This case report illustrates a complication of a revascularization procedure following a table saw injury to the forearm. The patient underwent open reduction of both forearm bones, repair of flexor and extensor tendons, median and ulnar nerve repair, and repair of both the radial and ulnar arteries immediately following injury. The patient experienced massive swelling of the hand within the first week of the operation. Diagnosis was not made for 3 months, during which time the patient was treated empirically, without success, with antibiotics for a presumptive infection. The patient was transferred for care to the authors, and a diagnosis of iatrogenic arteriovenous fistula was made on the basis of hand-held Doppler exam and arteriogram. It was determined that an inadvertent anastomosis was made between the proximal radial artery and the distal cephalic vein. The area was explored, but the degree of swelling and tissue pressure necrosis resulted in a below-elbow amputation, which relieved the patient's pain.
This is reported as the first case of iatrogenic arteriovenous fistula complicating revascularization surgery. The authors emphasize that careful proximal and distal dissection of the radial and ulnar arteries with lumen size-matching should always be performed prior to anastomosis. Vessel wall thickness can also be an important clue to arterial or venous anatomy in the vessels being considered. Early identification with appropriate clinical suspicion, given this landmark case, should result in immediate reoperation to prevent tissue loss and amputation.
Journal of Reconstructive Microsurgery