Anastomosis and Endovascular Treatment of Iatrogenic Vertebral Artery Injury

Abstract

Iatrogenic vertebral artery injury (VAI) that occurs during cervical spine surgery can cause life-threatening complications, such as arteriovenous fistulas, catastrophic bleeding, neurological impairment, cerebral ischemia, and death. We report a case of dominant VAI during surgery and the treatment of a 60-year-old man diagnosed with a C1-2-3 metastatic spine tumor from urothelial carcinoma. Active bleeding occurred during tumor resection using pituitary forceps, immediately followed by gauze packing and manual compression. Post further resection, we found that the vertebral artery (VA) was completely severed. After temporary clamping on both sides of the damaged VA, an artificial graft anastomosis was performed. After verifying that the flow was intact using Doppler Sonography, Occiput-C1-4-5-6 posterolateral fusion was performed. Angiography was performed immediately after surgery. We found a thrombus occluding the left VA, and performed mechanical thrombectomy and stent insertion. The final angiography showed good VA flow with no emboli. In this case, VA anastomosis and endovascular treatment were performed within a relatively short period of time post VAI, and the patient was able to recover without any neurological deficits.

Keywords: Endovascular procedure; Metastasis; Surgical anastomosis; Vertebral artery.

FIGURE 1. Pre op T1-weighted enhanced magnetic resonance imaging. (A) Enhanced mass involving C1-2 posterior elements extending into the posterior neck muscles on T1-weighted enhanced magnetic resonance imaging. (B) The left vertebral artery slightly deviated toward lateral side and was encased by a tumor (white arrow), normal right vertebral artery (black arrow).

FIGURE 2. Preoperative Computed tomography angiography. (A) Computed tomography angiography showing left vertebral artery dominance. (B) A preoperative 3-dimensional reconstruction image of a computed tomographic scan of the cervical spine revealed a C2-3 osteolytic lesion (arrow).

FIGURE 3. (A) Gross image of the exposed tumor. The tumor was found to be approximately 7.91 (black dotted line) × 5.24 cm (white dotted line) in size, to have an irregular margin (yellow line), to be pinkish, to be located at the C2-3 level and to involve the C2 lamina. (B) Postoperative cervical spine X-ray.

FIGURE 4. Post operative transfemoral cerabral angiography. (A) AP view of the left VA. Occlusion of the left VA at the proximal part of the anastomosis. (B) AP view of the post-thrombectomy left VA. The recanalized left VA. (C) Lateral view of the post-thrombectomy left VA. Narrowed left VA at the anastomosis site. (D) AP view of the right VA. No significant stenosis and good flow of the right VA with some of the collateral circulation. (E) Lateral view of the right VA. Good flow of the right VA. (F) Lateral view of a postdeployed endovascular stent on the left VA. The narrowed left VA with maintained blood flow. The arrows mark the proximal and distal parts of the stent.

AP: anterior posterior, VA: vertebral artery.

FIGURE 5. Final angiography. Anteroposterior view (A) and lateral view (B) of the left VA. Angiogram showing good flow of the left VA and collateral circulation maintenance of the blood flow of the contralateral side.

VA: vertebral artery.

FIGURE 6. Seven-day postoperative computed tomography angiography. (A) Anterior posterior view. Demonstrating good flow of the posterior circulation, including the vertebro-basilar artery. (B) Lateral view. Red arrows are proximal and distal part of stent.