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Image of Vascular Surgery

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Image of Vascular Surgery

Vasc Specialist Int (2022) 38:39

Published online December 30, 2022 https://doi.org/10.5758/vsi.220056

Copyright © The Korean Society for Vascular Surgery.

Endovascular Stent Graft Treatment of an Iatrogenic Symptomatic Extracranial Carotid-Jugular Arteriovenous Fistula

Tiago F. Ribeiro1 , Rita S. Ferreira1,2, Alberto Henrique1, and Carlos Amaral1

1Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Hospital Center of Centre Lisbon, Lisbon, Portugal
2NOVA Medical School, NOVA University Lisbon, Lisbon, Portugal

Correspondence to:Tiago F. Ribeiro, Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Hospital Center of Centre Lisbon, Rua de Santa Marta 50, 1169-024, Lisbon, Portugal
Tel: 35-1938020049, Fax: 35-1213594000, E-mail: ribeirotiago@campus.ul.pt, https://orcid.org/0000-0001-9207-5226

Received: December 15, 2022; Revised: December 21, 2022; Accepted: December 23, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

Trauma is a major health concern, and despite the development of solid trauma systems, the associated morbidity and mortality continue to rise [1]. Cervical trauma, in particular, is notoriously difficult to treat, mainly because of the complex anatomy in a narrow anatomic space. Due to its multiple mechanisms and locations, surgical techniques can also be highly variable. In Zone II cervical vascular injuries, open surgical repair is the norm due to its feasibility, ability to explore other cervical structures and relatively low risks when compared to other proximal or distal locations [2,3]. However, in highly-unstable patients, a lengthy procedure with risks of severe hemorrhage can offset a successful outcome, when compared to an endovascular approach.

We describe the case of a 56-year-old male admitted in critical care for septic shock due to severe pneumonia, along with acute renal failure. After an inadvertent right carotid puncture during an attempt to place a temporary dialysis catheter in the internal jugular vein, he developed sudden hemodynamic and ventilatory deterioration. He also presented a carotid bruit and neck engorgement. Ultrasound revealed a right common carotid–internal jugular arteriovenous fistula and allowed precise location marking, as well as the measurement of the diameter and proximal and distal seal lengths (proximal to the carotid bifurcation). Due to the unfavorable neck anatomy and high surgical risk, endovascular treatment was preferred. Right femoral access was used, and unfractionated heparin administered. After selective catheterization of the innominate artery and angiographic marking the fistula and carotid side branches (Fig. 1A), a covered stent-graft 9 mm×38 mm (Advanta V12; Atrium Medical Corp., Hudson, NH, USA) was successfully deployed, covering the fistula without branch compromise (Fig. 1B). The procedure required 25 minutes and 20 mL of iodinated contrast. The patient experienced immediate relief of the hemodynamic and ventilatory burden of the fistula; however, he was unable to withstand the severity of his underlying pathology and died after a prolonged hospitalization (41 days).

Figure 1. (A) Intraoperative digital subtraction angiography evidenced the fistula between the common carotid artery (CCA) and internal jugular vein (IJV). (B) After deploying a covered stent-graft, completion angiography showed patent carotid branches and completely excluded fistula. F, arteriovenous fistula.

Fig 1.

Figure 1.(A) Intraoperative digital subtraction angiography evidenced the fistula between the common carotid artery (CCA) and internal jugular vein (IJV). (B) After deploying a covered stent-graft, completion angiography showed patent carotid branches and completely excluded fistula. F, arteriovenous fistula.
Vascular Specialist International 2022; 38: https://doi.org/10.5758/vsi.220056

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