Proximal and distal endovascular embolization of a penetrating V3 vertebral artery transection with adjunctive surgical ligation: A case report

Background: Penetrating vertebral artery injuries are rare, accounting for <1% of trauma admissions, and complete transection of the V3 segment is exceptionally uncommon. The resulting limited evidence base and complex V3 anatomy make management challenging. This case describes a hybrid endovascular and surgical strategy for a complete V3 transection refractory to primary surgical control. Case Description: A man in his 40s sustained complete transection of the right vertebral artery (V3 segment) after an accidental fall onto a machete, causing a penetrating neck injury with massive hemorrhage and cardiac arrest requiring pre-hospital resuscitation. Surgical exploration failed to achieve hemostasis, as both vessel ends had retracted behind the C2 transverse processes. Sequential endovascular embolization achieved proximal control through ipsilateral brachial access and distal control through contralateral retrograde access, with adjunctive external carotid branch embolization and surgical ligation achieving definitive hemostasis. Despite severe associated injuries, including traumatic brain injury, subarachnoid hemorrhage, and spinal cord infarction, the patient’s Glasgow Coma Scale returned to 15, and he was independent with mobility and personal care by hospital day 72. At 9-month follow-up, cerebral angiography confirmed stable, occluded vessels with no recanalization, and he had returned to independent activities of daily living with mild residual memory impairment and fatigue. Conclusion: A combined endovascular and surgical approach can achieve hemorrhage control in complete vertebral artery transection when surgical hemostasis alone is unsuccessful. Contralateral retrograde access facilitates distal embolization in anatomically challenging injuries, and close multidisciplinary collaboration between interventional neuroradiology and neurosurgery is critical to favorable outcomes.