Endovascular Management of Aortic Injuries Caused by Pedicle Screws: A Two-Case Series With a Proposed Decision-Making Framework.

IntroductionPedicle screw-related aortic injuries are rare but potentially life-threatening complications of spinal instrumentation. While some cases remain asymptomatic for extended periods, delayed recognition increases the risk of catastrophic vascular events. Early diagnosis and appropriate management are critical to prevent severe morbidity and mortality. Traditional open vascular repair carries significant risks, whereas thoracic endovascular aortic repair (TEVAR) has emerged as a minimally invasive alternative. However, clear guidelines for diagnosis and treatment in spine surgery remain lacking.MethodsWe present 2 cases of aortic injury caused by pedicle screws following spinal instrumentation. Both patients underwent multidisciplinary management, including intravascular ultrasound (IVUS) for vascular assessment, TEVAR for aortic repair, and pedicle screw removal/repositioning. A review of the literature was conducted to contextualize these cases within existing management strategies.ResultsBoth patients were successfully treated with TEVAR and pedicle screw revision, without perioperative complications. IVUS played a crucial role in confirming the extent of vascular involvement and guiding intervention. At 18-month and 24-month follow-up, both patients remained asymptomatic, with no evidence of graft migration, endoleak, or spinal instability.ConclusionsPedicle screw-related aortic injuries, though uncommon, pose a serious risk in spine surgery. Multidisciplinary management involving spine and vascular surgery is essential for optimal outcomes. IVUS enhances diagnostic accuracy, allowing for precise treatment planning. Endovascular stent placement, combined with appropriate pedicle screw revision, is an effective and safe management strategy. Given the lack of standardized guidelines, we propose a structured decision-making approach for spine surgeons encountering vascular complications. Future research should focus on risk stratification, screening protocols, and long-term outcomes of endovascular management in spinal instrumentation.