Images in cardiovascular medicine
Multimodality imaging and transcatheter coil embolization of an iatrogenic subclavian artery–internal jugular vein fistula Qiangjun Cai, Cory Sickler, Stuart Christenson and Imran Dotani A 69-year-old man was found to have a loud continuous bruit in the neck. Duplex carotid ultrasound showed highvelocity turbulent flow in the dilated and pulsatile right internal jugular vein. Computed tomography angiogram demonstrated markedly enlarged right internal jugular vein with a posteriorly located arteriovenous communication. Invasive angiography revealed an arteriovenous fistula originating from the right subclavian artery draining into the dilated and tortuous right internal jugular vein. An endovascular coil was successfully deployed in the fistula tract. Subclavian artery–internal jugular vein fistula is rare. Our case is most likely iatrogenic towing to previous central venous cannulation during coronary bypass grafting. The anatomic challenge of this fistula, being located in the
A 69-year-old white man presented for routine follow-up. His medical history was significant for ischemic heart disease with coronary artery bypass grafting performed 3 years ago. The physical examination was remarkable for a loud continuous bruit at the base of the right neck. Fig. 1
thoracic outlet, makes endovascular repair particularly favourable. J Cardiovasc Med 2015, 16 (suppl 1):S25–S26
Keywords: angiography, duplex ultrasonography, fistula, transcatheter therapy Department of Cardiology, McFarland Clinic, Ames, Iowa, USA Correspondence to Qiangjun Cai, MD, Department of Cardiology, McFarland Clinic, 1215 Duff Avenue, Ames, IA 50010, USA 50010 Tel: +1 515 239 4472; fax: +1 515 239 4539; e-mail: [email protected] Received 3 May 2013 Revised 8 July 2013 Accepted 1 August 2013
The duplex carotid ultrasound showed dilated and pulsatile proximal right internal jugular vein (IJV). The colour Doppler demonstrated a mosaic pattern in the IJV indicating high-velocity turbulent flow (Fig. 1a). An arterial-like flow jet communicating with the proximal IJV posteriorly was revealed (Fig. 1b). On the computed tomography angiogram, the right IJV was markedly enlarged (Fig. 2, arrowheads). A fistula draining into the right IJV posteriorly was seen (arrow).
(a)
IJV
Fig. 2
(b)
IJV
Duplex carotid ultrasound. (a) Turbulent colour flow in the right internal jugular vein (arrow). (b) Arterial-like flow jet posterior to the jugular vein (arrow).
1558-2027 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
Computed tomography angiogram of the neck. Arrowheads: right internal jugular vein; Arrow: fistula.
DOI:10.2459/JCM.0b013e328365aa0d
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
S26 Journal of Cardiovascular Medicine 2015, Vol 16 (suppl 1)
Fig. 3
Invasive angiogram. (a) Nonselective contrast injection in the right subclavian artery. (b) Selective contrast injection to the fistula. (c) Postcoiling angiogram. Arrowheads: right internal jugular vein; Arrow: fistula.
The feeding artery appeared to be the right subclavian artery. However, the exact arterial origin of the fistula was not clearly visualized due to prominent vessel tortuosity. The patient underwent invasive angiography. Contrast injection demonstrated an arteriovenous fistula originating from the right subclavian artery draining into the dilated and tortuous right IJV (Fig. 3a). A selective contrast injection better delineated this 5-mm diameter arteriovenous fistula (Fig. 3b). An endovascular coil was successfully deployed in the fistula tract without complication (Fig. 3c). Postcoiling angiogram revealed nonopacification of the fistula. Subclavian artery–IJV fistula is rare. It is usually iatrogenic or a complication of trauma.1–3 Without treatment, these lesions may cause complications such as distal embolization, arterial steal and heart failure.4 Our case is most likely iatrogenic due to previous central venous cannulation during coronary bypass grafting. Therapeutic options include surgical repair and
transcatheter intervention such as coil embolization, glue embolization and stenting.5,6 In our case, the anatomic challenge of the fistula (located in the thoracic outlet) makes endovascular repair particularly favourable.
References 1 2
3
4
5
6
Singh K, Lafleur N, Sinoff J, Goyal N. Traumatic arteriovenous fistula involving the subclavian artery and jugular vein. J Vasc Surg 2013; 57:1127. dos Santos ML, Demartini Z Jr, Matos LA, Borges MA, Spotti AR, Tognola WA. Radiculopathy due to iatrogenic fistula between subclavian artery and internal jugular vein. Clin Neurol Neurosurg 2008; 110:80–82. Merino-Angulo J, Cortazar JL, Saez-Garmendia F, Montejo M. Subclavian artery to internal jugular vein fistula following percutaneous internaljugular vein catheterization. Cathet Cardiovasc Diagn 1984; 10:593–595. Rossi R, Larcher M, Meneghello A, Tovena D, Cressoni MC, Poppi A. Cardiac insufficiency caused by iatrogenic arteriovenous fistula. G Ital Cardiol 1982; 12:676–680. Bakar B, Cekirge S, Tekkok IH. External carotid-internal jugular fistula as a late complication after carotid endarterectomy: a rare case. Cardiovasc Intervent Radiol 2011; 34:S53–S56. van Rooij WJ, Sluzewski M, Beute GN. Intracranial dural fistulas with exclusive perimedullary drainage: the need for complete cerebral angiography for diagnosis and treatment planning. AJNR Am J Neuroradiol 2007; 28:348–351.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Multimodality imaging and transcatheter coil embolization of an iatrogenic subclavian artery–internal jugular vein fistula Qiangjun Cai, Cory Sickler, Stuart Christenson and Imran Dotani A 69-year-old man was found to have a loud continuous bruit in the neck. Duplex carotid ultrasound showed highvelocity turbulent flow in the dilated and pulsatile right internal jugular vein. Computed tomography angiogram demonstrated markedly enlarged right internal jugular vein with a posteriorly located arteriovenous communication. Invasive angiography revealed an arteriovenous fistula originating from the right subclavian artery draining into the dilated and tortuous right internal jugular vein. An endovascular coil was successfully deployed in the fistula tract. Subclavian artery–internal jugular vein fistula is rare. Our case is most likely iatrogenic towing to previous central venous cannulation during coronary bypass grafting. The anatomic challenge of this fistula, being located in the
A 69-year-old white man presented for routine follow-up. His medical history was significant for ischemic heart disease with coronary artery bypass grafting performed 3 years ago. The physical examination was remarkable for a loud continuous bruit at the base of the right neck. Fig. 1
thoracic outlet, makes endovascular repair particularly favourable. J Cardiovasc Med 2015, 16 (suppl 1):S25–S26
Keywords: angiography, duplex ultrasonography, fistula, transcatheter therapy Department of Cardiology, McFarland Clinic, Ames, Iowa, USA Correspondence to Qiangjun Cai, MD, Department of Cardiology, McFarland Clinic, 1215 Duff Avenue, Ames, IA 50010, USA 50010 Tel: +1 515 239 4472; fax: +1 515 239 4539; e-mail: [email protected] Received 3 May 2013 Revised 8 July 2013 Accepted 1 August 2013
The duplex carotid ultrasound showed dilated and pulsatile proximal right internal jugular vein (IJV). The colour Doppler demonstrated a mosaic pattern in the IJV indicating high-velocity turbulent flow (Fig. 1a). An arterial-like flow jet communicating with the proximal IJV posteriorly was revealed (Fig. 1b). On the computed tomography angiogram, the right IJV was markedly enlarged (Fig. 2, arrowheads). A fistula draining into the right IJV posteriorly was seen (arrow).
(a)
IJV
Fig. 2
(b)
IJV
Duplex carotid ultrasound. (a) Turbulent colour flow in the right internal jugular vein (arrow). (b) Arterial-like flow jet posterior to the jugular vein (arrow).
1558-2027 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
Computed tomography angiogram of the neck. Arrowheads: right internal jugular vein; Arrow: fistula.
DOI:10.2459/JCM.0b013e328365aa0d
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
S26 Journal of Cardiovascular Medicine 2015, Vol 16 (suppl 1)
Fig. 3
Invasive angiogram. (a) Nonselective contrast injection in the right subclavian artery. (b) Selective contrast injection to the fistula. (c) Postcoiling angiogram. Arrowheads: right internal jugular vein; Arrow: fistula.
The feeding artery appeared to be the right subclavian artery. However, the exact arterial origin of the fistula was not clearly visualized due to prominent vessel tortuosity. The patient underwent invasive angiography. Contrast injection demonstrated an arteriovenous fistula originating from the right subclavian artery draining into the dilated and tortuous right IJV (Fig. 3a). A selective contrast injection better delineated this 5-mm diameter arteriovenous fistula (Fig. 3b). An endovascular coil was successfully deployed in the fistula tract without complication (Fig. 3c). Postcoiling angiogram revealed nonopacification of the fistula. Subclavian artery–IJV fistula is rare. It is usually iatrogenic or a complication of trauma.1–3 Without treatment, these lesions may cause complications such as distal embolization, arterial steal and heart failure.4 Our case is most likely iatrogenic due to previous central venous cannulation during coronary bypass grafting. Therapeutic options include surgical repair and
transcatheter intervention such as coil embolization, glue embolization and stenting.5,6 In our case, the anatomic challenge of the fistula (located in the thoracic outlet) makes endovascular repair particularly favourable.
References 1 2
3
4
5
6
Singh K, Lafleur N, Sinoff J, Goyal N. Traumatic arteriovenous fistula involving the subclavian artery and jugular vein. J Vasc Surg 2013; 57:1127. dos Santos ML, Demartini Z Jr, Matos LA, Borges MA, Spotti AR, Tognola WA. Radiculopathy due to iatrogenic fistula between subclavian artery and internal jugular vein. Clin Neurol Neurosurg 2008; 110:80–82. Merino-Angulo J, Cortazar JL, Saez-Garmendia F, Montejo M. Subclavian artery to internal jugular vein fistula following percutaneous internaljugular vein catheterization. Cathet Cardiovasc Diagn 1984; 10:593–595. Rossi R, Larcher M, Meneghello A, Tovena D, Cressoni MC, Poppi A. Cardiac insufficiency caused by iatrogenic arteriovenous fistula. G Ital Cardiol 1982; 12:676–680. Bakar B, Cekirge S, Tekkok IH. External carotid-internal jugular fistula as a late complication after carotid endarterectomy: a rare case. Cardiovasc Intervent Radiol 2011; 34:S53–S56. van Rooij WJ, Sluzewski M, Beute GN. Intracranial dural fistulas with exclusive perimedullary drainage: the need for complete cerebral angiography for diagnosis and treatment planning. AJNR Am J Neuroradiol 2007; 28:348–351.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
