Interact CardioVasc Thorac Surg 2007;6:501-502. doi:10.1510/icvts.2007.151993
© 2007 European Association of Cardio-Thoracic Surgery
ESCVS article - Vascular general |
Lower limb paralysis from ischaemic neuropathy of the lumbosacral plexus following aorto-iliac procedures
Adel Abdellaouia,*,
Nick J. Westb,
Mark A. Tomlinsona,
Martin H. Thomasb and
Neil Browningb
a Department of Vascular Surgery, Royal Lancaster Infirmary, Ashton Road, Lancaster, LA1 4RP, UK
b Department of Vascular Surgery, St Peter's Hospital, Chertsey, Guildford Road, KT16 0PZ, UK
Received 13 January 2007;
received in revised form 25 March 2007;
accepted 2 April 2007
 Presented at the 55th International Congress of the European Society for Cardiovascular Surgery, St Petersburg, Russian Federation, May 11–14, 2006.
*Corresponding author. Tel.: +44 7906 004953; fax: +44 1752 315300.
E-mail address: adel.abdellaoui{at}gmail.com (A. Abdellaoui).
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Abstract
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Objective: Neurological injuries following aorto-iliac procedures are rare, unpredictable and cause significant morbidity. We report four cases of lower limb paralysis following aorto-iliac procedures, in which two patients suffered internal iliac occlusion and discuss potential aetiological factors. Methods: Four male patients, age ranging between 56 and 77 years, underwent aorto-iliac procedures. Three patients underwent repair of infra-renal abdominal aortic aneurysm (2 open and 1 endovascular repair) and one patient had percutaneous angioplasty of the internal iliac artery. Results: All patients developed a unilateral lower limb paralysis early post procedure. Neurophysiological studies were performed in three patients and confirmed the injury to the lumbosacral plexus in two cases. MRI scan performed in two patients did not show any abnormality. In two of the cases, occlusion of one internal iliac artery was implicated as the cause of lumbo-sacral plexopathy: one with the coverage of the internal artery origin with the stent, the other due to thrombotic occlusion of common and internal iliac in arteries after an elective open repair of abdominal aortic aneurysm with a bifurcated graft. Follow up ranged between 2 and 4 months. Only one patient recovered completely; the other three were left with permanent disability. Conclusions: Ischaemic neuropathy following aorto-iliac intervention, whether open or endovascular, remains a rare, unpredictable and devastating complication. When it occurs it is likely to result in permanent neurological disability. It is important to note that it may be related to internal iliac artery thrombosis.
Key Words: Arteries; Ischaemia; Thrombosis
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1. Introduction
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Lower limb paralysis following abdominal aortic or iliac procedures are rare, unpredictable and cause significant morbidity. We report four cases of lower limb paralysis after aorto-iliac procedures.
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2. Case report 1
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A 77-year-old man with significant pulmonary co-morbidities underwent endovascular stent graft repair of an infrarenal aortic aneurysm. A bifurcated device was inserted under regional anaesthesia. The right internal iliac orifice was inadvertently covered by the stent. However, the left internal artery was patent and so the device was left in position.
On the third day post procedure, the patient noticed increasing weakness in all the muscle groups of his right leg. His reflexes were reduced and clinical examination suggested a problem within the lumbosacral plexus. Neurophysiological studies confirmed an injury to the lumbosacral plexus or sciatic nerve. A magnetic resonance (MR) scan failed to demonstrate any spinal cord or other nerve tissue deficit.
After one week, the patient's right buttock became frankly ischaemic and required surgical debridement. By three months, the buttock wound had virtually healed. The patient was able to walk with the aid of a frame, although he still displayed significant weakness of the right leg.
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3. Case report 2
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A 75-year-old man with abdominal pain was shown on a computerised tomography (CT) scan to have 5.8 cm abdominal aortic aneurysm (AAA) and a right common iliac artery aneurysm of 4.3 cm. At open elective operation, the aneurysms were repaired using a bifurcated graft. Prior to the application of clamps, intravenous heparin (5000 IU) was administered. After opening the aorta, no internal iliac orifice could be identified. The right limb of the graft was sutured into the external iliac artery, thus excluding the thrombosed common iliac, and the left limb was sewn into the common iliac artery, as the internal iliac was patent on that side.
On the second postoperative day the right leg was noticed to be paralysed, asensate and areflexic. The right buttock appeared dusky but viable and no tissue was lost. Clinical examination and neurophysiology studies suggested a lumbosacral problem. An MRI scan was reported as normal.
At four months, the patient's lower limb had not recovered and he was mobilizing in a wheelchair.
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4. Case report 3
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A 57-year-old male smoker presented with bilateral claudication affecting both buttocks and thighs. He had undergone femoro-femoral crossover grafting two years previously, for a left common iliac artery (CIA) stenosis. Angiography revealed a tight inflow stenosis in the right CIA, which was angioplastied, apparently uneventfully, with an 8x40 mm balloon after systemic anticoagulation with 3000 units heparin. However, the next day he was complaining of severe pain in the right leg, requiring opiate analgesia. The ankle-brachial pressure index (ABPI) had risen from 0.75 pre-procedure to >1.0 bilaterally post-procedure. All lower limb pulses were palpable and there was no evidence of groin swelling. He was discharged with adequate analgesia.
Upon review four weeks later the pain was persisting and he was exhibiting sensory and motor neurological signs of sciatic or lumbosacral neuropathy, being unable to stand without the aid of a stick. ABPI were normal (>1.0) and a CT scan did not reveal any retroperitoneal or paraspinal haematoma or spinal cord pathology. A neurological opinion and electromyelographic studies (EMG) were planned but the patient's symptoms improved such that two months later they were all normal and his weakness had resolved.
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5. Case report 4
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A 56-year-old man presented with a ruptured AAA. CT scanning confirmed a 7 cm aneurysm that was subsequently repaired using a tube graft. During the operation, two significantly sized right lumbar arteries causing excessive back bleeding were oversewn.
He was not extubated for three days, but then complained of a lack of sensation and weakness in his right leg. Reflexes were absent and clinical examination suggested a lumbosacral plexus problem. A spinal cord drain was inserted. Neurophysiological studies showed neurapraxia of the lumbosacral plexus. When discharged from hospital, he was unable to use his right leg and was mobilizing in a wheelchair.
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6. Discussion
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Neurological events following abdominal aortic and iliac surgery are rare. However, these devastating complications are unpredictable, often permanent and cause significant morbidity. The overall neurological risk for endovascular and open abdominal aortic surgery ranges between 0–1% [1–4]. They encompass central cord lesions, lumbosacral and peripheral nerve lesions. Often the precise site of the lesion is difficult to locate with certainty. Investigations such as MRI scans and neurophysiological studies are often unhelpful, and recovery rates are difficult to predict.
The blood supply to the distal spinal cord and nerve roots derives from the lumbar, iliolumbar and lateral sacral arteries, that form anastomoses with the intrinsic spinal arteries [5]. A major anterior segmental medullary artery, called the Adamkiewicz Artery, arises from one of the paired suprarenal intercostal arteries. It supplies the lower two-thirds of the spinal cord via the anterior spinal artery. Occasionally it may arise from an infrarenal lumbar artery. If the artery of Adamkiewicz is diseased, the lumbar arteries and branches from the internal iliac arteries (IIA) become the main blood supply to the distal spinal cord and nerve roots. Any damage to the IIA in this case would impede the blood supply to the lower part of the spinal cord with ischaemic neuropathy as a result [6].
The pelvis receives its primary blood supply from the internal iliac artery (IIA) and its branches. After ligation of one IIA, the pelvic blood flow is maintained by the contralateral artery if it anastomoses widely. However, in those elderly patients with atherosclerotic disease, occlusion of even one IIA, with an apparently patent contralateral IIA, can cause pelvic ischaemia [7].
In our patients we believe that the explanation for their plexopathy was the interference with the blood supply of the lower part of their spinal cord, via the internal iliac artery, when their Adamkiewicz arteries were chronically compromised, and was probably arising from an infrarenal lumbar artery. In two patients who had their abdominal aortic aneurysm repaired, the IIA was excluded. In one patient, during an emergency abdominal aortic aneurysm repair, a significant size lumbar artery was oversewn, which would have excluded the Adamkiewicz artery, with the possibility of diseased or occluded IIAs and disruption of flow whilst clamped.
In the fourth patient the angioplasty could have resulted in embolisation or occlusion of the IIA.
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7. Conclusion
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Ischaemic neuropathy following aorto-iliac interventions, whether open or endovascular, remains a rare, unpredictable and devastating complication. When it occurs it is likely to result in permanent neurological disability. It is important to note that it may be related to internal iliac artery occlusion and the variability of the artery of Adamkiewicz.
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References
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Abstract
1. Introduction
