A challenging problem. Vertebral pseudoaneurysm and arteriovenous fistula involving vertebral artery and ipsilateral internal jugular vein due to craniocervical penetrating trauma

Penetrating Vertebral Artery Injuries: A Literature Review and Proposed Treatment Algorithm

BACKGROUND

Penetrating vertebral artery injuries (VAIs) are rare but devastating trauma for which the approach to treatment varies greatly. The literature on treatment modalities is limited to case reports, case series, and 1 review, with the majority of cases being treated surgically. However, with the advent of digital subtraction angiography, treatment has shifted toward less invasive endovascular modalities that allows one to assess the flow and risks of sacrificing the vertebral artery (VA).

METHODS

In accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses, a systematic review of VAI was performed. Two case reports were also detailed. Using a multidisciplinary team, a decision algorithm was proposed for approaching penetrating VAIs.

RESULTS

We identified 169 patients. Of the penetrating VAI, the majority were occlusions, most commonly managed conservatively. Other injuries including pseudoaneurysm, dissection, transection, and arterial-venous fistula were treated predominantly endovascularly and occasionally with the surgical exploration/ligation. Most endovascular treatments included embolization without significant stroke or complication from VA sacrifice. However, there are incidences in which VA sacrifice should be avoided and these scenarios can be better delineated with digital subtraction angiography to assess flow and anatomy.

CONCLUSIONS

This systematic review not only details the updated treatment options but also provides a decision algorithm for the treatment of penetrating VAI. It highlights the shifting treatment options of penetrating VAI to endovascular therapy, as well as details VAI variants that may suggest stenting over embolization.

Vertebral Arteriovenous Fistula: A Review Article

OBJECTIVE

Vertebrovertebral fistulas (VVFs) are uncommon lesions that can arise spontaneously or secondarily to iatrogenic or mechanical trauma. We performed a systematic review of the literature to obtain information regarding demographics, clinical presentation, treatment modalities, outcome, and complications associated with treatment.

METHODS

A literature search was performed by a reference librarian and after screening, 128 case reports and 16 case series were left for inclusion in the review. All possible data were abstracted by 3 authors, results were tabulated, and descriptive statistics (mean, range, and proportions) were reported. No formal statistical analysis was performed as part of this study.

RESULTS

A total of 280 patients were analyzed. VVFs can be categorized in 3 subgroups (iatrogenic, spontaneous, and traumatic), based on the mechanism of formation, and these different causes share different underlying demographics that bear important treatment considerations. Traumatic VVFs are more commonly seen in young men; the spontaneous form is more commonly seen in young women. Iatrogenic VVFs are more commonly seen in elderly people. Spontaneous VVFs are most commonly located between C1 and C2. Most iatrogenic (n = 39; 57%), spontaneous (n = 106; 82%), and traumatic (n = 53; 73%) VVFs were treated with deconstructive (defined as occlusion of fistula and feeding vessels) endovascular therapy. Overall treatment-related permanent morbidity was 3.3% (9/270) and mortality was 1.5% (4/270).

CONCLUSIONS

VVFs are uncommon lesions, and treatment is often indicated, even in patients without retrograde venous drainage. When treatment is undertaken, the cause of presentation and associated patient demographics should be considered when planning the treatment strategy.

Endovascular stent-graft treatment for a traumatic vertebrovertebral arteriovenous fistula with pseudoaneurysm

The rarely occurring vertebrovertebral arteriovenous fistula (VVAVF) is characterized by abnormal direct communications between the vertebral artery or its branches and the neighboring venous system. We present our experience using a stent graft to occlude a chronic, traumatic VVAVF. A 40-year-old woman with dizziness and loud bruits from the occiput underwent digital subtraction angiography (DSA), which revealed a VVAVF with pseudoaneurysm at the C5-C6 level, with retrograde flow from the right vertebral artery. A stent graft was placed across the fistula after balloon dilation. The fistula and pseudoaneurysm disappeared immediately. After 9 months, the patient remained asymptomatic with a patent stent.