Complex aortic intervention: Optimal management of traumatic aortic injury with aberrant vertebral artery

Case History: A 61-year-old woman was admitted to the trauma center after falling from a height of 3 meters.

Clinical Findings: The initial CT scan revealed traumatic aortic injury, along with an aberrant left vertebral artery originating directly from the aorta. Upon admission, the aortic injury was managed conservatively, in accordance with the treatment strategy for low-grade injuries.

Investigation: A follow-up CT scan, conducted 24 hours later, indicated the progression of the aortic injury to grade III. Given the injury"s location just below the origin of the left subclavian artery (LSCA) and the presence of the aberrant left vertebral artery, we decided to perform a left common carotid artery (LCCA) to LSCA bypass followed by zone II thoracic endovascular aortic repair (TEVAR).

Diagnosis: Grade III traumatic aortic injury with an aberrant left vertebral artery.

Therapy and Progressions: Following the LCCA to LSCA bypass and transposition of the left vertebral artery to the LCCA, we performed zone II TEVAR. To prevent type 2 endoleak, embolization was performed using the Amplatzer Vascular Plug in the proximal portion of the subclavian artery. Subsequent CT scans revealed no evidence of endoleak.

Conclusion: Recognizing and addressing rare anatomical variants like aberrant vertebral artery anatomy are essential in complex aortic interventions. A comprehensive preoperative evaluation plays a pivotal role in achieving optimal outcomes in TEVAR for traumatic aortic injuries.

Figure. [A] The left vertebral artery (white arrow) originating from the aorta between the LCCA and LSCA [B] Pseudoaneurysm (white asterisk) corresponding to grade III aortic injury confirmed on follow-up CT [C] CT image after TEVAR and LCCA to LSCA bypass (black arrow)

References. Zhu J, Xi E, Zhu S, et al. Management of the vertebral artery during thoracic endovascular aortic repair with coverage of the left subclavian artery. J Thorac Dis. 2017;9(5):1273

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