Iatrogenic Subclavian Arteriovenous Fistula: Rare Complication of Plate Osteosynthesis of Clavicle Fracture

Abstract

Iatrogenic subclavian arteriovenous fistula is rare and has not been reported as a complication of plate osteosynthesis of clavicle fracture. This article describes the first case of iatrogenic subclavian arteriovenous fistula caused by plate osteosynthesis. A 36-year-old man sustained a right middle clavicle fracture in an injury and underwent open reduction and internal fixation with clavicular compression plate 3 days later in a local hospital. On the second postoperative day, a pulsatile mass and thrill were detected at the right supraclavicular region. The patient was discharged 3 days postoperatively with no extra inspection. Three months later, he was admitted to our institution because the mass was getting bigger and weakness was felt in his right upper limb. Digital subtraction angiography confirmed a subclavian arteriovenous fistula. Vascular surgeons treated the patient successfully using endovascular techniques. The subclavian arteriovenous fistula was eliminated with a fully expanded stent graft, and the plate was removed simultaneously. The result was satisfactory, and the postoperative course was uneventful. This case demonstrated that subclavian arteriovenous fistula could be an iatrogenic complication of screw-and-plate osteosynthesis of clavicle fracture. The operative manipulation in the process of fracture reduction and hole drilling should be meticulous, and the screw length must be accurate. Orthopedic surgeons should be aware of this uncommon complication with plate osteosynthesis of clavicle fracture. We recommend using an endovascular surgical technique for treatment of this complication.

Major neurovascular complications of clavicle fracture surgery

“…All reports of arterial injury [14][15][16][17]21 have consistent features. There are no reported fatalities, there is no mention of significant bleeding at the time of the initial surgery and the injury was always associated with a prominent screw in the medial two thirds of the clavicle.…”

“…Left untreated, persistent venous hypertension can result in congestive heart failure or limb threatening ischaemia. 14 The reported case of AV fistula 14 presented as a pulsatile supraclavicular mass and ipsilateral arm weakness 3 months post clavicle fixation.…”

“…However, there are several case reports and small series of limb threatening and even fatal neurovascular complications following clavicle surgery. [13][14][15][16][17][18][19][20][21][22][23][24][25][26] This represents a potentially devastating outcome from an operation that is treating a problem that is neither life nor limb threatening.…”

Neurovascular Injuries with Shoulder Surgery

“…Arteriovenous (AV) fi stulae are a result of injury to both the artery and an adjacent vein [ 24 ]. Like pseudoaneurysms they are commonly associated with penetrating injury.…”

Clavicular caution: An anatomic study of neurovascular structures

“…Open reduction and internal fixation (ORIF) of these fractures provides stable anatomic reduction that restores length and prevents symptomatic malunion [8]. However, injuries to the nearby neurovascular structures have been reported as a result of surgical intervention [9][10][11].…”