Iatrogenic axillary arteriovenous fistula complicating permanent pacemaker implantation: successful management with a balloon-expandable covered stent—a case report

Third-degree atrioventricular block is a class I indication for permanent pacemaker implantation. Iatrogenic axillary arteriovenous fistula is an extremely rare vascular complication of this procedure with limited clinical reports to date. We present the case of a 57-year-old male with third-degree atrioventricular block who developed an axillary arteriovenous fistula during permanent pacemaker implantation via the left axillary vein approach. The complication was promptly diagnosed by emergency axillary arteriography and was successfully occluded with an 8 mm × 37 mm balloon-expandable covered stent. Owing to the ipsilateral vascular injury, the pre‑created left pacemaker pocket was then closed in layers. Permanent pacemaker implantation was subsequently completed uneventfully via the contralateral right axillary vein approach, with a new pacemaker pocket created on the right side. The patient had an uncomplicated postoperative course and normal pacemaker function at the 1-month follow-up, with no recurrence of symptoms or vascular abnormalities. We review the relevant literature, analyze the pathophysiology, diagnosis and interventional management of this rare complication, and propose clinical recommendations for its prevention and acute management, including rational pacemaker pocket management after successful vascular fistula occlusion. This case reinforces the efficacy and safety of balloon-expandable covered stents for iatrogenic axillary arteriovenous fistula and highlights the importance of multidisciplinary collaboration, prompt angiographic diagnosis, and deliberate pocket selection in the management of such acute procedural complications.