Iatrogenic vertebral artery injury

Abstract

Iatrogenic vertebral artery injury (VAI) results from various diagnostic and therapeutic procedures. The objective of this article is to provide an update on the mechanism of injury and management of this potentially devastating complication. A literature search was conducted using PubMed. The iatrogenic VAIs were categorized according to each diagnostic or therapeutic procedure responsible for the injury, i.e., central venous catheterization, cervical spine surgery, chiropractic manipulation, diagnostic cerebral angiography, percutaneous nerve block, and radiation therapy. The incidence, mechanisms of injury, and reparative procedures were discussed for each type of procedure. The type of VAI depends largely on the type of procedure. Laceration was the dominant type of acute injury in central venous catheterization and cervical spine surgery. Arteriovenous fistulae and pseudoaneurysms were the delayed complications. Arterial dissection was the dominant injury type in chiropractic manipulation and diagnostic cerebral angiography. Inadvertent arterial injection caused seizures or stroke in percutaneous nerve block. Radiation therapy was responsible for endothelial injury which in turn resulted in delayed stenosis and occlusion of the vertebral artery (VA). The proximal VA was the most vulnerable portion of the artery. Although iatrogenic VAIs are rare, they may actually be more prevalent than had previously been thought. Diagnosis of iatrogenic VAI may not always be easy because of its rarity and deep location, and a high level of suspicion is necessary for its early detection. A precise knowledge of the surgical anatomy of the VA is essential prior to each procedure to prevent its iatrogenic injury.

Variations in the Origin and Course of the Extracranial Vertebral Artery on Multidetector Computed Tomography Angiography

“…For example, during cervical spine surgery, one may injury the VA with high level of entrance when dissecting the anterior branch of the transverse process and the longus colli muscle with unawareness and overconfidence. The abnormal course of extradural VA can also complicate the corpectomy foraminotomy, and percutaneous nerve block, causing arterial laceration or pseudoaneurysm formation (5,8,9). Therefore, it is important to perform appropriate imaging study to delineate the extradural VA course preoperatively and prevent iatrogenic injury.…”

Vertebral artery anomaly with entry at C4—avoiding a surgical pitfall: a case report

“…Entry in the transverse foramen varies from C7 up to C2 [5,7,9]. Although the lateral position of VA does not hinder the anterior approach and therefore vertebral artery injury (VAI) in anterior cervical spine surgery is a rare complication with incidences of 0.3-0.5% [14], it might be an underestimated problem [8]. There have been reports of laceration due to anatomical variations [4].…”

Vertebrojugular arterio-venous fistula and psudo-aneurism formation due to penetrating vertebral artery injury: case report and review of the literature

“…The concurrence of a vertebral artery pseudoaneurysm and arteriovenous fistula between the vertebral artery and internal jugular vein is extremely rare and mostly occurs following penetrating traumas of the craniocervical region or may be iatrogenic (1,16,19,20,26). Penetrating traumas include firearm injuries while iatrogenic reasons include surgery, jugular venous catheterization, diagnostic angiography and nerve blocks (19).…”