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.