Download Subclavian Artery- Internal Jugular Vein Fistula and Heart Failure

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© JAPI • february 2013 • VOL. 61
Case Report
Subclavian Artery- Internal Jugular Vein Fistula and
Heart Failure: Complication of Internal Jugular Vein
Catheterization
Jai Prakash1, Brojen Takhellambam2, Biplab Ghosh2, Tauhidul Alam Choudhury2,
Shivendra Singh3, Om Prakash Sharma4
Abstract
Hemodialysis in patients with end-stage renal disease (ESRD) requires vascular access which can be either
temporary or permanent. However, these procedures are not without complications. Arterial puncture is the most
common immediate complication and pseudoaneurysm formation is the most common late sequel of internal
jugular venous catheterization (IJVC). However, arterio-venous fistula (AVF) formation following IJVC is rare. We
are reporting a case of AVF formation between subclavian artery (SCA) and internal jugular vein (IJV) following
IJVC which later on leads to the development of cardiac failure.
I
Introduction
n patients with end-stage renal disease (ESRD), cannulation
of the central venous system with large-bore double
lumen catheter is used for hemodialysis until a functioning
permanent vascular access is available. Internal jugular venous
catheterization (IJVC) is the most preferred route as subclavian
approach is frequently associated with stenosis.1 However,
serious adverse events such as arterial injury, pneumothorax
and nerve injury can occur with these procedures.2-4 Arterial
puncture, especially of the carotid artery is the most common
complication of IJVC.4 Rarely subclavian artery injuries can also
occur.2,3 The most frequent sequelae of accidental puncture of
an artery is pseudoaneurysm formation.5 However, subclavian
artery (SCA) to internal jugular venous (IJV) fistula after IJVC
is extremely rare.
We are reporting a rare case of SCA to IJV-fistula formation
after IJVC which lead to the development of congestive cardiac
failure (CCF).
Case Report
A 45-years-old non-diabetic lady having chronic kidney
disease (CKD) for the last three years progressed to ESRD and
became dialysis dependent. The baseline physical examination
and investigations revealed anemia, hypertension, stage I left
ventricular diastolic dysfunction, mild mitral regurgitation
(MR) and good systolic function with left ventricular ejection
fraction (LVEF) of 63.82% without any regional wall motion
abnormalities. She received renal replacement therapy (RRT)
initially in the form of acute peritoneal dialysis and later on
maintenance hemodialysis with femoral vein catheterization
as the vascular access since November 2009. A radio–cephalic
arterio-venous fistula (AVF) was constructed and IJVC was
planned to be used till the fistula becomes mature.
On 21st January 2010 right IJVC was attempted using the
blind landmark-guided technique with 18 G introducer needle
which resulted in an accidental arterial puncture. The needle was
removed and firm pressure was applied for about 15 minutes
till a good hemostasis was achieved. A pressure dressing was
Professor, 2Senior Resident, 3Assistant Professor, Department of
Nephrology, 4Professor, Department of Radio Diagnosis, Institute of
Medical Sciences, Banaras Hindu University, Vanarasi, Uttar Pradesh
Received: 28.03.2011; Accepted: 01.04.2011
1
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applied and patient was sent home. A double-lumen 11.5 Fr
Quinton intrajugular catheter was inserted next day successfully
by the same technique without any problem. At the end of the
process vitals were stable and chest x-ray confirmed the position
of the catheter tip at the junction of superior vena cava and right
atrium. Patient was put on thrice weekly hemodialysis schedule
since then. However because of exit site infection catheter was
removed on 26th February 2010. Unfortunately the radio–cephalic
fistula did not become functional and a brachio-cephalic fistula
was constructed subsequently. Repeated femoral vein was used
as access for hemodialysis for the next one and half months as
patient did not give consent for other mode of access.
After, 45 days of removal of IJVC, patient presented in the
hospital emergency with breathlessness and swelling of body. On
physical examination she had features of CCF and a continuous
murmur was audible in the right supra-clavicular fossa. An
emergency echocardiography showed global hypokinesia
with LVEF of 33%, stage III diastolic dysfunction, severe mitral
regurgitation (MR), moderate pulmonary regurgitation, and
moderate tricuspid regurgitation with mild aortic regurgitation
without any regional wall movement abnormality. Color
Doppler study of neck vessels showed a fistulous communication
between right SCA and IJV with a high blood velocity of 481cm
/s (Figures 1 and 2). CT angiography of neck vessels confirmed
the finding of AVF showing a vascular channel of maximum
lumen diameter of 4.6mm and approximate length of 3 cm
arising from the right SCA, coursing anteriorly and superiorly
and communicating with right IJV about 19.3mm cranial to its
termination to brachiocephalic vein (Figure 3). She improved
with medical management of CCF and MHD was continued
with repeated femoral vein puncture as vascular access as the
brachio-cephalic fistula also did not become functional. After 2
months she agreed to switch over to CAPD because no vascular
access was available for continuing maintenance hemodialysis.
Discussion
Anatomical variations of the internal jugular vein which
occurs in about 5% of patients, makes it difficult to locate the
vein using the blind technique. In the vast majority of cases, IJVC
is successful and uncomplicated, but sometimes inadvertent
arterial injury can result in the development of hematoma,
pseudoaneurysm or AVF.2,3 The most common arterial injury
associated with IJVC is carotid artery puncture and its incidence
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Fig. 1 : Color Doppler study of right neck vessels showing high
velocity blood flow (481cm/s) at the level of fistula strongly
suggestive of arterio-venous fistula
Fig. 3 : CT angiography showing communication (arrow) between
costo-cervical trunk of subclavian artery and internal jugular vein at
the level of lower neck on right side
correlation between the increase in atrial natriuretic peptide level
and the elevation in CO as well as a direct positive correlation
between the increase in brain natriuretic peptide level and the
subsequent development of diastolic dysfunction.13 Previously
it was thought that high-output failure was relevant only with
longstanding fistulae but recently it was found that AVFs can
reach their maximum flow as early as 6 weeks after creation and,
thus, perhaps high-output cardiac failure can occur sooner than
initially thought.14 This may explain the deteriorating cardiac
status (from stage I diastolic dysfunction to stage III, severe MR
and global hypokinesia, LVEF-33.69%) two and half months after
the cannulation in our patient. To the best of our knowledge this
is probably the first case of heart failure which developed due
to fistula formation between SCA and IJV following IJVC in a
patient of ESRD.
Fig. 2 : Color Doppler study of right neck vessels revealed mosaic
appearance at the site of arterio-venous communication between the
subclavian artery and internal jugular vein.
is as high as 11%, which frequently leads to pseudoaneurysms
(0.05–2%) formation.3,5
The actual incidence and frequency of SCA injuries
following IJVC are unknown because many cases are probably
underreported. Three cases of AV fistula between SCA to IJV
had been reported so far.6-8 In our case, we assume that the
fistula formation was because of arterial puncture during the
needle insertion. The arterial lesion could have been temporarily
closed, but reopened days later by increasing hypertension, use
of anticoagulant, abnormal calcium and phosphate metabolism
which usually occurs in ESRD patients.
In summary, one should be aware of development of arteriovenous fistula between SCA and IJV as a complication of IJVC
which can lead to CCF later on.
AVF bypasses a good proportion of left ventricular (LV)
output from systemic circulation to right atrium and thus
increases preload of the right ventricle and LV in turn.
Subsequently the left ventricle dilates and LVEF declines
causing heart failure.9 Savage at el reported that a decrease in
the subendocardial perfusion occurred immediately after AVF
creation in ESRD patients leading to the development of cardiac
failure in some patients.10 Location of the AVF also predicts its
outcome, as fistulae located centrally near the heart as in our
patient, are more likely to produce heart failure.11 Most dialysis
patients can tolerate the increased hemodynamic disturbances
imposed by a fistula. However, individuals with pre- existing
cardiac disease as in our patient are more susceptible to develop
high-output cardiac failure.12 CCF with a low EF can be present
despite a concomitant high-output state if the high-output states
superimpose on the underlying cardiomyopathy. Because LVEF
is a proportion of cardiac output (CO) and preload, increase in
preload in excess of increase in CO will yield a low LVEF and
CCF will develop as in our case.
Iwashima et al observed that most of the increase in CO and
left ventricular end-diastolic diameter occurred within the 7 to
10 days of AVF creation for hemodialysis.13 There was a positive
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