Discussion

Although very uncommon, vertebral artery injury is well-defined in the literature. The most common causes are blunt or penetrating cervical trauma (from knives, firearms, etc.) and iatrogenic trauma (from surgery, jugular venous catheterization, diagnostic angiography, nerve blocks, etc.) (17). Delayed haemorrhage, thrombosis, stenosis, cerebral ischemia, AV fistula, and pseudoaneurysm formation can all occur in conjunction with vertebral artery injury (18). Rarely do a vertebral artery pseudoaneurysm and an arteriovenous fistula between the internal jugular vein and vertebral artery coexist. A pseudoaneurysm is a locally restricted hematoma outside an artery caused by damage to the vessel wall. The injury penetrates through all three layers of the vessel, causing a leak, which is contained by a new, weak wall formed by the products of the clotting cascade. No vessel wall layer is present in a pseudoaneurysm. A typical complication of vascular access, in addition to haematoma and arteriovenous fistula, is the iatrogenic pseudoaneurysm, which is caused by a perforation in the arterial wall. Despite the fact that pseudoaneurysms can resolve spontaneously(19), ruptures have been observed in 31% to 54% of instances (20). It is imperative that these lesions be diagnosed and treated quickly in order to reduce the chance of morbidity and mortality. The recommended course of treatment in the past was surgery, specifically microvascular repair or vessel ligation. Treatment for aneurysms has evolved due to recent advancements in less-invasive endovascular procedures. An arteriovenous fistula is an abnormal communication between an artery and a vein within which blood flows directly from the artery to the vein, avoiding the capillary network. AVFs can be created surgically, arise from a genetic or congenital defect, or be secondary to an iatrogenic injury or trauma. Apart from the surgically produced varieties, these are quite uncommon. Congenital disorders such as fibromuscular dysplasia and neurofibromatosis create a strong predisposition (21). Clinical manifestations differ and are dependent on the fistula’s location. The most common signs and symptoms are intracranial hypertension, headaches, seizures, dizziness, drowsiness, and abnormal eye movements (11). The ability of surgeons to be vigilant in the postoperative period and to be aware of the likelihood of fistula formation is crucial for the quick and accurate evaluation of patients who present with these symptoms following surgery. Fistulas that are detected and treated promptly are usually curable; yet, because they progress quickly, they require immediate surgical intervention. Pseudoaneurysm and vertebral AVF can be treated with endovascular and surgical techniques. Surgical procedures such as proximal ligation, trapping, and direct surgical closure are more challenging due to the abnormal anatomical path of the vertebral artery and the difficulty of manipulating it. In addition to requiring significant exposure, surgery also carries the risk of damaging nearby blood vessels and nerve roots. Our primary objective is to repair the pseudo-aneurysm and fistula while safeguarding the principal artery. Endovascular treatments (such as stenting, coiling, detachable balloon, embolization, etc.) are more effective in achieving this goal since they are less intrusive, painless, and require less recovery time (22) (23). AVFs and pseudoaneurysms have been successfully treated with covered stents with few problems. Therefore, covered stents ought to be the first choice of treatment.