SUBMITTED 7 OCT 21 1 REVISION REQ. 17 NOV 21; REVISION RECD. 13 DEC 21 2 ACCEPTED 6 JAN 22 3 ONLINE-FIRST: JAN 2022 4 DOI: https://doi.org/10.18295/squmj.1.2022.010 5 6 A CVC Line Misadventure 7 “Doctor why do I have a humming sound in my ear?” 8 *Edwin Stephen,1 Maitha Al Asmi,1 Thekra Al Hadhrami,1 Mohsin Al 9 Riyami,2 Mohammed Al Badri,3 Hanan Al Mawaali,1 Khalifa Al Wahaibi1 10 11 1Vascular Surgery Unit, 3Division of Surgery, Sultan Qaboos University Hospital, Muscat, 12 Oman; 2General Surgery, Oman Medical Specialty Board, Muscat, Oman 13 *Corresponding Author’s e-mail: edwinmay2013@gmail.com 14 15 Abstract 16 We report a 32-year-old female patient who was referred to a tertiary care hospital in Muscat, 17 Oman, in 2021 with an iatrogenic arteriovenous fistula (AVF) that presented as a neck swelling 18 which developed few weeks after an attempt of central venous catheterization through the right 19 internal jugular vein (IJV). The fistula was corrected surgically at our institute with a successful 20 outcome. AVF is an abnormal communication between an artery and vein which can occur as a 21 congenital anomaly, after trauma or iatrogenic following central venous catheter (CVC) or 22 endovenous thermal ablation. 23 Keywords: Arteriovenous fistula, Iatrogenic, central venous catheter, critically ill, ICU 24 25 Introduction 26 An arteriovenous fistula (AVF) is an abnormal communication between an artery and vein. It can 27 occur as a congenital anomaly1 or iatrogenic during any arterial or venous instrumentation, trauma, 28 or endovenous thermal ablation2. One of the earliest cases of iatrogenic AVF was published by 29 James and Myers in 1973.3 The incidence of iatrogenic AVFs has previously been described to be 30 mailto:edwinmay2013@gmail.com less than 0.6% of central line insertions.4 However, the introduction of ultrasound guidance causes 31 reduction in the incidence.5 Our case report describes an iatrogenic AVF that presented as a neck 32 swelling that developed several weeks after an attempt of central venous catheterization through 33 the internal jugular vein (IJV). The fistula was corrected surgically at our institute with a successful 34 outcome. 35 36 Case report 37 We report a 32-year-old female patient who presented to a tertiary care hospital in Muscat, Oman, 38 in 2021. She was admitted earlier to the intensive care unit (ICU) with an impression of sepsis; 39 hypotension with multiorgan failure and acute kidney injury (AKI). The patient was 40 hemodynamically unstable at presentation to the center where she was managed, so a Central 41 Venous Catheter (CVC) insertion was attempted through the right IJV for hemodialysis under 42 ultrasound guidance. As the dilator was not traversing freely, the procedure was abandoned, 43 pressure applied, and a Femoral Quinton line inserted. Several days after discharge, the patient 44 developed a swelling on the right side of the neck associated with a humming sound in her right 45 ear and a thrill, she didn’t have coagulation abnormalities, so she was referred to us to rule out 46 iatrogenic AVF and treat accordingly. 47 48 On examination, the patient had a pulsatile swelling that was 3 cm x 4 cm in size, with a thrill, and 49 a bruit on the right side of the neck between sternal head of sternocleidomastoid, clavicular head 50 of sternocleidomastoid and the clavicle. Neurological examination was normal, and pulses were 51 intact. Duplex Ultrasound (US) was performed, a fistula was seen between the right IJV and the 52 right common carotid artery (CCA), the IJV was pulsatile in the region of the fistula, and it showed 53 a focal dilation. A Computed Tomography Angiography (CTA) was performed (Figure 1A & 1B), 54 and it showed an arteriovenous fistulous communication between the right CCA and IJV. 55 56 The patient was taken for surgical closure of the iatrogenic AVF. An incision along the lateral 57 border of the neck anterior to the sternocleidomastoid muscle was performed. A 4 mm mature neck 58 between the right IJV and CCA was found, (Figure 2). The fistula was divided between vascular 59 clamps (Figure 3) and repaired directly on the venous and arterial side with 6-0 prolene sutures 60 (Figures 4). CCA was not clamped during surgery, she had normal left CCA and intracranial 61 circulation, therefore cerebrovascular monitoring was not considered. 62 63 Postoperatively, the patient was neurologically normal, the thrill and bruit on the neck disappeared. 64 At follow up, 4 weeks post-operatively, she remained well. 65 Patient consent was obtained for publication. 66 67 Discussion 68 Catheterization of the IJV is commonly done for temporary hemodialysis, compared to subclavian 69 and femoral access, as it is considered a safer option.6 In the experience of the senior authors, an 70 IJV access is the preferred route for a CVC insertion, as a Trendelenburg position is often used in 71 hemodynamically unstable patients. However, femoral access has been used when access to the 72 IJV is not possible - usually when another team airway control of cases of maxilla-facial surgery / 73 trauma. 74 75 IJV catheterization can lead to several complications including venous perforation7, puncture of 76 the CCA, pneumothorax8, cardiac tamponade9, and Horner’s syndrome10. Literature mentions that 77 valve incompetence in the IJV could impair cerebral venous drainage.11 Another rare complication 78 of IJV catheterization is traumatic CCA- IJV Fistula (CJF).2 Traumatic CJF has an incidence of 4-79 7% of all traumatic AVFs and it can be iatrogenic or due to penetrating injuries like gunshots or 80 stab injuries.2 Although it is considered a rare entity there are several cases reported and published 81 where an iatrogenic AVF was created by central venous catheterization of the IJV.2, 6, 12-13 If left 82 untreated, it can lead to further serious life-threatening complications such as embolization, 83 infection, and at later stages high-output cardiac failure.2 Therefore, early detection and 84 intervention is crucial to prevent such consequences. 85 86 Several techniques have been described to reduce the rate of complications during IJV cannulation 87 which include: cannulation under ultrasound guidance, locating the vein using a needle with a 88 smaller gauge, reducing head rotation to less than 40° as this reduces overlap between the vein and 89 artery, and using an alternative access if there’s difficulty during cannulation.5 & 10 90 91 There are various modalities that can be used to diagnose iatrogenic AVF, including duplex, 92 Magnetic Resonance Angiography (MRA) and CTA. Duplex imaging in AVF shows an 93 arterialized enlarged vein, high flow fistulous communication and a low resistance waveform of 94 the artery involved.11 It has an advantage of being fast. CTA and MRA provide a better anatomical 95 view of the vascular injury, like the size, type, and region, which will aid in choosing the best 96 treating modality.14 97 98 The options to consider while treating Iatrogenic AVFs are open surgery, endovascular stenting, 99 or embolization. A complex AVF fistula has multiple draining vessels and a complex anatomy, 100 therefore it is better treated with endovascular embolization or stent grafting.11 Embolization of 101 traumatic or iatrogenic AVF’s can be offered if the communication is from side branches and not 102 for end arteries.16 Furthermore, it can be done with Coils, cyanoacrylate glue or Onyx (Covidien, 103 Mansfield, MA).11 In our patient the CJF was not complex, and it was superficial, hence an open 104 surgical approach was preferred. 105 106 Conclusion 107 Iatrogenic AVF is a rare complication of central venous catheterization, but it can have serious 108 outcomes. To prevent such outcomes, CVC insertion and other procedures should be carefully 109 performed i.e., under ultrasound-guidance, by experienced personnel and/or skilled supervision. It 110 is important to detect and treat iatrogenic AVF early to prevent more severe complications such as 111 embolization, infection, atrial fibrillation and at later stages high-output cardiac failure. This case 112 report is to sensitize the medical fraternity about avoiding iatrogenic CVC misadventures and how 113 they can be managed. 114 115 Authors’ Contributions 116 MAA, TAH, MAB, MAR, HAM – Manuscript, Literature Review 117 ES - Concept, Manuscript, Literature review, Final Approval 118 KAW - Manuscript, Final Approval 119 120 References 121 1. Al Mahruqi G, Stephen E, Abdelhedy I, Al Mawaali H, Al Musalhi B, Al Balushi Z, Al 122 Sukeiti R, Al Wahaibi K. Congenital vascular malformations – a quick recap. Oman Med 123 J. 2020 Nov.  https://doi.org/10.5001/omj.2021.46. 124 2. Sinha VK, Yaduvanshi A, Kataria V, Nair M. Traumatic Common Carotid–Internal Jugular 125 Arteriovenous Fistula Manifesting as Life-Threatening Epistaxis. 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Int J Angiol. 2009 Spring;18(1):41-4. 168 http://doi.org/10.1055/s-0031-1278322. 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 https://evtoday.com/articles/2012-apr/arteriovenous-fistulas-etiology-and-treatment 184 185 Figure 1A: Computed Tomography Angiography (CTA), coronal view, showing a right Internal 186 Jugular Vein (IJV)-Common Carotid Artery (CCA) fistula 187 188 189 Figure 1B: CTA, axial view, showing a right IJV-CCA fistula 190 191 Figure 2: Identification of the IJV-CCA fistula intraoperatively 192 193 Figure 3: Division of the fistula 194 195 Figure 4: Post-repair of the fistula 196