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An Adult Case of Idiopathic Internal Carotid–Internal Jugular Vein Arteriovenous Fistula
An Adult Case of Idiopathic Internal CarotideInternal Jugular Vein Arteriovenous Fistula Aniello E. Puca, and Francesco Pignatelli, Napoli, Italy
Carotidejugular fistula is an abnormal connection between the carotid artery and/or its branches and jugular vein. It can develop either because of trauma or spontaneous causes. Traumatic fistula may occur after head injuries and can range from minor falls to severe penetrating wounds. Traumatic fistula may also result from endovascular therapy; however, these fistulas may be congenital arteriovenous connections that open spontaneously in the setting of collagen vascular disease, atherosclerotic disease, hypertension, or childbirth. Spontaneous fistulas between internal carotid artery and internal jugular vein are very exceptional diseases; therefore, this case is presented for its rare incidence in literature.
CASE REPORT A 59-year-old woman with dizziness and headaches came to our observation in November 2013 to undergo duplex scanning of the supra-aortic trunk. The results of the examination found a dilated right internal jugular vein with arterial flow inside and high peak of systolic velocity with turbulence of color Doppler in the absence of stenosis of carotid artery. The patient had no history of neck trauma or surgical interventions or biopsy of the neck, she has had headaches and dizziness for a year and had undergone eye surgery several years ago for bilateral degeneration of the cornea. She experienced arterial hypertension and gait disturbance for decreased vision due to a degenerative disease of the retina. On hospital admission, the patient’s clinical findings included headaches and dizziness, there was no cardiac failure or other
Congresses: None. Funding: None. Conflicts of Interest: None. Complex Vascular Surgery Unit, Ospedale dei Pellegrini ASL NA1, Napoli, Italy. Correspondence to: Aniello E. Puca, Complex Vascular Surgery Unit, Ospedale dei Pellegrini, via Portamedina alla Pignasecca 41, Napoli 80100, Italy; E-mail: [email protected] Ann Vasc Surg 2015; 29: 842.e5e842.e7 http://dx.doi.org/10.1016/j.avsg.2014.12.030 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: October 24, 2014; manuscript accepted: December 4, 2014; published online: March 3, 2015.
cardiopathy, no peripheral edema, and the serum biochemical levels were all found to be within normal levels. On examination of the neck, there was no visible or palpable swelling, and the right side of the neck was warm with a continuous thrill (Fig. 1,2). Angio magnetic resonance (MR) imaging revealed venous congestion, a dilated right internal jugular vein, and the presence of a fistula between the internal carotid artery and the internal jugular vein. There was no sign of cerebral ischemia at MR. The patient underwent surgical repair of the arteriovenous communication with standard approach like carotid surgery for stenosis, with general anesthesia, but vessel clamping and arterial reconstruction was not needed. The fistula was closed using hemostatic single points with 6/0 polypropylene monofilament. The patient was discharged 3 days after surgical repair and returned for follow-up after 1 month. Duplex scanning performed after 1 month showed normal size of right internal jugular vein with low flow and the absence of turbulence of color Doppler. The patient reported complete resolution of headaches and dizziness.
DISCUSSION Spontaneous carotidejugular fistulae are uncommon. A high index of suspicion is necessary for the diagnosis. Unlike arteriovenous fistulae in the limbs, carotidejugular fistulae are particularly prone to complications such as intractable high-output 842.e5
842.e6 Case reports
Annals of Vascular Surgery
Fig. 1. Angio-MR of aortic arch and supra aortic trunks.
Fig.2. Angio-MR of right carotid and right jugular vein.
cardiac failure, atrial fibrillation, and embolization. The development of high cardiac output and heart failure depends on the proximity of the fistula to the heart and the degree of left-to-right shunting. The latter is determined by the diameter of the fistula and the number of fistulae present, when possible, the degree of shunting and the number of fistulae should be ascertained before surgery to assist in planning the procedure. Noninvasive color-flow echo Doppler scanning is highly sensitive for these fistulae when it is performed by an experienced physician. Other diagnostic methods, such as chest radiography and two-dimensional echocardiography, may be needed to detect cardiomegaly and also to rule out the possibility of an intracardiac foreign body. For long-standing cases, atrial fibrillation and bundle branch block may be revealed by electrocardiography. Surgery for carotidejugular
fistulae involves adequate exposure, vascular control, heparinization, and direct vascular procedures. The ideal treatment is to divide the fistula and maintain the vascular continuity of both vessels. These goals can be achieved by direct lateral suturing, as we did. When direct suturing is not possible, patch arterioplasty and venoplasty or interposition of graft may be necessary. In literature are described cases of endovascular treatment1e3 or combined endovascular and surgical approach to treat arteriovenous fistulas if they are associated with arteriovenous malformation (AVM) in the neck, in the cerebral vessel, or in the legs like the Parkes Weber’s Syndrome or with congenital heart malformation (persistent arterial ducteBotallo’s duct). This approach is possible in the aorta and the pulmonary artery because the vessels we are going to treat are larger than the carotid artery and is possible to insert
Vol. 29, No. 4, May 2015
a plug like an umbrella that ensures the closure of the communication with low complications if it is compared with a complex surgical open treatment. In the case of fistulas associated with AVM is possible to embolize with coils or glue the AVM nidus and close the arteriovenous shunt. Congenital or acquired internal carotideinternal jugular vein fistulas are to avoid treatment with endovascular approach for several causes because of anatomic and pathophysiological aspects. The use of plugs or coils and/or glue is to be avoided at the level of internal carotid artery because of the association with a high risk of pulmonary and cerebral embolization; moreover, the use of carotid stent does not ensure the effective closure of the communication. In conclusion, early treatment of carotidejugular fistula is necessary to avoid associated complications, and as we think, in consideration of the safety and
Case reports 842.e7
more efficacy, surgical approach is preferable compared with endovascular technique, reserving the latter in very complex cases or associated with a high surgical risk.
REFERENCES 1. Kawakami K, Takahashi A, Sugawara T, et al. Spontaneous arteriovenous fistula of external carotid artery treated by detachable balloon: a case report. Neurol Surg 1986;15: 549e53. 2. Gobin YP, de la Fuente AG, Herbreteau D, et al. Endovascular treatment of external carotid-jugular fistula in the parotid region. Neurosurgery 1993;33:812e6. 3. Horiuchi Masahiro, Kamo Tsutomu, Sugihara Hiroshi, et al. An adult case of congenital external carotidejugular arteriovenous fistula with reversible circulatory insufficiency in the cerebellum and lower brain stem. AJNR Am J Neuroradiol 2001;22:273e6.
Carotidejugular fistula is an abnormal connection between the carotid artery and/or its branches and jugular vein. It can develop either because of trauma or spontaneous causes. Traumatic fistula may occur after head injuries and can range from minor falls to severe penetrating wounds. Traumatic fistula may also result from endovascular therapy; however, these fistulas may be congenital arteriovenous connections that open spontaneously in the setting of collagen vascular disease, atherosclerotic disease, hypertension, or childbirth. Spontaneous fistulas between internal carotid artery and internal jugular vein are very exceptional diseases; therefore, this case is presented for its rare incidence in literature.
CASE REPORT A 59-year-old woman with dizziness and headaches came to our observation in November 2013 to undergo duplex scanning of the supra-aortic trunk. The results of the examination found a dilated right internal jugular vein with arterial flow inside and high peak of systolic velocity with turbulence of color Doppler in the absence of stenosis of carotid artery. The patient had no history of neck trauma or surgical interventions or biopsy of the neck, she has had headaches and dizziness for a year and had undergone eye surgery several years ago for bilateral degeneration of the cornea. She experienced arterial hypertension and gait disturbance for decreased vision due to a degenerative disease of the retina. On hospital admission, the patient’s clinical findings included headaches and dizziness, there was no cardiac failure or other
Congresses: None. Funding: None. Conflicts of Interest: None. Complex Vascular Surgery Unit, Ospedale dei Pellegrini ASL NA1, Napoli, Italy. Correspondence to: Aniello E. Puca, Complex Vascular Surgery Unit, Ospedale dei Pellegrini, via Portamedina alla Pignasecca 41, Napoli 80100, Italy; E-mail: [email protected] Ann Vasc Surg 2015; 29: 842.e5e842.e7 http://dx.doi.org/10.1016/j.avsg.2014.12.030 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: October 24, 2014; manuscript accepted: December 4, 2014; published online: March 3, 2015.
cardiopathy, no peripheral edema, and the serum biochemical levels were all found to be within normal levels. On examination of the neck, there was no visible or palpable swelling, and the right side of the neck was warm with a continuous thrill (Fig. 1,2). Angio magnetic resonance (MR) imaging revealed venous congestion, a dilated right internal jugular vein, and the presence of a fistula between the internal carotid artery and the internal jugular vein. There was no sign of cerebral ischemia at MR. The patient underwent surgical repair of the arteriovenous communication with standard approach like carotid surgery for stenosis, with general anesthesia, but vessel clamping and arterial reconstruction was not needed. The fistula was closed using hemostatic single points with 6/0 polypropylene monofilament. The patient was discharged 3 days after surgical repair and returned for follow-up after 1 month. Duplex scanning performed after 1 month showed normal size of right internal jugular vein with low flow and the absence of turbulence of color Doppler. The patient reported complete resolution of headaches and dizziness.
DISCUSSION Spontaneous carotidejugular fistulae are uncommon. A high index of suspicion is necessary for the diagnosis. Unlike arteriovenous fistulae in the limbs, carotidejugular fistulae are particularly prone to complications such as intractable high-output 842.e5
842.e6 Case reports
Annals of Vascular Surgery
Fig. 1. Angio-MR of aortic arch and supra aortic trunks.
Fig.2. Angio-MR of right carotid and right jugular vein.
cardiac failure, atrial fibrillation, and embolization. The development of high cardiac output and heart failure depends on the proximity of the fistula to the heart and the degree of left-to-right shunting. The latter is determined by the diameter of the fistula and the number of fistulae present, when possible, the degree of shunting and the number of fistulae should be ascertained before surgery to assist in planning the procedure. Noninvasive color-flow echo Doppler scanning is highly sensitive for these fistulae when it is performed by an experienced physician. Other diagnostic methods, such as chest radiography and two-dimensional echocardiography, may be needed to detect cardiomegaly and also to rule out the possibility of an intracardiac foreign body. For long-standing cases, atrial fibrillation and bundle branch block may be revealed by electrocardiography. Surgery for carotidejugular
fistulae involves adequate exposure, vascular control, heparinization, and direct vascular procedures. The ideal treatment is to divide the fistula and maintain the vascular continuity of both vessels. These goals can be achieved by direct lateral suturing, as we did. When direct suturing is not possible, patch arterioplasty and venoplasty or interposition of graft may be necessary. In literature are described cases of endovascular treatment1e3 or combined endovascular and surgical approach to treat arteriovenous fistulas if they are associated with arteriovenous malformation (AVM) in the neck, in the cerebral vessel, or in the legs like the Parkes Weber’s Syndrome or with congenital heart malformation (persistent arterial ducteBotallo’s duct). This approach is possible in the aorta and the pulmonary artery because the vessels we are going to treat are larger than the carotid artery and is possible to insert
Vol. 29, No. 4, May 2015
a plug like an umbrella that ensures the closure of the communication with low complications if it is compared with a complex surgical open treatment. In the case of fistulas associated with AVM is possible to embolize with coils or glue the AVM nidus and close the arteriovenous shunt. Congenital or acquired internal carotideinternal jugular vein fistulas are to avoid treatment with endovascular approach for several causes because of anatomic and pathophysiological aspects. The use of plugs or coils and/or glue is to be avoided at the level of internal carotid artery because of the association with a high risk of pulmonary and cerebral embolization; moreover, the use of carotid stent does not ensure the effective closure of the communication. In conclusion, early treatment of carotidejugular fistula is necessary to avoid associated complications, and as we think, in consideration of the safety and
Case reports 842.e7
more efficacy, surgical approach is preferable compared with endovascular technique, reserving the latter in very complex cases or associated with a high surgical risk.
REFERENCES 1. Kawakami K, Takahashi A, Sugawara T, et al. Spontaneous arteriovenous fistula of external carotid artery treated by detachable balloon: a case report. Neurol Surg 1986;15: 549e53. 2. Gobin YP, de la Fuente AG, Herbreteau D, et al. Endovascular treatment of external carotid-jugular fistula in the parotid region. Neurosurgery 1993;33:812e6. 3. Horiuchi Masahiro, Kamo Tsutomu, Sugihara Hiroshi, et al. An adult case of congenital external carotidejugular arteriovenous fistula with reversible circulatory insufficiency in the cerebellum and lower brain stem. AJNR Am J Neuroradiol 2001;22:273e6.