Giant pseudoaneurysm of the extracranial vertebral artery successfully treated using intraoperative balloon catheters.

Traumatic pseudoaneurysms of the extracranial vertebral artery rarely occur, because of its deeply protected anatomical location. Because the direct surgical approach has resulted in high morbidity and mortality rates, ligation of the vertebral artery has been adopted, but this can cause an ischemia in the vertebrobasilar system. We report the case of a 73-year-old woman with a huge pseudoaneurysm of the right vertebral artery that occurred after attempted placement of a cardiac pacemaker. The aneurysm was 7 x 7 x 5 cm in size and its neck was situated just distal to the right subclavian artery. Direct surgical repair of the injured vessel and removal of the aneurysm were successfully performed using balloon catheters placed intraoperatively in both the innominate artery and the right vertebral artery.     

Spontaneous Pseudoaneurysm of the Vertebral Artery in Behçet’s Disease

A pulsatile mass and severe neck pain developed suddenly in a 15-year-old female patient suffering from Behçets disease. Magnetic resonance imaging showed a pseudoaneurysm at the C₃-C₄ level that was 51 × 49 × 45 mm in size, originating from the left vertebral artery, with a thin neck and thrombus inside. Repair of the vertebral artery wall by percutaneous transluminal intervention was not successful. Because of the possibility of rupture, the patient underwent surgical repair. Ligation of the left vertebral artery was applied 1 cm above the origin of the subclavian artery. During the subsequent postoperative period, no further complications were seen. From our review of the literature, this is the first reported case of surgical treatment of spontaneous development of a pseudoaneurysm at the vertebral artery in association with Behçets disease. Ligation of the vertebral artery can be safely used to control a pseudoaneurysm related to Behçets disease.     

Delayed treatment of a traumatic left subclavian artery pseudoaneurysm

A 22-year-old man sustained 4 gunshot wounds to the upper torso resulting in left pneumothorax, an expanding right neck hematoma, left humerus fracture, a traumatic arteriovenous fistula from the right subclavian artery to the right brachiocephalic vein, and pseudoaneurysm formation from partial transection of the right subclavian artery. The patient underwent emergent repair of the confluence of the right internal jugular, subclavian and brachiocephalic veins, and laparotomy secondary to compartment syndrome. Seven weeks later, with the pseudoaneurysm enlarged to 6 cm, it was repaired with combined access via the right common femoral artery and right brachial artery. The pseudoaneurysm was covered with a 7 mm x 8 cm fluency-covered stent graft and postdilated with a 7 mm x 4 cm balloon. Postoperatively, the patient had palpable pulses, occlusion of the pseudoaneurysm, and excellent blood flow into the arm.     

Pseudoaneurysm of the extracranial vertebral artery; a case report

Traumatic injury of the vertebral artery is rare and only a few reports have been presented. We treated a case of iatrogenic pseudoaneurysm of the extracranial vertebral artery. A 65-year-old man complained of headache and had a pulsating mass in the soft tissue of the neck which had continued for one month after evacuation of hypertensive cerebellar hemorrhage. The left VAG revealed a large pseudoaneurysm at the third portion of the vertebral artery and the right retrograde VAG revealed agenesis of the vertebral artery. To select the proper treatment was a dilemma. This case was treated by embolization using an occluding spring embolus with direct transcutaneous puncture of pseudoaneurysm. Following this treatment, the mass and associated symptoms resolved without neurological deficit.     

Staged hybrid treatment of complex ascending aortic and distal aortic arch pseudoaneurysm after repair of aortic coarctation

A 49-year-old operated for aortic coartaction patient presented with thoracic and ascending aortic aneurysm. He was asymptomatic. Angio-magnetic resonance nuclear scan and angiography revealed an ascending aortic aneurysm (5.2 cm), bicuspid aortic valve, 6-cm proximal descending aortic pseudoaneurysm at the site of the previous operation with involvement of the left subclavian artery. Restenosis at the original site of coarctation and aortic arch hypoplasia distally to the brachiocefalic trunk was also found. The operation performed was a "modified Bentall - De Bono". The pseudoaneurysm was not accessible through median sternotomy due to the massive lung adhesions following the previous surgery. The left common carotid artery was explanted from the aortic arch and connected with a graft to the ascending aortic conduit. A proximal neck suitable for landing zone of the endovascular stent-graft was then established. The postoperative course was uneventful. After two weeks, the patient was readmitted. The exclusion of the thoracic descending aortic pseudoaneurysm by endovascular implantation of the stent-graft prosthesis was performed. The left subclavian artery was excluded because left vertebral artery was closed. The patient did not develop hand claudicatio. The procedure was successful.     

Pseudoaneurysm of the subclavian artery. Case reports

Five patients suffering from subclavian artery false aneurysms underwent surgery in the last 6 years at the Institute of General and Cardiovascular Surgery University of Milan. The management was considerably different from the treatment of atherosclerotic lesions of this artery, because of the various nature of such traumatic lesion and the variable (stable or unstable) hemodynamic conditions of the patients. Arteriography was extremely useful in the evaluation of site and extension of pseudoaneurysms. When pseudoaneurysm was in the left side (in one case), supraclavicular incision and posterolateral thoracotomy were adopted to allow the control of both proximal and distal portion of subclavian artery. When the pseudoaneurysm was in the right side (in 3 cases) a median sternotomy with extension of the soft tissue incision into the right side of the neck provided the exposure of the proximal and distal right subclavian artery. In the last case, proximal infected false aneurysm (after right axillo-femoral bypass graft) was removed and substituted by contralateral axillo-bifemoral bypass.     

Pseudoaneurysm of the right subclavian artery-tracheostomy tube as a causative factor

The subclavian artery pseudoaneurysm developing in a patient of axonal head injury triggered a search for possible causative factor. Intimacy between the aneurysm and the tracheostomy tube suggested possibility of constant irritation of subclavian artery by the tube leading to pseudoaneurysm. The hypothesis is supported by the short neck, long uncuffed tube and constant posture of the neck with absence of any other causative factor. Pseudoaneurysm was repaired without reconstruction of subclavian artery considering well developed collaterals.     

Recurrence of a vertebral artery dissecting pseudoaneurysm after successful stent-supported coil embolization: case report

OBJECTIVE AND IMPORTANCE: Dissecting aneurysms of the intracranial vertebral artery are increasingly recognized as a cause of subarachnoid hemorrhage. We present a case involving technical success of the stent-supported coil embolization but with recurrence of the dissecting pseudoaneurysm of the intracranial vertebral artery. The implications for the endovascular management of ruptured dissecting pseudoaneurysms of the intracranial vertebral artery are discussed. CLINICAL PRESENTATION: A 36-year-old man with a remote history of head injury had recovered functionally to the point of independent living. He experienced the spontaneous onset of severe head and neck pain, which progressed rapidly to obtundation. A computed tomographic scan of the head revealed subarachnoid hemorrhage centered in the posterior fossa. The patient underwent cerebral angiography, which revealed dilation of the distal left vertebral artery consistent with a dissecting pseudoaneurysm. INTERVENTION: Transfemoral access was achieved under general anesthesia, and two overlapping stents (3 mm in diameter and 14 mm long) were placed to cover the entire dissected segment. Follow-up angiography of the left vertebral artery showed the placement of the stents across the neck of the aneurysm; coil placement was satisfactory, with no residual aneurysm filling. Approximately 6 weeks after the patient's initial presentation, he developed the sudden onset of severe neck pain. A computed tomographic scan showed no subarachnoid hemorrhage, but computed tomographic angiography revealed that the previously treated left vertebral artery aneurysm had recurred. Angiography confirmed a recurrent pseudoaneurysm around the previously placed Guglielmi detachable coils. A test balloon occlusion was performed for 30 minutes. The patient's neurological examination was stable throughout the test occlusion period. Guglielmi detachable coil embolization of the left vertebral artery was then performed, sacrificing the artery at the level of the dissection. After the procedure was completed, no new neurological deficits occurred. On the second day after the procedure, the patient was discharged from the hospital. He was alert, oriented, and able to walk. CONCLUSION: We appreciate the value of preserving a parent vessel when a dissecting pseudoaneurysm of the intracranial vertebral artery ruptures in patients with inadequate collateral blood flow, in patients with disease involving the contralateral vertebral artery, or in patients with both. However, our case represents a cautionary note that patients treated in this fashion require close clinical follow-up. We suggest that parent vessel occlusion be considered the first option for treatment in patients who will tolerate sacrifice of the parent vessel along its diseased segment. In the future, covered stent technology may resolve this dilemma for many of these patients.     

Vertebral artery embolic protection via ipsilateral brachial approach during left subclavian artery angioplasty and stenting--a case report

The purpose of this report is to explore angioplasty and stenting with cerebral embolic protection as a salvage procedure for a compromised carotid-subclavian bypass in the presence of antegrade vertebral artery flow. A 76-year-old woman with a carotid-subclavian bypass presented with graft infection. Failure of medical therapy to treat the infection prompted surgical removal of the graft. The native subclavian artery was still patent, but a severe complex proximal stenosis was present with antegrade flow into the left vertebral artery. Angioplasty and stenting of the subclavian artery was performed with cerebral protection achieved by positioning a FilterWire EX in the left vertebral artery via the left brachial artery approach. Deployment of a filter device in the vertebral artery via the brachial or radial approach can provide embolic protection without interfering with the subclavian artery stenting. The successful treatment of the subclavian artery enabled the complete removal of the infected graft without need for major vascular reconstruction.     

Occipital artery to extradural vertebral artery bypass procedure. Case report

A 17-year-old boy suffered blunt trauma to the posterior cervical spine and later developed vertebrobasilar transient ischemic attacks refractory to medical management. At angiography, a pseudoaneurysm of the distal left vertebral artery was found. By means of a posterior midline approach, an extradural occipital artery to vertebral artery anastomosis was performed and the affected vertebral artery was clipped distal to the pseudoaneurysm. The indications for this procedure, the operative approach, and the clinical outcome are described.     

Combined open and endovascular repair of a true right subclavian artery aneurysm without proximal neck

A 52-year-old man, without a medical history, presented with an incidentally detected large, intrathoracic aneurysm of the right subclavian artery. The aneurysm was characterized by the absence of a proximal neck and extended distally close to the origin of the right vertebral artery. We successfully excluded this aneurysm with a combined endovascular and minimally invasive open repair, thereby avoiding a sternotomy or lateral thoracotomy: a stent-graft was placed from the proximal brachiocephalic trunk to the common carotid artery, completely covering the origin of the right subclavian artery. The right subclavian artery was oversewn just distally to the aneurysm and revascularization of the right arm was assured by a carotido-subclavian bypass. Clinical follow-up was uneventful and radiological follow-up by CT-scan showed discrete, but progressive shrinkage of the completely excluded aneurysm.     

Axilloaxillary bypass for the treatment of subclavian artery stenosis complicated by bilateral common carotid artery occlusion: technical case report

OBJECTIVE AND IMPORTANCE: We successfully treated a patient with stenosis of the left subclavian artery, complicated by bilateral common carotid artery occlusion, via axilloaxillary bypass surgery. CLINICAL PRESENTATION: A 67-year-old patient with a history of hypertension and cerebral infarction underwent neck irradiation for treatment of a vocal cord tumor. Three months later, he began to experience transient tetraparesis several times per day. The blood pressure measurements for his right and left arms were different. Supratentorial blood flow was markedly low. The common carotid arteries were bilaterally occluded, and the right vertebral artery was hypoplastic. Therefore, only the left vertebral artery contributed to the patient's cerebral circulation; his left subclavian artery was severely stenotic. INTERVENTION: The patient underwent axilloaxillary bypass surgery because the procedure avoids thoracotomy or sternotomy, manipulation of the carotid artery, and interruption of the vertebral artery blood flow. The patient has been free of symptoms for more than 5 years. CONCLUSION: Neurosurgeons should be aware that extra-anatomic bypass surgery is an effective treatment option for selected patients with cerebral ischemia.     

Cervical root compression by a traumatic pseudoaneurysm of the vertebral artery: case report

We report the case of a patient with cervical monoradiculopathy secondary to a pseudoaneurysm of the vertebral artery caused by a knife wound to the neck.     

Ruptured extracranial vertebral artery aneurysm associated with neurofibromatosis type 1. Case report

A 31-year-old man presented with a ruptured right extracranial vertebral artery aneurysm associated with neurofibromatosis type 1, manifesting as acute onset of right neck and shoulder pain, and right supraclavicular mass. Three-dimensional computed tomography angiography showed a large aneurysm involving the right extracranial vertebral artery associated with a pseudoaneurysm. The aneurysm was successfully treated by transarterial endovascular trapping with detachable coils. Extracranial vertebral artery aneurysm is rare, but the mortality of ruptured cases is extremely high, so early diagnosis and early treatment are important. The present case shows that endovascular treatment was very effective.     

Subclavian artery stenosis: hemodynamic aspects and surgical outcome

Ninety seven patients (mean age: 58 years) with lesions involving the subclavian artery were studied to determine the relationship between clinical symptoms, angiographic lesions and Doppler-detected hemodynamic disorders. Ninety patients had vertebro-basilar insufficiency (VBI) and 7 had hemispheric manifestations or upper limb ischemia. Of the 105 lesions of the subclavian artery, we observed 76 stenoses greater than 50% and 29 complete occlusions. Thirty seven patients presented a unilateral subclavian lesion and 63 multiple lesions. Doppler examination of the vertebral artery including an upper limb hyperaemic test allowed classification of the patients into three stages: stage 1 "pre-subclavian steal" (35 patients): sudden decrease in the systolic vertebral flow with complete interruption during hyperaemia; stage 2 "intermittent subclavian steal" (18 patients): transient inversion of vertebral during systole with permanent inversion for 1 or 2 minutes after hyperaemia; stage 3 "permanent subclavian steal" (33 patients): complete inversion of the vertebral flow without diastolic flow and increase of flow during hyperaemia. The clinical, hemodynamic and angiographic findings were compared. In stage 1, 65.7% of the patients presented severe VBI (at least two signs) and 66% had a 50 to 70% stenosis of the subclavian artery. In stage 2, 66.6% of the patients presented severe VBI and 78% had a 75 to 95% stenosis. In stage 3, 72.7% of the patients had severe VBI and 73% had either subtotal or complete occlusion of the subclavian artery. There was no correlation between the severity of VBI and the hemodynamic stages but a strong correlation between the hemodynamic grades and the anatomical lesions.(ABSTRACT TRUNCATED AT 250 WORDS)     

Melioidosis presenting as an infected intrathoracic subclavian artery pseudoaneurysm treated with femoral vein interposition graft

We present the first case of in situ replacement of an infected subclavian artery using superficial femoral vein and the fourth reported case of an infected arterial pseudoaneurysm caused by pseudomonas pseudomallei. Sepsis and hoarseness developed in a 58-year-old man after recent travel to Borneo, Indonesia. Indirect laryngoscopy revealed a paralyzed right vocal cord. Computed tomography and arteriography revealed a 6.5-cm pseudoaneurysm of the proximal right subclavian artery. Blood cultures grew pseudomonas pseudomallei. An abnormal cardiac stress test prompted a coronary angiography, which revealed severe coronary artery disease.The patient underwent coronary artery bypass and in situ replacement of the infected subclavian artery pseudoaneurysm with a superficial femoral vein, along with placement of a pectoralis major muscle flap to cover the vein graft. Operative cultures of the pseudoaneurysm grew pseudomonas pseudomallei. The patient was treated with a 6-week course of intravenous ceftazidime and oral doxycycline and then continued on oral amoxicillin-clavulanate. One week after discontinuing intravenous antibiotics, the patient presented to the emergency department with a rapidly expanding, pulsatile mass in the right supraclavicular space. He was taken emergently to the operating room. After hypothermic circulatory arrest was accomplished, the disrupted vein graft and aneurysm cavity were resected and the subclavian artery was oversewn proximally and distally. Parenteral ceftazidime was continued for 3 months and oral amoxicillin-clavulanate (augmentin) was continued indefinitely. There was no evidence of infection clinically or by computed tomographic scan 2 years later. Although autogenous vein replacement of infected arteries and grafts may be successful in the majority of cases, this strategy should probably be avoided when particularly virulent bacteria such as the organism in this case are present.     

Subclavian steal with ipsilateral vertebral artery occlusive disease

The classical subclavian steal syndrome is a larcenous vertebrobasilar insufficiency, secondary to retrograde flow in the vertebral artery. The authors present their experience with an unusual variant of subclavian steal in which the ipsilateral vertebral artery was completely or partially occluded, or arose from the aortic arch. These patients had symptoms typical of vertebrobasilar insufficiency--dizziness or brain stem transient ischemic attacks--despite steal through relatively small cervical collaterals to the obstructed subclavian artery. Physical findings of diminished pulses and blood pressure in the involved upper extremity are similar to those in the common form of subclavian steal. The alternate collaterals found in these patients are documented by angiography and other potential collaterals are reviewed. All three symptomatic patients were treated successfully by carotid-subclavian bypass or anastomosis of the subclavian to the common carotid artery. They have remained asymptomatic for 1 1/2 to 3 years following operation. The potential for development of subclavian steal in the absence of a vertebral artery to provide collateral flow adds another reason for abandoning vertebral artery ligation as an alternative treatment for the subclavian steal syndrome.     

Surgical reconstruction for radiation-induced extracranial vertebral artery stenosis: a case report]

We report a case of symptomatic extracranial vertebral artery stenosis after radiation therapy. This 49-year-old female received radiation therapy to the neck for nasopharyngeal carcinoma 11 years earlier, was admitted because of continuous dizziness and a floating sensation. Magnetic resonanse imaging showed no abnormalities, but an aortography demonstrated complete occlusion of the right common carotid artery as well as occlusion of the right vertebral artery and severe stenosis of the left vertebral artery at its origin, which was presumed to be the result of previous radiation therapy. Percutaneous transluminal angioplasty (PTA) for the left vertebral artery was performed using conventional balloon treatment, which resulted in wall dissection. Because of this, she underwent end-to-side vertebral artery to subclavian artery transposition, and she has had no further ischemic events science that time. PTA has been successfully performed as the first treatment of choice for vertebral artery stenosis, but surgical reconstruction can be a therapeutic management of choice for cases of failed PTA.     

Subclavian artery disruption resulting from endovascular intervention: treatment options

Endovascular intervention is a commonly accepted form of treatment in patients with subclavian artery stenosis. Complications will undoubtedly occur as the utility of catheter-based intervention continues to rise. We report two cases of subclavian artery disruption as a result of endovascular intervention. One patient had contrast extravasation after the deployment of a balloon-expandable stent in a stenotic subclavian artery, and the arterial injury was successfully treated with balloon tamponade. A second patient had a large subclavian pseudoaneurysm 4 months after a balloon-expandable stent placement. Successful repair was achieved in this patient by means of arterial reconstruction with a prosthetic bypass graft. These cases illustrate different therapeutic methods of treating subclavian artery rupture due to endovascular intervention.     

Pseudoaneurysm of the extracranial vertebral artery. Case report

The unusual association of a giant extracranial vertebral artery pseudoaneurysm, intracranial aneurysms, and extracranial carotid occlusion in a woman with neurofibromatosis is presented. Pain as a result of expansion of the mass in the soft tissue of the neck led to her seeking evaluation. Herniation of the mass intraspinally between the occiput and C-1 resulted in myelopathy. Following balloon occlusion of the vertebral artery, the mass and associated symptoms resolved without the need for direct resection. The salient features of these unusually associated problems are discussed.