Penetrating neck injuries are stressful events for surgeons. The risk of iatrogenic damage to surrounding structures is high and makes flawless knowledge of the neck anatomy mandatory. K-wire migration into the cervical spine after fixation of a fractured clavicle is rare. Apart from injury to the vertebral artery, it may cause damage to the nerve roots, dura mater, and spinal cord. When such material penetrates the vertebral canal, a wide laminectomy is required to expose both ends of the K-wire, followed by dura mater repair and hemostasis [
4,
5]. In the presented case there was a risk of causing injury to the vertebral artery while removing the K-wire. Mwipatayi
et al. never attempted to repair the vertebral artery in cases with such an injury. In all cases the vessel was ligated, clipped or hemostasis was attained using bone wax [
6].
In general, the vertebral artery can be divided in four anatomical segments: V1 to V4 [
14,
15]. Care must be taken to account for anatomical variations of these segments to avoid serious complications by iatrogenic injury [
16]. The first part of vertebral artery (V1) originates from the subclavian artery and ends by entering the transverse foramen. In 90 % of cases, its entrance is at the level of C6, but it can be as high as C3 [
16]. The artery is relatively unprotected during this path and its injury would require wide surgical exposure and ligation of the vessel. The V2 segment travels through the C6 to C2 transverse processes and merges into the V3 from the C2 vertebra to its entry point through the dura mater [
14]. Bleeding, due to arterial injury, in these segments should be stopped using bone wax. However, if performed carelessly, this may harm the cervical nerve root. The last part of the vertebral artery (V4) has an entirely intracranial course, merging with the basilar artery. Occlusion of the vertebral artery at this point may cause cerebellar ischemia. Other complications, due to injury to the vertebral artery, are massive neck hematomas, pseudoaneurysms, dissections or arteriovenous fistulas [
6]. The mortality rate associated with vertebral artery injury is estimated to be 6.9 % [
6]. Apart from severe and uncontrollable bleeding, most vertebral artery injuries are asymptomatic. Reid and Weigelt suggested that neurological deficits accompanying vertebral artery injury are caused by direct physical damage to the spinal cord and cervical roots rather than ischemic changes within these structures [
17]. An open neck exploration procedure is the preferred method for acute and unstable cases with an uncontrolled hemorrhage and a growing hematoma in the cervical region [
6]. Stable patients, that is, vertebral dissections, can be treated by endovascular techniques, which are the recommended procedures compared to an open surgical intervention. These techniques allow vascular repair using a minimal invasive approach and have proven their value in earlier studies [
18]. Blunt vertebral artery injuries can be successfully managed as well using endovascular techniques including stenting, occlusion or pseudoaneurysm coil occlusion [
6,
7,
18,
19]. Lesions that do not qualify for endovascular treatment are those that are within 2 cm from the origin of the vertebral artery or in the V4 segment close to the posterior inferior cerebral artery (PICA) [
6]. Herrera
et al. presented the endovascular treatment of 18 patients with penetrating injury of the vertebral artery. In all cases, sacrifice of the artery was a necessity due to severe hemorrhage. Occlusion was carried out if patency of the PICA was visualized. The authors did not observe any neurological complications; the unaffected vertebral artery seemed to sufficiently supply the contralateral circulation [
19].
The presented case can be subdivided into two main categories of surgical management: open surgery or endovascular procedures. The open approach was necessary to safely remove the foreign body and to prevent vertebral artery injury. If, during surgery, a hemorrhage had occurred, direct pressure could have been applied to achieve hemostasis. In case of an uncontrollable bleeding, the patient would have been moved to the angiography unit for endovascular occlusion of the vessel.