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Selective catheterisation of the left vertebral artery with 5-French guiding catheter demonstrates a normal appearance of this vertebral artery with retrograde filling of the right cervical vertebral artery down to the level of C7.  There is fistula is demonstrated to the internal jugular vein.  

Subsequent catheterisation of the right subclavian artery demonstrates a normal origin of the vertebral artery with fistula again seen.  The vertebral artery distal to the fistula cannot be visualised.  5000 units of IV heparin were administered and 300 mg of aspirin given through the orogastric tube.  The vertebral artery was selectively catheterised with the 5-French guiding catheter and the artery probed with a micro catheter and micro guide wire.  Access could be gained to the distal vertebral artery with some difficulty.  The 5-French guiding catheter was exchanged for a Neuron Max guiding catheter and a Graftmaster balloon expanding covered stent (Abbott Vacular) measuring 4 x 19 mm successfully deployed with exclusion of the fistula and patency restored to the vertebral artery.