Imad F. Tabry, MD

Case Presentation

A 91-year-old female was admitted in June 2009 with left-sided hemiplegia and congestive heart failure. She had undergone aortic valve replacement with coronary bypass surgery in 2003, an inferior vena cava filter insertion in 2006 and re-do coronary bypass off-pump in 2008. In addition to her neurologic findings, she also had a loud bruit at the base of the right neck associated with a palpable thrill. Review of her most recent surgery records confirmed the use of a right internal jugular central venous catheter for monitoring purposes. A brain magnetic resonance imaging scan (MRI) showed an acute infarct in the territory of the right middle cerebral artery involving the posterior parietal lobe. Ultrasound evaluation of the neck disclosed a sizable communication between the right internal jugular vein and the common carotid artery (Figure 1). After unsuccessful attempts at percutaneous occlusion of the fistula (Figure 2), it was suture-ligated and divided surgically. The patient continues to receive rehabilitative services.

Discussion

It is widely acknowledged today that all patients undergoing cardiac surgery — as well as other major surgeries — need placement of a central venous line for administration of fluids and or monitoring purposes. Because of the increased incidence of local infection and sepsis with transfemorally inserted catheters, this route has been largely abandoned in favor of the subclavian or internal jugular vein approach.

Although usually safe, this alternative approach has been known to cause a variety of serious vascular complications including life-threatening bleeding and large neck hematomas, particularly in heparinized patients,¹ carotid dissection,² vertebral artery to internal jugular vein fistulae,³ aorta-right atrial fistulae,⁴ ruptured superior thyroid artery,⁵ thrombosis of the vertebral artery⁶ and carotid artery-jugular vein fistulae,^7,8 as in our patient. Some complications, particularly the latter, have at times resulted in congestive heart failure and even stroke secondary to vessel thrombosis or distal arterial emboli.⁶ It is thus surprising to find, upon review of the literature, that cervical arterio-venous fistulae were created intentionally in the 1950s in a futile attempt to increase the blood supply to the brain in mentally retarded patients and those with cerebral palsy!⁹

The potential for this seemingly innocuous procedure to result in such serious complications has thus led to the recommended routine use of ultrasound localization of the subclavian and internal jugular veins in relation to their respective arteries during its performance.¹⁰

Though immediate recognition and management of these complications are preferable and often result in patient salvage, some, particularly the arterio-venous fistulae of the neck may go unsuspected for a long time and remain dormant until a stroke or a bout of congestive heart failure occurs. Once diagnosed, coil embolization of these fistulae is nowadays the first line of treatment,¹¹ followed by surgical ligation and division when unsuccessful.

Conclusion

Although “practice makes perfect,” central venous cannulation of the subclavian or internal jugular vein, even in the best hands, can cause immediate or delayed and potentially lethal vascular complications. Its universal use demands routine ultrasound localization of the target vessel, whether in the operating theater or at the bedside.

References

1. Mitchell SE, Clark RA. Complications of central venous catheterization. Am J Roentgenol 1979;133:467–476.
2. Parsons A, Alfa J. Carotid dissection: A complication of internal jugular vein cannulation with the use of ultrasound. Anesth Analg.2009;109:135–136.
3. Varga Z, Gyori-Molnar I, Kollar L, et al. A surgically treated arterio venous fistula between the vertebral artery and internal jugular vein after insertion of a central venous catheter for mitral valve replacement. J Thorac Cardiovasc Surg 2002;123: 571.
4. Danenberg HD, Hasin Y. Aorto-atrial fistula following internal jugular vein catheterization. Eur Heart J 1995;16:279–2816.
5. Jeganath V, McElwaine JG, Stewart P. Ruptured superior thyroid artery from central vein cannulation:Treatment by coil embolization. Br J Anaesth 2001;87:302–305.
6. Sloan M, Mueller J, Adelman L, et al. Fatal brainstem stroke following internal jugular vein catheterization. Neurology 1999;41:1092.
7. Sharma V, Pereira A, Ong B, et al. External carotid artery-Internal jugular vein fistula:a complication of internal jugular cannulation. Circulation 2006;113:e722–e723.
8. Thalhammer C, Aschwanden M, Jaeger K. Carotid artery to internal jugular vein fistula: A complication of internal jugular cannulation. Circulation 2006;114:e517–e517.
9. Hammer J, Heersma H. Complications and effects observed in thirty-three patients with cervical arteriovenous fistulas. AMA Arch Surg 1951;63:477–479.
10. National Institute for Clinical Excellence: Guidance on the use of ultrasound locating devices for placing central venous catheters. NICE Technical Report 49, September 2002.
11. Kirkwood M, Wahlgren CM, Desai T. The use of arterial closure devices for incidental arterial injury. Vasc Endovasc Surg 2008;42:471–476.

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From the Department of Surgery, Holy Cross Hospital, Fort Lauderdale, Florida.
The author reports no conflicts of interest regarding the content herein.

Address for correspondence: Imad F. Tabry, MD, Department of Surgery, Holy Cross Hospital, 2773 N.E. 37 DR, Fort Lauderdale, FL 33308. E-mail: itabry@comcast.net

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VASCULAR DISEASE MANAGEMENT 2010;7:E55–E56