Impending Rupture Traumatic Large Pseudoaneurysm of (V2) of Vertebral Artery: A Successful Hybrid Approach and Outcome. A Vascular Surgeon View

Khalid A Mowafy*, Mosaad A Soliman and Samer A Regal

Department of Vascular and Endovascular Surgery, Mansoura College of Medicine, Mansoura University, Egypt

^*Correspondance to: Khalid Abdel Aziz Mowafy 

 PDF  Full Text DOI: 10.25107/2474-1647.2726

Abstract

Objectives: Vertebral artery aneurysms are rare clinical findings, representing 1% of supra-aortic aneurysms, and the most common cause of Extracranial Vertebral Artery Aneurysms (EVAA) is penetrating neck trauma, but they can also occur secondary to dissection, atherosclerosis, infection, collagen vascular diseases, and inherited connective tissue disorders. Extracranial VA aneurysms are very uncommon accounting for 0.5% of all arterial aneurysms; they generally affect the most mobile segment, the V3 segment, followed by the V1 segment. The rupture of an EVAA can lead to catastrophic bleeding and pose a diagnostic and therapeutic challenge. VA injuries constitute less than 1% of all the vascular injuries and less than 1% to 6% of all the vascular injuries in the cervical region penetrating vertebral artery injuries leading to serious external bleeding are rare, and their injuries were previously missed prior to the routine use of angiography in diagnosing penetrating neck injuries. This frank hemorrhage was the impetus for the decision for operative exploration. Here, in our article we report the largest pseudoaneurysm reported in the literature. It was impending to rupture and arising from the second part of the right vertebral artery (V2) in a 23-years-old male. Duplex study and Urgent CT angiography confirmed the presence of an extracranial pseudoaneurysm involving the 2nd part of right VA, measuring 10 cm × 7.5 cm × 4.8 cm. Aim: The aim of this article is focusing and highlighting on a very rare vascular injury that any vascular or general surgeon could encounter throughout his daily work and highlighting the treatment options in emergency situations, putting into consideration the availability of different tools. Methods: We went through a hybrid approach where endovascular proximal parent vertebral artery was controlled with a 3 mm balloon diameter 30 mm length, through a rapid right trans brachial access followed by surgical exposure and ligation of V1 part that ameliorated the risk of rupture for a great extent, but postoperative duplex 14 days later showed retrograde filling of the aneurysmal sac that necessitated distal V3 control. Results: The first and second postoperative periods were free of any cerebrovascular or vertebrobasilar ischemic or neurological signs. Conclusion: The consequences of VA injury are fetal and even result in death because of the difficulty in controlling the pulsating hemorrhage which cause severe hypotension resulting in cardiac arrest and finally death. Therefore, timely diagnosing and intervention is crucial in determining the interventional outcome. Whether the treatment of VA injury is surgery or endovascular approach depends on the location and radius of the lesion. VA is divided into four segments along its course and the decision of intervention, the postoperative outcome is determined according to the VA segment affected. Finally If the patient has a patent contralateral VA or well-developed collateral circulation from posterior circulation. If the contralateral VA is underdeveloped or slender, vessel repair or endovascular restoration of flow is a must.

Keywords

Aneurysm; Cerebral revascularization; Pseudo aneurysm; Vertebral artery

Cite the article

Mowafy KA, Soliman MA, Regal SA. Impending Rupture Traumatic Large Pseudoaneurysm of (V2) of Vertebral Artery: A Successful Hybrid Approach and Outcome. A Vascular Surgeon View. Clin Surg. 2020; 5: 2726..