Case report
Iatrogenic iliac arteriovenous fistula following lumbar disc surgery

Introduction
Iatrogenic arteriovenous fistula (AVF) after lumbar disc surgery is a rare but potentially life threatening complication [1]. It may present with a diverse array of manifestations. Hence the diagnosis is often delayed and overlooked leading to increase in morbidity and mortality. Early diagnosis and treatment can be life saving. We are reporting a case of iatrogenic iliac AVF following lumbar disc surgery, treated with endoluminal stent-graft.
Case report
A 40-year-old previously healthy male underwent lumbar discectomy for a documented disc herniation at L4-L5 level on 2/6/2006. The surgery lasted for 3 hours and was uncomplicated. Patient had no significant past medical history. His social and family histories were unremarkable. Twenty-four hours after the surgery patient developed sudden onset of dyspnea and sweating. His blood pressure was 120/70 mm Hg. He had tachycardia and mild oxygen desaturation. Electrocardiogram (ECG) showed sinus tachycardia and ‘S1 Q3 T3’. Venous Doppler study of lower limbs showed dilated right common iliac and external iliac veins with decreased and intermittent flow. It was interpreted as acute thrombosis of right iliac veins. Echocardiogram showed hyperactive right and left ventricles with normal pressures and increased pulmonary artery flow velocity. Based on post operative circumstances a diagnosis of pulmonary embolism was made and inferior vena cava (IVC) filter was inserted on 5/6/2006. There was little improvement in symptoms. He was discharged on 13/6/2006 with oral anticoagulant. Within a few days, his symptoms worsened. He developed increasing dyspnea, orthopnea, palpitations and cough with blood tinged sputum. He also noticed distension of abdomen, swelling of legs, loss of appetite and decreased urine output. In this critical condition patient was referred to our institute on 7/7/2006. Clinical examination revealed bilateral leg edema, tachycardia, elevated jugular venous pressure (JVP), hepatomegaly, ascites, bilateral basal rales and S3 gallop. Continuous murmur was heard all over the back up to the sacral region. He had anemia [Hb% 8 gms], abnormal liver function tests with a prolonged INR of 10. Chest X ray revealed cardiomegaly with increased vascular markings. An echocardiogram showed dilated IVC, right atrium, right ventricle and pulmonary artery with mild elevation of pulmonary artery pressure. An abdominal ultrasound showed moderate...


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