a 57-year - old male patient presented with a sudden onset of low back pain radiating to the left lower leg after running on a treadmill .
magnetic resonance imaging revealed a posterior herniated ruptured disc between the fourth and fifth vertebrae in the lumbar spine .
a neurosurgeon evaluated the patient 's condition , which indicated the need for a microdiscectomy of the left l4-l5 intervertebral disc .
an emergency operation was decided because the patient complained of severe pain and numbness . inside the operating room ,
the non - invasive blood pressure ( nibp ) , electrocardiography ( ecg ) and pulse oximeter ( spo2 ) were connected to the patient .
general anesthesia was induced with propofol 120 mg and endotracheal intubation was facilitated using rocuronium 60 mg as a muscle relaxant .
anesthesia was maintained with desflurane in a 50% n2o and o2 mixture , and rocuronium .
the lungs were ventilated mechanically with a semiclosed circuit system to maintain the end - tidal co2 ( etco2 ) at approximately 35 mmhg .
intraoperative monitoring included the heart rate , nibp , ecg , spo2 , etco2 , anesthetic gases analysis and the airway pressures .
a sudden spurt of blood occurred when the disc was almost completely removed . as the blood continued to gush out ,
the systolic bp decreased to 50 mmhg , the nibp was not detectable and patient began to have tachycardia ( 156 bpm ) .
three 16 g cannulas were quickly secured on the dorsum of the other hand and both external jugular veins .
arterial cannulation was achieved with a 20 g cannula on the left radial artery . under the suspicion of a large vessel injury ,
the laminectomy wound was closed immediately and the patient was turned to the supine position for a laparotomy . at that time , the patient showed an inflating abdomen . a 16 g double lumen central line was placed in the right internal jugular vein and fluids were infused .
dopamine and dobutamine infusions were started but they had no effect , so a norepinephrine infusion was also started .
the neurosurgeons , anesthesiologists and cardiothoracic surgeons agreed about the necessity of cardiopulmonary bypass ( cpb ) due to the suspicion of severe bleeding from an iatrogenic large vessel injury .
a right iliac artery injury was suspected so the left femoral artery and vein were used for cannulation .
an arterial cannula was cannulated into the left femoral artery , with a flow of 2,000 ml / m / min , and partial cpb was started .
, a wedge - shape rent was found in the right external iliac artery around the l4 - 5 level . during the operation ,
the intravascular volume was replaced with 9 liters of crystalloid , 0.5 liters of colloid , 18 units of packed red blood cells , 14 units of fresh frozen plasma and 8 units of platelet concentrates .
as soon as the external iliac artery injury had been repaired , the hemodynamic parameters of the patient began to improve . after the bleeding was controlled , and the cpb was stopped , and protamine ( 185 mg ) was administrated .
postoperatively , the patient was sent intubated and ventilated to the intensive care unit ( icu ) . in the icu ,
the patient was extubated on the fourth postoperative day . under the appropriate treatment for seven days
four weeks later , the patient was discharged from hospital neurologically intact and with a healthy laparotomy wound .
the aorta is ventral to the vertebral column , which transverses the diaphragm at the level of the l1 intervertebral space and bifurcates at the level of the l4 intervertebral space into the common iliacs .
the inferior vena cava is located to the right of the aorta in these segments , and is divided further into left and right common iliac veins , also at the level of the l4 intervertebral space .
the incidence of major vascular injury during lumbar disc operations is 0.01 - 0.05%   with an overall mortality of 10 - 65% [ 2 - 4 ] .
the broad range of the mortality is associated with the diameter of the injured vessels , size of the tear , speed of diagnosis , laparotomy and control of bleeding .
many factors predisposing the patients to vascular injury during lumbar surgery have been reported , including anterior disc rupture , preexisting defects in the anterior annulus fibrosus and anterior longitudinal ligaments , vertebral anomalies , body habitus , patient positioning , use of different techniques , use of a surgical microscope , prior intraabdominal surgery , surgery for recurrent disc herniation , and the surgeon 's experience .
major vascular injuries can manifest as acute life - threatening hemorrhage , chronic arteriovenous fistula or pseudoaneurysm formation .
acute blood loss can lead to an intractable and progressive decrease in blood pressure due to hypovolemia , wide pulse pressure , tachycardia , a decrease in haematocrit , pallidness , and a decrease in skin temperature .
an arteriovenous fistula and aneurysms may often be undetected initially and patients may present with symptoms months or years later . the mortality rate for lacerations ,
the most common injury among them is on the right common iliac artery , which is located immediately anterior to the l4-l5 lumbar disc space .
next in order of frequency is an arteriovenous fistula between the right common iliac artery and left common iliac vein .
the most common surgical techniques for repair of these complication include the following techniques : primary suturing , interposition grafting , excision with end - to - end anastomosis , suturing from within the vessel , patch angioplasty , ligation and endovascular embolisation or stent - graft placement .
laceration of a major artery or vein will result in life - threatening bleeding complications that should be treated by rapid fluid resuscitation and immediate vascular surgical intervention .
the surgical decision and repair of the arterial wall injury in patients presenting with an acute and rapid course of deterioration should be made as early as possible .
the mortality rate approaches 100% when surgery is not performed immediately in arterial injuries . during lumbar disc surgery , ureteral and intestinal injuries can also occur but , the diagnosis can be more difficult due to a lack of specific diagnostic signs .
generally , cpb with the femoral artery and vein is indicated for an aneurysm of the ascending aorta , or severe atherosclerosis or difficult cannulation in the ascending aorta during cardiac surgery due to the complex surgical technique .
in addition , it can be used when difficult airway management is predicted or , like this case , when severe bleeding caused by a major vessel injury occurs . in summary ,
correct crisis resolution protocols , such as proper massive transfusion algorithms and successful surgical intervention , are quite effective during the critical period .
a high index of suspicion , prompt diagnosis and action will result in improved patient salvage .
 iatrogenic vascular injury during lumbar disc surgery is a rare but serious complication . 
 this paper reports a patient who sustained an injury to the iliac artery while undergoing intervertebral disc surgery at the lumbar region . 
 he suffered from massive bleeding and shock . 
 an urgent laparatomy was performed under cardiopulmonary bypass , and the vascular injuries were repaired successfully . 
 this case shows that a rapid diagnosis and immediate intervention can result in a favorable outcome . 
Case Report
Discussion