Vertebral artery transection with pseudoaneurysm and arteriovenous fistula requiring antegrade and retrograde embolization
Maham Karatela, Hope Weissler, Mitchell W. Cox, Zachary F. Williams
Duke University School of Medicine, Durham, NC
BACKGROUND: Traumatic vertebral artery injury (VAI) is a rare yet life threatening injury. Treatment options include medical management, open surgery, and endovascular intervention. Endovascular methods usually approach the lesion ipsilaterally, but this can be complicated by impassable lesions or the failure of proximal endovascular intervention alone to occlude traumatic pseudoaneurysm (PSA) or high flow arteriovenous fistula (AVF), requiring surgical reoperation for distal control. Here, we present a case in which failure of antegrade embolization of a traumatic vertebral artery transection with associated PSA and AVF was managed through retrograde embolization from the contralateral vertebral artery.
METHODS/RESULTS: A healthy 27-year-old male presented to the ED following a stab wound to the neck with a firm, expanding hematoma and pulsatile hemorrhage. CT angiogram of the head and neck demonstrated a large, extracranial, right vertebral artery PSA with active extravasation, a dissection flap, and a traumatic vertebral artery to vein fistula in the V2 vertebral artery segment at the level of C3 (Figure 1). In the operating room, cerebral arteriography demonstrated extravasation from the right vertebral artery with no ipsilateral carotid artery injury. Despite multiple attempts, the injury could not be crossed. The right vertebral artery was coiled proximally to stop the acute bleeding. Completion angiogram demonstrated successful embolization with no ongoing extravasation. While in recovery, the patient developed a possible right abducens nerve palsy and absent corneal light reflex. Brain MRI was negative for acute ischemia but repeat CTA raised concern for a persistent AV fistula causing a steal phenomenon. Right vertebral angiogram re-demonstrated complete occlusion of antegrade blood flow beyond the coil embolization, while left vertebral angiogram demonstrated a large PSA arising from the V2 segment of the right vertebral artery with an AVF draining into the epidural venous plexus. Retrograde embolization was accomplished by accessing the left vertebral artery and traversing the basilar artery to access the PSA. A 5 Fr catheter was advanced into the distal left vertebral artery V2 segment, then a Headway 17 microcatheter (Terumo Corp., Tokyo, Japan) and Synchro-2 microwire (Stryker Neurovascular, Fremont, CA) combination were advanced up the basilar artery and down the right vertebral artery adjacent to the PSA and AVF. Five embolic coils were deployed. Final anteroposterior and lateral angiography demonstrated complete occlusion of the PSA and AVF and stasis within the right vertebral artery (Figure 2). The patient's neurologic symptoms resolved completely and he was extubated the next day with good recovery.
CONCLUSION: The present case report demonstrates successful treatment of a symptomatic traumatic vertebral artery PSA and AVF with antegrade and retrograde embolization. Retrograde access to the distal vertebral artery through contralateral vertebral artery access broadens the endovascular options for injuries that are difficult to treat in an antegrade fashion. 
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