Iatrogenic pseudoneurysms of the aortic arch are rare but potentially life-threatening complications following surgical interventions near major thoracic vessels. The resection of the dorsal vertebrae, particularly from T3 to T5, poses unique risks due to the close anatomical relationship between the thoracic spine and the aortic arch. We present the endovascular repair of an iatrogenic pseudoaneurysm of the descending thoracic aorta following the removal of thoracic spinal fusion hardware.

A 64-years old female smoker with a history of arterial hypertension presented a large pulmonary mass of the right upper lung lobe, that infiltrated the intervertebral foramina and the posterior arch of the 4th rib. She underwent a dorsal spondylodesis from the first to the seventh thoracic level, with en bloc resection of the right upper lobe and the 3rd, 4th and 5th ribs on the right side, with synchronous reconstruction of the thoracic wall. A follow-up thoracic CT scan after two months showed a screw grazing the aortic wall a few millimeters after the origin of the left subclavian artery (Figure1) necessitating a surgical revision for partial hardware removal. Further CT scan imaging three month later revealed the formation of a 15x15 mm pseudoaneurysm at the level where the osteosynthesis material was removed (Figure 2a). The patient was then referred to vascular surgery for further management. An endovascular repair of the thoracic aorta (TEVAR) with a 28mm x 10cm Gore-TAG Thoracic endograft was successfully performed via right femoral access, with coverage of the left subclavian artery, due to insufficient proximal landing zone.

The patient had an uneventful recovery after TEVAR and was discharged 3 days later. A follow- up CT scan three months after the procedure showed complete exclusion of the aneurysm with no evidence of migration or endoleak. Long-term follow-up at five years confirms the complete remodeling of the aortic wall and the absence of late complications (Figure 2b).

This report highlights the rare but serious risk of iatrogenic lesions of the thoracic aorta following dorsal thoracic vertebral resection. In such cases, TEVAR is a safe and minimally invasive procedure with excellent long-term results and should be considered as the first line treatment to prevent potentially catastrophic complications.