What is the management of a vertebral artery pseudoaneurysm?

Management of Vertebral Artery Pseudoaneurysm

Endovascular treatment with stenting or coil embolization is the first-line approach for vertebral artery pseudoaneurysms, with surgical repair reserved for cases where endovascular techniques fail or are contraindicated. 1

Diagnostic Approach

• MRA or CTA is recommended over ultrasound for initial evaluation of vertebral artery pseudoaneurysms due to higher diagnostic accuracy (94% vs 70% sensitivity) 2, 3
• Catheter-based contrast angiography is typically required before intervention as it provides superior visualization of the pseudoaneurysm and surrounding vascular anatomy 2, 4
• Serial imaging is reasonable to assess progression of the pseudoaneurysm if immediate intervention is not performed 4

Management Algorithm

1. Initial Medical Management

• For pseudoaneurysms with angiographic evidence of thrombus, anticoagulation therapy is recommended for at least 3 months 2, 4
• For pseudoaneurysms without evidence of thrombus, antiplatelet therapy with aspirin (75-325 mg daily) is recommended as first-line therapy 2, 3
• For patients with aspirin contraindications, clopidogrel (75 mg daily) or ticlopidine (250 mg twice daily) are reasonable alternatives 3

2. Endovascular Treatment

• Endovascular approaches are preferred for most vertebral artery pseudoaneurysms due to lower morbidity compared to open surgery 1
• Options include:
  • Flow-diverter stents (most commonly used) 1
  • Stent-assisted coiling 1, 5
  • Covered stents 6
  • Parent vessel occlusion with coils (if the contralateral vertebral artery provides adequate flow) 5
• Risks of endovascular treatment include:
  • Death (0.3%) 2, 3
  • Periprocedural neurological complications (5.5%) 2, 3
  • Posterior stroke (0.7%) 2, 3
  • Restenosis (approximately 26% of cases) 2, 3

3. Surgical Management

• Surgical intervention is indicated when:
  • Endovascular treatment fails 7
  • Significant mass effect from the pseudoaneurysm is present 2
  • Contraindications to endovascular therapy exist 7
• Surgical options include:
  • Trans-subclavian vertebral endarterectomy 8, 2
  • Transposition of the vertebral artery to the ipsilateral common carotid artery 8, 2
  • Reimplantation of the vertebral artery with vein graft extension to the subclavian artery 8, 2
  • Direct repair of the pseudoaneurysm 7
• Surgical complication rates:
  • Early complications: 2.5% to 25% 8, 2
  • Perioperative mortality: 0% to 4% 8, 2

Special Considerations

• When both vertebral arteries are patent and one has a pseudoaneurysm, the contralateral vertebral artery usually supplies sufficient blood flow to the basilar artery, provided there is anatomic continuity 8, 2
• Parent vessel occlusion should be considered the first option for treatment in patients who can tolerate sacrifice of the parent vessel, particularly if the contralateral vertebral artery is dominant 5
• Reconstructive techniques should be favored over deliberate endovascular occlusion when the affected vessel is dominant 1
• Close clinical follow-up and imaging surveillance are essential after treatment, as recurrence can occur even after initially successful treatment 5
• For iatrogenic pseudoaneurysms (e.g., after central line placement), prevention through proper technique is paramount 7

Follow-up Recommendations

• Serial noninvasive imaging is recommended at intervals similar to those for carotid revascularization 4
• Monitoring for recurrent symptoms such as headache, neck pain, or neurological deficits is essential 4, 5
• If recurrence is detected, prompt re-evaluation and consideration of additional intervention is warranted 5