (approximately 30% height loss), without associated kyphotic deformity or scoliosis. A dedicated preprocedural computed tomography examination was not performed; therefore, anterior cortical integrity and the vertebral-aortic distance were not specifically assessed before the procedure.

Vertebroplasty was performed by the primary operator, an interventional radiologist with 20 years of procedural experience, using a unipedicular transpedicular approach with an 11-gauge vertebroplasty needle at L3 and L4 under biplane fluoroscopic guidance. During needle advancement at L3, fluoroscopic checks were performed intermittently rather than continuously, reflecting institutional practice aimed at minimizing cumulative radiation exposure to both the patient and the operating team. This intermittent monitoring allowed the needle to inadvertently traverse the vertebral body. Upon removal of the inner stylet, retrograde blood flow through the needle was observed, prompting reflexive withdrawal of the needle back into the vertebral body. Once the needle tip was confirmed to be within the vertebral body, cement injection was performed cautiously to stabilize the fracture and prevent further vertebral collapse.

PMMA cement was manually injected by syringe at medium viscosity, without pressure monitoring, at a volume of 3-5 mL into each of L3 and L4. Cement injection was performed first at L4, followed by L3. Following the injection at L3, lateral radiography (Figure 1) confirmed adequate cement filling of both L3 and L4 but revealed anterior extravasation of PMMA from L3. The location and extent of the extravasation, together with the retrograde blood flow observed during the procedure, warranted further investigation.

Figure 1 Lateral fluoroscopic view of the lumbar spine obtained during vertebroplasty. The orange arrow indicates anterior extravasation of polymethylmethacrylate beyond the anterior cortex of the vertebral body, suggestive of cortical breach with leakage into the prevertebral region.

Contrast-enhanced computed tomography angiography (CTA) of the abdomen was performed approximately 30 minutes after the procedure, revealing PMMA migration beyond the vertebral body, a pseudoaneurysm of the infrarenal abdominal aorta, and an associated retroperitoneal hematoma (Figure 2).

Figure 2 Axial contrast-enhanced computed tomography angiography demonstrating abdominal aortic pseudoaneurysm after vertebroplasty. The blue arrow indicates migration of polymethylmethacrylate anterior to the vertebral body, and the orange arrow indicates the abdominal aortic pseudoaneurysm.

Given these findings, an aortic angiogram was urgently performed immediately after CTA, confirming the pseudoaneurysm at the site of cement extravasation (Figure 3A). At that time, the hemoglobin level had decreased to 9.6 g/dL from the preprocedural baseline of 12.8 g/dL, reflecting ongoing blood loss.

Figure 3 Aortic angiography before and after endovascular stent-graft placement. A: Abdominal aortic pseudoaneurysm (orange arrow); B: Complete exclusion of the pseudoaneurysm, with no evidence of contrast extravasation after stent-graft deployment (blue arrow).

FINAL DIAGNOSIS

Iatrogenic infrarenal abdominal aortic pseudoaneurysm with retroperitoneal hematoma secondary to inadvertent aortic puncture and anterior cortical breach during L3 percutaneous vertebroplasty.

TREATMENT

The patient underwent successful endovascular stent-graft placement during the same session using a Treo^® Abdominal Stent-Graft System (15 mm × 60 mm; Terumo Aortic, Inchinnan, Scotland) to exclude the pseudoaneurysm and reinforce the aortic wall (Figure 3B).

After the procedure, dual antiplatelet therapy with aspirin (75 mg daily) and clopidogrel (75 mg daily) was initiated for 6 months, following institutional protocol to reduce the risk of stent thrombosis. Therapy was subsequently transitioned to lifelong single antiplatelet therapy with aspirin to maintain graft patency and minimize long-term cardiovascular risk.

The patient was scheduled for regular imaging follow-up to monitor for potential complications, including endoleak, graft migration, and thrombosis.

OUTCOME AND FOLLOW-UP

The patient was closely monitored after endovascular stent-graft placement, with regular assessments of graft integrity and overall clinical recovery. At the 1-month follow-up, she was clinically stable, with no evidence of recurrent bleeding or graft-related complications.

Six-month CTA confirmed stable stent positioning without endoleak, thrombosis, or migration (Figure 4). The patient reported no limitations in daily activities and had returned to her normal routine. Ongoing surveillance, including annual imaging, was planned in accordance with current guidelines. The patient remains asymptomatic, with no procedure-related complications.

Figure 4 Six-month follow-up computed tomography angiography after endovascular stent-graft placement. Contrast-enhanced computed tomography angiography demonstrates stable stent positioning, without endoleak, thrombosis, or migration.

DISCUSSION

The aortic injury in this case most likely resulted from uncontrolled anterior advancement of the needle at L3, related to intermittent rather than continuous fluoroscopic depth monitoring during needle advancement.

Biplane fluoroscopy, with true lateral and anteroposterior projections, allows more precise depth assessment and reduces parallax error compared with single-plane imaging. In this case, despite the availability of biplane fluoroscopy, the needle position was assessed intermittently rather than continuously; this created a gap during which the anterior cortical breach likely went unrecognized. Maintaining the needle within the upper one-third of the vertebral body and strictly in the midline on both projections is generally recommended to avoid breaching the anterior cortex and injuring the adjacent aorta and iliac vessels[3].

The needle was withdrawn reflexively once retrograde blood flow was observed rather than left in place for further assessment. In retrospect, leaving the needle in situ until a more definitive assessment had been performed may have been the safer approach because the withdrawal may have converted a partially tamponaded puncture into a source of ongoing bleeding[3].

Although exceedingly rare, aortic and other major vascular injuries during vertebroplasty have been reported. Previous case reports describe injuries ranging from aortic perforation to lumbar artery pseudoaneurysm, with management including conservative treatment, endovascular techniques, and emergent vascular surgery (Table 1).

Table 1 Cases of major vascular injury after vertebroplasty.

Ref.	Vertebroplasty level	Vascular injury	Management	Outcome
Umeda et al[3]	T12, L1 osteoporotic compression fractures	Abdominal aortic penetration	Conservative treatment	Uneventful at 2-year follow-up
Puri et al[9]	L3, L4 compression fractures	Lumbar artery pseudoaneurysm	Coil embolization	Not available
Puri et al[9]	Th11, L1–L3, L5 compression fractures	Lumbar artery pseudoaneurysm	Coil embolization	Not available

The risk of pseudoaneurysm rupture is traditionally influenced by lesion size, with smaller pseudoaneurysms (< 2 cm) generally considered low risk, lesions measuring 2-5 cm carrying moderate risk, and those larger than 5 cm associated with a high risk of rupture[4]. In acute iatrogenic aortic injury, however, lesion size is less important than active bleeding, hemodynamic status, and imaging findings, which guided management in this case.

The Society of Interventional Radiology and the American Academy of Orthopedic Surgeons guidelines emphasize preprocedural review of cross-sectional imaging and fluoroscopic guidance throughout the procedure, with particular vigilance in high-risk patients, such as those with severe osteoporosis[5]. When vascular injury is suspected, prompt CTA and early involvement of interventional radiology or vascular surgery are key to improving patient outcomes[6].

In this case, endovascular stent-graft placement allowed rapid, minimally invasive exclusion of the pseudoaneurysm. This approach is generally preferred over open repair because of its lower morbidity[7], but it necessitates long-term surveillance for endoleak, graft migration, or thrombosis[8].

CONCLUSION

Aortic injury during vertebroplasty is rare but can be catastrophic. This case illustrates how easily such an injury can go unrecognized when fluoroscopic monitoring during needle advancement is intermittent rather than continuous. A midline trajectory confined to the upper third of the vertebral body, prompt recognition of warning signs such as retrograde blood flow, and ready access to endovascular or surgical support remain the key safeguards. This is particularly important for patients with severe osteoporosis, in whom the cortical margins may be thinner than expected.