Introduction: Vertebral artery injury is a rare complication of anterior cervical operations with severe morbidity. Primary repair is an ambitious goal during severe hemorrhage, and vessel sacrifice by open ligation or endovascular embolization is common. Endovascular stent repair anti-platelet treatment and increases operative risk.

Methods: Severe vertebral artery injury occurred during the exposure of a corpectomy performed for a progressive hemiparesis from multilevel cervical disc herniation. This patient had one vertebral artery supplying the posterior circulation. Despite localization of the hemorrhage site, further dissection and direct visualization, hemostatic control for a primary repair was not feasible. A proximal temporary clip was attempted but also not feasible due to the caliber of the vertebral artery. Endovascular balloon occlusion at the site of extravasation provided improved hemostatic control, allowing direct visualization of the site of injury for high-quality primary suture repair.

Results: Repeat angiography was completed 2 days following the repair and demonstrated robust filling through a patent lumen without evidence of extravasation. The patient was taken back to the operating room 3 days postoperatively for completion of his corpectomy. At 2 month follow-up, he had complete resolution of his left hemiparesis and was living at home. He had a repeat angiogram demonstrating complete resolution of vertebral artery irregularity.

Conclusions: This is a representative case of combined open and endovascular approach to the immediate repair of an iatrogenic critical vertebral artery injury. Artery preserving techniques were crucial in preserving this patient's posterior circulation, but in other cases, the critical nature of a vertebral artery may not be immediately apparent when the contralateral vertebral artery is present but insufficient. Furthermore, this combined approach of avoided the requirement of antiplatelet agents, allowing the patient to quickly return to the operating room for completion of his corpectomy with short-term follow-up demonstrating significant improvement in his neurologic function.

Patient Care: Introduce advanced techniques for the management of a complication of anterior approaches to the cervical spine.

Learning Objectives: Describe the incidence and outcomes of vertebral artery injury Describe the approaches for management of vertebral artery injury

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