Direct Percutaneous Puncture and Glue Embolization of a Cervical Prevertebral Bleeding Pseudoaneurysm Using Cone-Beam CT Navigation Technology.

A 91-year-old man presented emergently with anterior neck pain, severe dysphagia, and neck expansion after a fall 1 day earlier. His oxygen saturation level was 88% on 4 L of oxygen. A triple-phase computed tomographic (CT) angiogram of the neck showed a massive prevertebral hematoma from a bleeding pseudoaneurysm (Fig 1). A right vertebral artery angiogram showed the prevertebral pseudoaneurysm to be supplied by a tiny muscular branch that was too small for selective transarterial catheterization (Fig 2). Given the inability to treat the pseudoaneurysm via a transarterial route, we decided to treat it via a direct percutaneous puncture with the use of cone-beam CT navigation technology (Philips Medical Systems, Best, The Netherlands), as described previously for other applications (Fig 3). We advanced a 22-gauge, 3.25-inch spinal needle percutaneously via anterolateral approach into the pseudoaneurysm under fluoroscopic guidance by using a live overlay technique. After angiographic confirmation, 3 mL of a mixture of N-butyl cyanoacrylate and Ethiodol (33%; Guerbet, Roissy, France) was injected under fluoroscopic imaging during right vertebral arteriography (Fig 4); this confirmed no residual pseudoaneurysm (Fig 5). The patient was extubated after 2 days, made a full recovery, and was discharged home symptom-free after 2 weeks. The patient remained symptom-free 3 months after the procedure (modified Rankin scale score 0). Figure 2Anteroposterior right vertebral artery digital subtraction angiography shows active pseudoaneurysm bleeding from a small prevertebral muscular branch at the C3/4 level (arrow). View Large Image Figure Viewer Download Hi-res image Figure 3Axial CT image with needle guidance technology displays the target (arrow), needle trajectory (green line), and entry point (asterisk). The green line shows the trajectory the needle will follow during the “progress view” under fluoroscopic guidance with the live overlay fluoroscopy technique. View Large Image Figure Viewer Download Hi-res image Figure 4Right vertebral artery angiography during percutaneous glue embolization from the spinal needle (arrow) shows slow, complete filling of the pseudoaneurysm with the 33% glue mixture (asterisk). View Large Image Figure Viewer Download Hi-res image Figure 5Right vertebral artery angiography after percutaneous glue embolization shows no residual active pseudoaneurysm bleeding (arrow). View Large Image Figure Viewer Download Hi-res image