Understanding Postoperative Vascular Risks

Upper cervical spine surgery involves high-risk anatomical corridors where vascular injury can occur. Iatrogenic vertebro-vertebral arteriovenous fistula (VVAVF) is a rare but life-threatening complication. Effective iatrogenic VVAVF management requires a high index of suspicion in the postoperative phase. Surgeons must recognize that these abnormal shunts can lead to massive hemorrhage or neurological deterioration if left untreated.

The Case of Bilateral VVAVF

A recent case report describes a 64-year-old woman who underwent fixation for an odontoid fracture. She previously suffered a high-altitude fall and underwent a craniotomy for head trauma. One week after her spinal fixation, she developed active bleeding at the surgical site. Physicians immediately ordered an emergency angiography. The imaging revealed a rare occurrence of bilateral VVAVF at the V3 segment of the vertebral arteries. This finding necessitated urgent intervention to stabilize the patient.

Advanced Strategies for Iatrogenic VVAVF Management

Endovascular intervention has become the gold standard for treating complex vascular injuries. In this instance, the medical team chose a dual approach to seal the fistulas. Specifically, they performed coiling of the left vertebral artery and embolization of the right fistula. These procedures successfully obliterated the abnormal connections while preserving essential circulation. Consequently, the patient showed substantial clinical improvement and returned to a stable state. Follow-up imaging confirmed that the fistulas did not recur, proving the efficacy of the selected treatment.

Clinical Lessons for Surgical Teams

Meticulous surgical technique is vital during upper cervical procedures to avoid vertebral artery damage. However, when injuries occur, rapid diagnosis through digital subtraction angiography is crucial. Medical professionals should prioritize endovascular options over open surgery due to lower procedural morbidity. Furthermore, vigilant postoperative surveillance remains the best way to catch delayed bleeding early. This case emphasizes that early recognition and precise intervention lead to successful patient outcomes.

Frequently Asked Questions

What are the symptoms of an iatrogenic VVAVF?

Patients may present with active surgical site bleeding, a palpable thrill, or a cervical bruit. Some also report pulsatile tinnitus or show signs of vertebrobasilar insufficiency due to vascular steal.

Which imaging tool is best for diagnosing VVAVF?

Digital subtraction angiography (DSA) remains the definitive diagnostic tool. It provides detailed visualization of the vascular anatomy and allows for immediate endovascular treatment during the same session.

Is surgery always required to fix a fistula?

No, endovascular techniques like coiling, stenting, or embolization are often preferred today. These minimally invasive methods are safer and highly effective for closing abnormal arteriovenous shunts.

Disclaimer: This content is for informational and educational purposes only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Refer to the latest local and national guidelines for clinical practice.

References

Sun Y et al. Bilateral vertebro-vertebral arteriovenous fistula after upper cervical spine surgery: a case report. J Cardiothorac Surg. 2026 Apr 28. doi: 10.1186/s13019-026-04240-4. PMID: 42045934.

Choi JW et al. Epidemiology and Management of Iatrogenic Vertebral Artery Injury Associated With Cervical Spine Surgery. Korean J Neurotrauma. 2022 Apr;18(1):33-43.

Briganti F et al. Endovascular treatment of vertebro-vertebral arteriovenous fistula. A report of three cases and literature review. Neuroradiology. 2006 Dec;33(5):319-27.