The concomitant vertebral artery injury as a complication during posterior C1&2 screw fixation has been described before and found to occur in approximately 3% of cases and may remain asymptomatic (30%) or cause sequelae that include an arterial steal phenomenon with cerebral hypoperfusion, increased flow in cerebral veins resulting in intracranial venous congestion or hemorrhage, headaches, a bruit, tinnitus or vertigo. The nature of the fistula and its associated symptoms, the onset and nature of the injury and the concurrent clinical status of the patient, and the necessity of treatment, these factors influence choosing the treatment modality and approach which range between conservative management, endovascular techniques to occlude the fistula, and/or on rare occasions direct surgical clipping could be used also, see Abstract E-008 table 2 in (Endovascular therapy of arteriovenous fistulae with electrolytically detachable coils. 1999), E-008 tables 1 and 2 in (Herrera et al., 2008). Variable endovascular techniques have been described in many publications, (Kattner, Roth, Nardone, & Giannotta, 2004), (Gonzalez et al., 2001), (Lee et al., 2007), (Beaujeux et al), (Feyyaz Baltacıoğlu, 2009), (Chuhan Jiang, Xianli Lv, Youxiang Li, Jingbo Zhang, Zhongxue Wu, 2009), (Macdonald, Millar, & Barker, 2010), (Andreou, Ioannidis, & Nasis, 2008), (Li et al., 2007), (Guo et al., 1998). In this case, we are first to report the practical use of Amplatzer Vascular Plug (II), which has been only known to be used in treating peripheral vascular AVF, and it has never been reported to be used in treating AVFs until the time of submitting this case-report. Amplatzer Vascular Plug Family, are designed to provide optimal embolization of peripheral veins and arteries through single device occlusion, full cross-sectional vessel coverage, controlled and precise deployment. Using the Amplatzer Vascular plug is a very efficient and cost-effective alternative to coils or surgery. It can also be repositioned or recaptured, if necessary. The Amplatzer Vascular Plug (II), is a unique multi-segmented, multilayered device, that reduces the time to occlusion for transcatheter embolization procedures. Its adjustable lobes are designed to better conform to vessel landing zone. (AGA medical corporation, 2010), (Cil B, Peynircioğlu B, Canyiğlit M, Geyik S, Ciftçi T., 2008).
Conclusion Using Amplatzer Vascular Plug (II) in treating vertebral AVFs has never been previously reported. In this case; the large size of the AVF and the and the altered and complicated vertebral vascular anatomy secondary to the previous cervical surgeries were strong indications to choose a larger vascular plug in attempt to cause a complete occlusion of the AVF and attempt complete cure of its clinical sequelae on our patient.
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