Transvenous Embolization of a Traumatic Vertebral Artery AVF Sustained from Gun Shot Wound

Discover the case of a late 20's police officer who sustained a gunshot wound to the base of the left neck. Imaging revealed an occlusion of the vertebral artery at the origin with reconstitution at the distal segment, along with irregularities in the V4 segment. Following the trauma, the patient experienced intermittent headaches, lightheadedness, neck pain, and numbness in both hands. A repeat angiography confirmed the presence of a traumatic AVF in the left V1/V2 segment. The medical team opted for a transvenous embolization of the traumatic vertebral artery AVF.

Case presentation

Patient presentation

Late 20’s man, police officer, who sustained GSW while on active duty to base of left neck with coronal trajectory towards right clavicle
CT Head: unremarkable
CT C-Spine: anterior C7 burst fracture
CT Chest: soft tissue edema + air in left supraclavicular region; no extravasation
CTA neck: occlusion of left VA at origin with reconstitution at distal V2 segment with irregularity/filling defect in V4 segment; no active extravasation/pooling
MRI brain: unremarkable
MRA neck: similar to CTA; retrograde filling of left VA via right VA
Exam: Tingling in bilateral hands; otherwise non-focal
Trauma tertiary survey: unremarkable
C-collar; PT/OT
ASA; DSA
Discharged home POD#3

Clinic follow-up

Intermittent HAs, lightheadedness; neck pain in bilateral shoulders; numbness in bilateral hands
3-month follow-up CTA done

CTA neck

Persistent occlusion of left proximal V1 segment with filling of distal V1 segment by vertebral venous plexus with fistulous connection at C6-C7
Repeat DSA

Repeat DSA

Traumatic AVF in left V1/V2 segment with drainage into parasagittal cervical venous plexus
Retrograde filling of the left VA via right VA, and collaterals of the left thyrocervical trunk, costocervical trunk, and left occipital artery

Technical Considerations

Trans-arterial?
Trans-venous?
Coiling?
Liquid Embolic Agents?

Intervention

Procedure Setup

6F right radial artery + 5F left femoral artery
6F right femoral vein
- 6F 95cm Envoy DA XB guide catheter
- 5F 125cm Berenstein select catheter
- 0.035 guidewire
5F 100cm Berenstein catheter into right VA via radial approach → roadmap guidance
160cm Phenom-27 microcatheter
Synchro-2 Soft microwire
3-5mm microvascular plug
POD 400 (4mm x 30cm) + PAC 400 coils (40, 60cm)
5F 60cm Soft-Vu C2 Cobra catheter

Transvenous AVF Embolization

Conclusion

Post-Procedure

Exam: normal; previous complaints resolved
Discharged home POD#1