|Year : 2019 | Volume
| Issue : 4 | Page : 327-329
Inadvertent carotid-jugular conduit: An uncommon yet dreaded jugular venous catheterization complication
R Vairakkani1, K Arun Alex2, M Edwin Fernando1, B Suhasini2, ND Srinivasaprasad1
1 Department of Nephrology, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India
2 Department of Radiology, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India
|Date of Submission||29-Apr-2019|
|Date of Acceptance||07-Jun-2019|
|Date of Web Publication||20-Dec-2019|
Department of Nephrology, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Carotid-jugular fistula is one of the uncommon complications of internal jugular vein catheterization. It can have serious consequences such as infection, embolization, and high output cardiac failure and requires invasive repair. We describe a case of a common carotid artery-jugular vein arteriovenous fistula following the insertion of a double-lumen catheter for hemodialysis access.
Keywords: Arteriovenous fistula, carotid jugular, catheterization, complications
|How to cite this article:|
Vairakkani R, Alex K A, Fernando M E, Suhasini B, Srinivasaprasad N D. Inadvertent carotid-jugular conduit: An uncommon yet dreaded jugular venous catheterization complication. Indian J Vasc Endovasc Surg 2019;6:327-9
|How to cite this URL:|
Vairakkani R, Alex K A, Fernando M E, Suhasini B, Srinivasaprasad N D. Inadvertent carotid-jugular conduit: An uncommon yet dreaded jugular venous catheterization complication. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2020 Jun 4];6:327-9. Available from: http://www.indjvascsurg.org/text.asp?2019/6/4/327/273592
| Introduction|| |
Given the ever more widespread use of central venous catheters for multiple indications, inadvertent complications of internal jugular venous catheterization are not uncommon; one among them being carotid-jugular arteriovenous fistula. These fistulae can be symptomatic or detected during investigation for an unrelated indication. Color flow Doppler can be used for screening, while angiography is required for diagnosis and planning treatment. Given the serious nature of complications of untreated fistulae, interventional repair is indicated in all patients.,,
| case Report|| |
A 24-year-old male has been having voiding difficulties since childhood in the form of straining at micturition, incomplete voiding, and enuresis. He started to have symptoms of reduced urine output, breathlessness, and easy fatigability in 2013. From 2015, he also started to develop volume overload and vomiting in addition to worsening of previous symptoms. He was treated by an urologist with chronic urinary catheterization and oral medications. Few months later, he was detected to have chronic kidney disease-stage 5 and was initiated on hemodialysis initially through left internal jugular vein, dual-lumen, nontunneled catheter. On evaluation, he was found to have spina bifida occulta with neurogenic bladder. He had multiple arteriovenous access primary failures. He was initiated on continuous ambulatory peritoneal dialysis in 2015. In October 2017, he had thalamic minor stroke. In November 2017, while on peritoneal dialysis, he developed uremic pericarditis which necessitated temporary hemodialysis through right internal jugular vein temporary catheter under ultrasound guidance. The central venous catheter was removed after pericarditis resolved with five sessions of hemodialysis. Subsequently, over the ensuing months, he had multiple episodes of peritonitis which necessitated removal of peritoneal dialysis catheter during the present admission in July 2018, and it was decided to insert a dual-lumen tunneled catheter into the right internal jugular vein. At preprocedure Doppler evaluation, a tiny fistulous communication between the right common carotid artery and right internal jugular vein was observed [Figure 1] and [Figure 2] and subsequently confirmed with computed tomography (CT) carotid arteriography [Figure 3]. He was then dialyzed through left femoral access. Unfortunately, definitive management of the carotid-jugular fistula could not be undertaken as he expired due to sudden cardiac death. The fistula might have formed due to inadvertent cannulation of the right common carotid artery while attempting to cannulate the right internal jugular vein either during initial attempts at failed cannulation or during the recent episode of uremic pericarditis.
|Figure 1: B-mode sonographic image showing abnormal communication between right common carotid artery and right internal jugular vein|
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|Figure 2: Color Doppler sonographic image showing a jet of flow from right common carotid artery to right internal jugular vein|
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|Figure 3: Carotid computed tomography arteriogram image showing entry of thin stream of contrast from right common carotid artery into right internal jugular vein through the abnormal communication seen in B-mode sonography|
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| Discussion|| |
Carotid-jugular fistula may be either congenital or acquired. Congenital arteriovenous communications are less common, compared to acquired ones from which they are differentiated by the presence of multiple communications in the former, in contrast to a single communication in the latter. Acquired carotid-jugular fistula results either from penetrating trauma as in case of stab injuries or gunshot wounds or from iatrogenic trauma. Deliberate iatrogenic carotid-jugular fistula was used as a treatment modality for mental retardation and convulsive disorders in children during the 1950s. Central venous catheterization is being increasingly used for venous pressure monitoring, hemodialysis, total parenteral nutrition, drug administration, and interventional radiological procedures with resulting increased risk for arterial trauma and subsequent arteriovenous fistula formation., Ortiz etal. in 1976 reported the first arteriovenous fistula from an internal jugular vein catheter placement, a fistula between the inferior thyroid artery and the internal jugular vein. The clinical presentation is determined by the factors related to fistula such as its size, quantum of blood flow through it, proximity to the heart, and distensibility. Large fistulae (>8 mm) tend to present early compared to smaller ones (<5 mm)., The clinical features are neck swelling which may be pulsatile, presence of distended veins, thrill on palpation, and continuous murmur with systolic accentuation, or it may be incidentally detected on the neck evaluation for a different purpose as in our case., Untreated carotid-jugular fistula may cause complications such as infection and systemic embolization, resulting from endothelial trauma caused by the jet of blood impinging on the wall of jugular vein and high output cardiac failure. Rarely, neurological deficits in the form of visual disturbance, tinnitus, or hemiparesis either from steal phenomenon or from venous congestion in the dural venous sinuses may occur.,,, Color flow Doppler is a sensitive tool for detecting these fistulae. Early visualization of the jugular vein in the arterial phase either by conventional angiography or by CT/magnetic resonance (MR) angiogram confirms the diagnosis. Catheter angiography also offers the prospect of simultaneous endovascular intervention. Compared to MR angiogram, CT has better spatial resolution and hence preferred for surgical planning. Because of potential serious complications, early intervention either surgical or endovascular is being advocated for carotid-jugular fistula and the preferred modality is decided on a case-by-case basis. Endovascular treatment with coils, detachable balloons, or covered stents is preferred for surgically difficult to access lesions or high surgical risk patients, with major limiting factors being expertise and availability.,,,, Surgical intervention with reconstruction or ligation is preferred in patients with associated vessel wall lesions such as pseudoaneurysm. Although inadvertent carotid-jugular conduit resulting from jugular vein cannulation is rare, certain measures taken at the time of catheterization including limiting the head rotation to 40°, using smaller gauge needle to locate the vein before cannulation, and ultrasound-guided catheterization wherever available can potentially help in preventing this rare but serious complication.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]