• Mizuka Ikezawa, Takashi Izumi, Masahiro Nishihori, Yoshitaka Nagashima, Yusuke Nishimura, Tetsuya Tsukuda, Asuka E Kropp, Shunsaku Goto, Takafumi Otsuka, Naoki Kato, and Mizuki Nakano.
• Department of Neurosurgery, Nagoya University, Nagoya, Japan.
• World Neurosurg. 2021 Feb 1; 146: 166-170.

BackgroundVertebro-vertebral arteriovenous fistula (VVAVF) is a condition in which there is an arteriovenous shunt directly connecting the extracranial vertebral artery to the vertebral venous plexus. Many reports have described fistula occlusion or vertebral artery trapping as treatments for VVAVF. Here, we describe a case in which endovascular treatment for recurrent VVAVF using a transfemoral approach was unsuccessful; thus, the vertebral artery (VA) was directly punctured during open surgery and the treatment was successful.Case DescriptionThe patient was a 47-year-old female who had undergone endovascular treatment for VVAVF. The patient developed subarachnoid hemorrhage. Digital subtraction angiography revealed a left VVAVF. The left VA was trapped with coils at the C2 and C3 levels and an arteriovenous shunt formed from the VA between the 2-coil mass to the vertebral venous plexus. In addition, reflux was observed in the spinal vein. Endovascular treatment was attempted with a transfemoral approach, but we could not reach the shunt. Five days post-treatment, the patient had a second subarachnoid hemorrhage and surgery was performed to occlude the radiculomedullary vein; however, residual reflux went into the spinal vein from another spinal level. Later, the VA was directly punctured and treated with N-butyl cyanoacrylate, and the shunt disappeared.ConclusionsDirect puncture of the vertebral artery was useful in this case, where it was difficult to reach the lesion. Although direct VA puncture is associated with more complications than the transfemoral or transbrachial approach, it may be an option when other methods are difficult.Copyright © 2020 Elsevier Inc. All rights reserved.

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