Asian Cardiovasc Thorac Ann 2000;8:366-368
© 2000 Asia Publishing EXchange Pte Ltd
Carotid Artery-to-Jugular Vein Fistula: Repair Using Cardiopulmonary Bypass
Sachin Talwar, MS,
Anil Bhan, MCh,
Rajesh Sharma, MCh,
Shiv Kumar Choudhary, MCh,
Panangipalli Venugopal, MCh
Department of Cardiothoracic and Vascular Surgery
Cardiothoracic Sciences Centre
All India Institute of Medical Sciences
New Delhi, India
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For reprint information contact: Anil Bhan, MCh Tel: 91 11 686 4851 Ext. 4844, 3368 Fax: 91 11 686 2663 Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
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Abstract
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An internal carotid artery-to-internal jugular vein fistula was observed at angiography in a 35-year-old man who had sustained a gunshot injury 6 months earlier. Successful repair required institution of cardiopulmonary bypass.
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Introduction
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Arteriovenous fistulas between the carotid arterial system and the internal jugular vein (IJV) are rare; of 30 cases reported so far, 21 were of congenital origin and 8 were acquired (Table 1
).1–8 The fistula was between the internal carotid artery (ICA) and the IJV in only 2 of the 30 cases reported.9,10 Treatment of these fistulas included manual compression, endovascular techniques, and simple surgical ligation. However, none required institution of cardio-pulmonary bypass (CPB) for distal control. A case of traumatic ICA-to-IJV fistula is reported, where institution of hypothermic CPB was mandatory for repair.
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Case Report
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A 35-year-old man presented with a pulsatile swelling in the upper left side of the neck. He had sustained a gunshot injury in that site 6 months earlier, a swelling had appeared subsequently and enlarged gradually. Physical examination revealed a 7 x 6 cm pulsatile swelling in the left anterior triangle of the neck, anterior to the sternocleidomastoid muscle. There was a healed scar over the swelling, it was compressible and had a palpable thrill. On auscultation, a loud bruit was heard over the swelling. The left IJV was distended. There was no neurological deficit and no sign of cardiac decompensation. Intraarterial digital subtraction angiography via the transfemoral route showed a normal aortic arch with normal origins of the innominate, left common carotid, and left subclavian arteries. The left common carotid artery showed mild dilatation. A fistulous tract was seen between the proximal left ICA and the IJV, with focal saccular dilatation of the left IJV at the site of the fistula.
An attempt was made to repair the fistula after looping the common and external carotid arteries and the IJV proximally. After tightening these vessels, the IJV was opened. A fistulous communication was seen between the ICA and the IJV, measuring l cm in diameter (Figure 1). There was a saccular dilatation of the IJV and its walls were thickened; this extended distally to the base of the skull. The IJV was opened on the assumption that blood flow could be controlled by inflation of a Foley catheter, the only outlet being through the fistula that could be controlled by a Fogarty catheter passed through it and inflated inside the ICA during the repair. However, this failed because bleeding from the distal IJV and the fistula was difficult to control. It was decided to institute CPB, cool the patient, and repair the fistula under reduced flow. The fistula was compressed manually, a median ster-notomy was performed, and CPB was established using ascending aortic cannulation for arterial inflow and right atrial cannulation for venous return. The patient was cooled to 25°C and under hypothermic perfusion, the proximal IJV was tightened to avoid air embolism to the heart. His head was tilted downward to decrease venous return from the distal IJV. Two Teflon-reinforced 4/0 polypropylene sutures (CR Bard, Inc., Haverhill, MA, USA) were used to repair the fistula. The aneurysmal section of the IJV was excised and the vessel was repaired. Deairing was carried out before completing closure of the IJV and the patient was rewarmed and weaned from CPB uneventfully. The total CPB time was 35 minutes and the carotid clamp time was 5 minutes. The patient recovered with no neurological deficit or other complications. At follow-up 3 months later, there was no swelling or bruit in the neck.
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Figure 1. Operative photograph showing the opened thickened internal jugular vein (V) and the cardiotomy sucker (arrow) in the fistula.
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Discussion
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One of the 2 previously reported cases of ICA-to-IJV fistula was of congenital origin; a 5-year-old boy presented with blindness, papilledema, and bilateral optic atrophy, the fistula was ligated but his vision did not recover.10 The other case was that of a 45-year-old woman with sudden onset of left-sided tinnitus and bilateral retro-orbital pain following a bout of heavy coughing; a high-flow fistula was found at the base of the skull between the petrous portion of the left ICA and the IJV via the pterygoid venous plexus.9 This fistula was attributed to a generalized connective tissue disorder. Daily manual compression of the left carotid artery was successful in treating this lesion.
In our patient, the fistula between the ICA and IJV was traumatic in origin and extended up to the base of the skull. This made it technically difficult to repair without CPB and hypothermic low flow. This approach ensured cerebral protection with the advantage of a bloodless operating field. Although we instituted CPB via a median sternotomy, femorofemoral partial bypass would have been a suitable alternative. To the best of our knowledge, this is the first case of its kind to be reported.
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References
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Abstract
Introduction
