Successful treatment of iatrogenic vertebral pseudoaneurysm using pipeline embolization device

Abstract

Traumatic pseudoaneurysms are uncommon and one of the most difficult lesions to treat. Traditional treatment methods have focused on parent vessel sacrifice with or without revascularization. We report the case of a patient who underwent successful treatment of an iatrogenic extracranial vertebral artery pseudoaneurysm using the Pipeline Embolization Device. A 47-year-old man sustained an inadvertent injury to the left vertebral artery during C1-C2 fixation. Subsequent imaging revealed an iatrogenic vertebral artery pseudoaneurysm. Immediate angiogram was normal. A repeat angiogram done after 3 days of the surgery revealed a vertebral artery pseudoaneurysm. He underwent aneurysm exclusion and vascular reconstruction using the Pipeline Embolization Device. Although flow-diverting stents are currently not being used for treating traumatic pseudoaneurysms, their use may be considered in such cases if active bleeding has ceased. In our case, the patient did well and the aneurysm was excluded from circulation while reconstructing the vessel wall.

Figure 1

(a) shows normal filling of the right vertebral artery immediately following intraoperative injury: a small irregularity in the wall can be seen. (b) (CT angiogram) and (c) and (d) (digital subtraction angiogram) show a large saccular pseudoaneurysm arising from the V3 segment of the vertebral artery. The imaging was performed on the third postoperative day.

Figure 2

(a) shows right vertebral injection image immediately after deployment of the Pipeline Embolization Device. There is nonfilling of the pseudoaneurysm while the vertebral artery fills normally. (b) shows stable complete pseudoaneurysm occlusion and patent right vertebral artery in the CT angiogram performed at 10-month follow-up.