Incidence and Management of Vascular Complications Associated With Exposure for Anterior Lumbar Interbody Fusion

Anterior lumbar interbody fusion (ALIF) is an important technique offering biomechanical advantages including improved disk height restoration, correction of sagittal and coronal imbalance, and improved fusion. Although generally safe, vascular injury remains a serious complication. Specific vascular injury mechanisms, management, and outcomes are insufficiently reported. We seek to better characterize the incidence, mechanism, management, and sequelae of intraoperative vascular injuries during ALIF.

We performed a retrospective single-center study of adult patients undergoing ALIF between 2018 and 2022. All exposures were performed by a vascular surgeon. Data analyzed included patient demographics, operative characteristics, and vascular complications (classified as major or minor). The primary outcomes were the incidence of vascular injury and postoperative venous thromboembolism (VTE). Statistical analyses included χ2 testing and logistic regression.

Of 418 patients, 26 (6.2%) sustained intraoperative vascular injuries, with 4 (1.0%) classified as major. Injuries were predominantly venous (n = 25), most frequently involving the left common iliac vein during L4-L5 exposure. One arterial dissection required stenting. Postoperative VTE occurred in 11 patients (2.6%); notably, 45.5% of these patients had sustained an intraoperative vascular injury. Vascular injury was a strong independent predictor of VTE (odds ratio [OR]: 15.9; P < .001; 95% CI: 4.3-58.8). The number of levels fused was significantly associated with both vascular injury (OR: 1.76; P = .007; 95% CI: 1.16-2.66) and VTE (OR: 1.91; P = .031; 95% CI: 1.03-3.42). No association was found between vascular complications and previous abdominal surgery, body mass index, revision surgery, age older than 50, spinal deformity, or sex. There was 0% perioperative mortality.

Vascular complications during ALIF are infrequent but significantly elevate the risk of postoperative VTE. Injuries cluster at the L4-L5 level and often involve the left common iliac vein. Preoperative planning, careful surgical technique, and experienced vascular access support are critical to minimizing complications.