Percutaneous obliteration of a postoperatively persistent vertebral arteriovenous fistula.

Traumatic vertebral arteriovenous fistulae (AVFs) are relatively uncommon lesions that often follow penetrating wounds of the neck or iatrogenic arterial trauma [1-7]. Such posttraumatic single-hole fistulae differ from congenital arteriovenous malformations, which are composed of multiple communications between the cervical arteries and an abnormal vascular nidus [8] . True single-hole vertebral fistulae may be treated surgically by ligation of the abnormal communication [9, 10] or by transcatheter embolization (arterial or venous approach), often with preservation of flow in the vertebral artery [11-15]. Surgical ligation or trapping of the vertebral artery segment supplying the fistula without obliteration of the fistulous communication is ineffective, since collateral flow from other cervical arteries will continue to supply the fistula, and the vertebral artery is unnecessarily sacrificed [2, 6, 8, 1619]. Also, once direct intravascular access to the fistula site has been obliterated by unsuccessful ligation, there may be no remaining arterial route available to attempt cure by embolization. We present here a case of a posttraumatic vertebral A VF previously treated (unsuccessfully) by ligation of the vertebral artery proximal and distal to the site of the fistula. Unusual transspinal interarterial collateral blood flow from the nonaffected left vertebral artery toward the affected right vertebral artery resulted in a neurologic disturbance related to a vertebrobasilar "steal syndrome" [20, 21]. In addition to the absence of an adequate intraarterial route for embolization, no venous route was available, since the right vertebral vein was thrombosed at the time of the initial injury. Total occlusion of the fistula hole was, therefore, accomplished by direct puncture of the blind segment of the affected vertebral artery (between the previously placed surgical ligatures) with introduction of Gianturco steel coils at the fistula site [22-24]. All neurologic symptoms and signs disappeared after the fistula was obliterated. We believe this case to be unique, although