CASE 13435 Published on 01.04.2016

A rare complication of vertebral metastasis surgery


Interventional radiology

Case Type

Clinical Cases


de la Vía Oraá, E. Lonjedo Vicent, E. Gómez Valdés, J. Ruiz Guanter, A. Casula, E. Alandete Germán.

Valencia, Spain;

71 years, male

Area of Interest Vascular ; Imaging Technique CT, Catheter arteriography
Clinical History
A 71-year-old male was diagnosed with colon adenocarcinoma. He underwent surgery of metastasis in the left dorsal paravertebral region with resection of T2 and T3 vertebral bodies and left costal arches. Two weeks later, he suffered a sudden episode of haemodynamic shock. Thoracic CT and angiography was performed.
Imaging Findings
AngioCT showed a large haematoma located in the posterior mediastinum, paravertebral region, left pleural space, dorsal and cervical musculature, reaching the subcutaneous tissue. (Fig. 1). Active extravasation of contrast between an aberrant right subclavian artery (SCA) and paravertebral region was observed but the vessel that caused bleeding was not clearly identified.

Selective arteriography of both subclavian arteries was performed by right femoral approach, viewing the aberrant right SCA with Kommerell´s diverticulum and identifying an image of active bleeding with high flow at its source (Fig. 3).

After placement of balloon occlusion and patient stabilization (Fig. 4), embolization of the right SCA in its proximal segment by double approach (right brachial and right femoral arteries) was done with an Amplatzer type II device (16 mm) and a detachable coil (10x50 mm). The cessation of bleeding and good flow compensation of the right upper limb through reversed vertebral artery flow was checked (Fig. 5).
Kommerell’s diverticulum is a very rare finding. An aberrant right SCA is the most common congenital aortic arch anomaly (approximately 1% of the population) [1] and has more risk to dilate than nonaberrant vessels. In fact, 60% of patients with an aberrant right SCA have an associated Kommerell’s diverticulum. This term usually refers to the bulbous configuration of the origin of an aberrant left subclavian artery in the setting of a right-sided aortic arch [2]. However, it was originally described as a diverticular outpouching at origin of an aberrant right subclavian artery with a left side aortic arch as in this case [3].

Kommerell’s diverticulum and aberrant subclavian artery can be discovered accidentally in asymptomatic patients like a bulbous enlargement of proximal subclavian artery at its origin. Sometimes they are associated with complications, such as compression of adjacent structures (oesophagus, trachea, and/or right mainstream bronchus), dissection, rupture or bleeding [4].
The rupture of an aneurysm of an aberrant right subclavian artery or Kommerell’s diverticulum can be life-threatening. This is the reason why surgical treatment is recommended even for small aneurysms [5]. However, hybrid [6] or endovascular treatments can be an alternative.
In our case, the situation of haemodynamic shock and the need to stop the bleeding made an emergency treatment necessary, deciding to perform the endovascular procedure. It was a difficult treatment with the available prosthesis because of the bulbous morphology of the aneurysm. For this reason, we decided to use an Amplatzer type II device and coil with a good morphological result and cessation of bleeding.

Iatrogenic arterial injury is an uncommon but recognized complication of posterior spinal surgery. The spectrum of injuries includes vessel perforation leading to haemorrhage, delayed pseudoaneurysm formation, and threatened perforation by screw impingement on arterial vessels [7]. This case is unusual in that the patient had an aberrant subclavian artery contacting the osteosynthesis material. After surgery there was progressive damage of the vessel wall leading to rupture, bleeding and shock. Repair of these injuries traditionally involved open direct vessel repair or graft placement, which can be associated with significant morbidity. However, endovascular repair is an alternative for the treatment of arterial injuries resulting from spinal surgery [7] that can occur unexpectedly and more likely when there are previous vascular alterations (like aberrant subclavian artery) in proximity to the treatment area. This procedure offers a safe and less invasive alternative to open repair.
Differential Diagnosis List
Active bleeding from the erosion of the aberrant right SCA caused by osteosynthesis material.
Spontaneus Kommerell's diverticullum bleeding
Postsurgical haematoma
Active bleeding from an intercostal artery
Left pleural effusion
Final Diagnosis
Active bleeding from the erosion of the aberrant right SCA caused by osteosynthesis material.
Case information
DOI: 10.1594/EURORAD/CASE.13435
ISSN: 1563-4086