Endovascular Bailout: Life-saving Covered Stent in a Case of Intraoperative Vertebral Artery Injury

Abstract

Iatrogenic vertebral artery pseudoaneurysm is rare, yet a critical condition that must be identified and treated promptly. A vertebral artery pseudoaneurysm may cause complications like thromboembolism and even arterial rupture, leading to posterior circulation stroke. We present a case of a 72-year-old male patient with a right vertebral artery pseudoaneurysm following surgery for cervical myelopathy. A pseudoaneurysm in the V2 segment of the right vertebral artery was confirmed by diagnostic angiogram. The patient was transferred to the catheterization laboratory immediately, and the decision to proceed with an endovascular approach using a covered stent to preserve the right vertebral artery was made. The patient did not develop any postsurgical complications and has now fully recovered. This case highlights that emergency endovascular intervention using a covered stent can be a promising therapeutic option in cases of pseudoaneurysms following open surgery.

Introduction

Among the types of vertebral artery injuries that can occur, pseudo-aneurysm formation (16.49%) is the second most common, just behind arterial rupture (41.24%). ¹ In our case, timely surgical intervention with a covered stent prevented neurological complications such as thromboembolism, posterior circulation stroke, compression of adjacent neurovascular structures, and arterial rupture.

Although numerous treatment options for a case of vertebral artery pseudoaneurysm have been reported, there is no universal agreement on which option is the best. Conventionally practiced treatment options include endovascular treatment, surgical clipping, repair, anastomosis, and ligation. Endovascular coil embolization, flow diverters, or parent artery occlusion are other options that have been performed previously. ² Treatment is best tailored specifically to each patient with a vertebral artery pseudoaneurysm. ³ The location of the pseudo-aneurysm in the vertebral artery remains one of the most important factors that determines the type of surgical intervention. ⁴ Vertebral artery is anatomically divided into four segments (V1–V4) according to the level of cervical vertebrae. The V3 segment of the vertebral artery is most commonly injured during surgery because of its location and tortuous course. ²

Treatment options that aim at preserving the vertebral artery and maintaining cerebral circulation have been previously reported to have favorable outcomes. ³ This typically includes an endovascular approach with a stent. Typical neurovascular specific stents and resources for coiling or parent artery occlusions are not readily available in a resource-limited country like Nepal, and although effective, the cost burden of these stents is very high for patients in our country. Therefore, we needed to intervene with a readily available endovascular covered stent instead of proceeding with coiling/parent artery occlusion, even though the flow dynamics of the bilateral vertebral arteries were normal. Any delay in surgical intervention would have resulted in the loss of our patient's life.

Case Presentation

The patient underwent posterior laminectomy via posterior cervical approach for the treatment of cervical myelopathy and was referred to our center a week after swelling ( Fig. 1 ) gradually developed in the incision site, which led to the suspicion of hematoma due to vertebral artery injury. On examination, he had no pallor, and his hydration status was normal. He had a 15/15 Glasgow Coma Scale score and had no neurological deficits when he was referred to our setting. MRI done in our hospital suggested hematoma formation ( Fig. 2A, B ). During re-exploration by opening the incision, bleeding was evident, which could not be controlled by wrapping. He was transferred to our catheterization laboratory immediately, where active bleeding with contrast extravasation was evident in a diagnostic angiogram ( Fig. 3 ). A pseudo-aneurysm at the V2 level of the right vertebral artery was confirmed, and anatomical abnormalities related to the posterior circulation were also ruled out. With the goal of promptly controlling the bleeding and isolating the pseudo-aneurysm from the primary circulation, we decided to proceed with an endovascular approach using Jostent Graftmaster Coronary Stent Graft.

Fig. 1.

Picture of the swelling caused by iatrogenic VA injury and pseudoaneurysm formation.

Fig. 2.

( A ) Coronal view of MRI postspine surgery for cervical myopathy, suggesting hematoma (arrows). ( B ) Sagittal view of MRI postspine surgery for cervical myopathy, suggesting hematoma (arrows) at the C4 to C5 level.

Fig. 3.

Diagnostic angiogram of right vertebral artery pseudoaneurysm with contrast extravasation (arrow).

Intravenous unfractionated heparin was administered during the procedure, maintaining activated clotting time between 200 and 260 seconds. We used a trans-femoral approach under local anesthesia to introduce a 6F introducer sheath followed by a 6F guiding catheter, which was navigated to the right subclavian artery, and the guiding catheter tip was placed at the origin of the right vertebral artery under fluoroscopic guidance. A Jostent Graftmaster Coronary Stent Graft of dimension 3.0 mm × 12 mm was carefully placed at this section. Two Abbott balloons were used to dilate the stent ( Fig. 4A ). First by 3.0 mm × 12 mm inflated at 1.2 MPa, followed by a 3.5 mm × 8 mm balloon inflated at 1.4 MPa. Complete exclusion of pseudo-aneurysm from arterial circulation with preserved antegrade flow was confirmed by angiography ( Fig. 4B ). The patient was stable and did not develop any complications postprocedure. Patient was placed on dual antiplatelet (Brillanta 90 mg BD + Ecosprin 75 mg OD) for 6 months postprocedure and single antiplatelet (Ecosprin 75 mg OD) for life. Although dual antiplatelet therapy is associated with perioperative bleeding risk, close monitoring and dose adjustments were key to preventing this complication.

Fig. 4.

( A ) Angiographic images showing balloon expandable covered stent (arrow) in place. ( B ) Pseudo-aneurysm (star) is excluded from arterial circulation after stenting is completed.

Following the procedure, he was closely monitored for 48 hours in the ICU and was discharged on the seventh postoperative day. The patient did not complain of any neurological symptoms and had normal findings on neurological examination. A CT scan done after 24 hours in the ICU was normal.

Discussion

Injury to the wall of the vertebral artery may lead to hemorrhage contained partially by the tunica adventitia or by the surrounding connective tissue, resulting in pseudo-aneurysm formation. ³ Among the types of vertebral artery injuries that can occur, pseudo-aneurysm formation (16.49%) is the second most common, just behind arterial rupture (41.24%). ¹ However, the overall reported incidence of iatrogenic vertebral artery injury is low (0.08–1.4%) and varies according to surgical approaches. Higher rates are documented for posterior access at the C1 to C2 level (4.1–8.2%) compared with anterior access (0.3–0.5%) procedures. Seventy-five percent of iatrogenic erosions of the vertebral artery after cervical spine surgeries are asymptomatic postoperatively. ⁵ Potential clinical features are related to posterior brain circulation, for example, facial paralysis, ataxia, dysphagia, and hoarseness. These features can be prominent later in cases of missed vertebral artery injury. ³

Endovascular approaches are being performed more widely as they evidently offer high success rates and low morbidity. However, the treatment option should be determined according to each individual case. ³ Treatment options primarily include endovascular treatment, surgical clipping, repair, anastomosis, and ligation. We opted for an endovascular approach using a covered stent for our patient. Ideally, this stent has dimensions most suitable for the coronary artery. However, it can also be used in the vertebral artery in the cervical region to maintain the patency of the blood vessel. ⁶

This stent was readily available in our setting and was cost-friendly for the patient as well. Covered stents, although rarely used, can be a suitable option to seal the injured site and to promptly control the active bleeding. This option was also more suitable for our patient as the rigid nature of the stent is easier to apply in the V2 segment of the vertebral artery than in V3/V4, which has a more complex and tortuous path. Table 1 mentions five previous cases of traumatic vertebral artery injury in the V2 segment that were treated using covered stents.

Table 1. List of cases where a covered stent has been used previously for traumatic vertebral artery repair.

Article	Citation	Cause of Vertebral artery injury	Part of the vertebral artery is injured	Type of covered stent used
Endovascular stent-graft treatment of a traumatic vertebral artery pseudoaneurysm and vertebrojugular fistula	Sancak et al (2008)	Penetrating trauma	V2	Coronary covered stent
Covered stent to salvage iatrogenic vertebral artery injury with uncontrolled bleeding in the operating room setting	Wangqin et al (2019)	Iatrogenic	V2	Balloon-expandable coronary covered stent
Iatrogenic left vertebral artery pseudoaneurysm treated with a covered stent	Carrillo-Martínez et al (2020)	Iatrogenic	V2	Coronary covered stent
Self-expanding covered stent placement to treat a pseudoaneurysm caused by iatrogenic vertebral artery injury	Gigliotti et al (2021)	Iatrogenic	V2	Viabahn self-expanding covered stent
Endovascular treatment of traumatic vertebral artery pseudoaneurysm	Aljalahma et al (2025)	Penetrating trauma	V2	Coronary covered stent

According to Gigliotti et al, an alternative, if available, would be self-expanding covered stents that are typically used for peripheral vascular diseases. They have better flexibility than balloon expansible stents used by us in this case and would offer better navigation, potentially helping in torturous segments of the vertebral artery. ⁴ Ambekar et al state that surgical options like flow diverting stents/pipeline embolization device are most effective when the active bleeding has stopped, which was not the case in our patient. ² Clipping and ligation are preferred when it is confirmed that the ipsilateral posterior circulation is compensated by the contralateral supply of the vertebral artery. Technical feasibility and hemodynamic stability of the patient are other indications. ¹

Conclusion

A covered stent can be used during an endovascular approach in the V2 segment of the vertebral artery. An injury to the vertebral artery is initially asymptomatic in the majority of cases, and it should be ruled out by angiography postoperatively. Timely referral to a well-equipped setting saves lives. Safe surgical access should be selected, respecting anatomical corridors during surgery.