Self-expanding covered stent placement to treat a pseudoaneurysm caused by iatrogenic vertebral artery injury

Vertebral artery injuries account for approximately 19% of cerebral vascular injuries and are typically managed conservatively. However, some patients require operative intervention to gain control of an active hemorrhage, either via surgical ligation or endovascular intervention. We present a case of iatrogenic vertebral artery injury occurring during cervical spine surgery which was treated emergently with a self-expanding covered stent. A 58-year-old male presented for cervical traction, C5 and C6 corpectomy, and possible C4 to T2 posterior fusion following a motor vehicle accident. Intraoperatively, following drilling the C5 endplate, copious bleeding was observed from injury to the right vertebral artery resulting in pseudoaneurysm formation. The patient was loaded with ticagrelor and a self-expanding covered stent was placed via a transfemoral approach, resulting in obliteration of the pseudoaneurysm prior to completion of his cervical spine surgery. Emergent self-expanding covered stent placement for iatrogenic vertebral artery injury in the setting of an intraoperative injury is a safe and effective option. Ticagrelor is a viable alternative to traditional dual antiplatelet therapy for preventing thromboembolic complications in this urgent setting.