Vertebral Artery Aneurysms and Cervical Arteriovenous Fistulae in Patients with Neurofibromatosis 1

Guillermo Higa; John P. Pacanowski Jr; David T. Jeck; Kaoru R. Goshima; Luis R. León Jr

Disclosures

Vascular. 2010;18(3):166-177. 

In This Article

Description of the Procedure

A microcatheter was advanced over a microwire through the right VA into the left VA (Figure 4). Digital subtraction angiography (DSA) showed collaterals from the cervical left VA into the LSA without direct filling. There was also filling to the AVF from enlarged left cervical VA arterial branches in the upper cervical region. The micro catheter was placed into the feeding branch, and this was coiled. However, DSA through the right VA demonstrated persistent flow through other left VA-dependent feeders.

Figure 4.

Right panel: Selective injection through the right vertebral artery (VA) shows the left VA aneurysm and the associated arteriovenous fistula. Then, by using the "saddling the vertebrobasilar junction" technique, a microcatheter was placed in the distal left VA, showing branches of the distal left VA reconstituting the distal left subclavian artery (left panel).

The decision was then made to sacrifice the left VA with coil placement at multiple levels of the artery. Subsequent DSA showed no residual supply from the left VA, but it did show some filling of the collaterals in the distal LSA from muscular branches of the midcervical right VA. There was also likely a midcervical VA branch supplying some flow to the left neck AVF.

A subsequent arch angiogram showed residual supply to the AVF from a large left external carotid artery (ECA) branch. A guiding catheter was advanced through the left ECA. Angiography showed an enlarged left occipital artery, with marked supply to the AVF. Several ECA branches were successfully embolized, but some were unable to be catheterized. Therefore, the decision was made to sacrifice the left ECA at its origin. Completion DSA showed a marked reduction in the AVF filling (Figure 5).

Figure 5.

An arch arteriogram at completion showing persistent residual but minimal flow into the AVF, in both early (left panel) and late (right panel) phases. The severe right-sided displacement of the left carotid arteries can still be seen in these images.

Owing to the large amount of dye and time required for the procedure, the decision was made not to pursue embolization of those small feeders and to stop the intervention at this point.

A CT scan the following morning showed successful coil aneurysm embolization with a slight hematoma size reduction and a marked decrease in the amount of contrast pooling, now filling only the superior hematoma component, with the inferior being occluded. Filling of the superior component was thought to be the likely result of flow from a small left ECA branch, which coursed inferior to the left carotid bifurcation. A decrease in the rightward deviation of the pharyngeal, laryngeal, and vascular structures was also seen. The patient eventually failed two spontaneous breathing trials, and, as a consequence, an open tracheostomy was required about 10 days after endovascular intervention, as well as percutaneous gastrostomy for nutrition. During the open tracheostomy, the trachea was noted to be deviated about 4 cm to the right side. The neck hematoma was then entered, and by removing a large amount of thrombi, the hematoma cavity was collapsed with resolution of the tracheal deviation.

The patient was discharged to a rehabilitation facility about 2 weeks after her aneurysm repair. She remained neurologically intact, except for mild left upper extremity weakness thought to be due to brachial plexus compression by the large hematoma. Her left upper extremity remained well perfused, with normal capillary refill with strong Doppler signals at the brachial, radial, and ulnar arteries. A repeated CT scan 3 weeks after intervention showed no contrast filling of the hematoma, with less tracheal deviation and carotid artery decompression (Figure 6). However, 3 months after intervention, the patient was still ventilator dependent, requiring enteral tube alimentation and suffering only mild left upper extremity neurologic deficits.

Figure 6.

Follow-up computed tomography done 3 weeks after intervention, now showing no contrast filling of the aneurysm cavity (right and left upper panels), with less tracheal deviation and carotid artery decompression. The tracheostomy tube can be seen in the upper left and lower panels as well.

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