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(Circulation. 2006;114:e518.)
© 2006 American Heart Association, Inc.

Correspondence

Response to Letter Regarding Article, "External Carotid Artery–Internal Jugular Vein Fistula: A Complication of Internal Jugular Cannulation"

Vijay K. Sharma, MD, RVT; Ashok W. Pereira, RVT; Benjamin K.C. Ong, FRCP; Rahul Rathakrishnan, MRCP; Bernard P.L. Chan, MRCP; Hock Luen Teoh, MRCP

Division of Neurology, Department of Medicine, National University Hospital, Singapore

We appreciate the comments and the issues raised by Thalhammer et al in their letter regarding our case report.¹ Our patient presented with an episode of transient right-sided weakness. Carotid duplex was performed as part of the stroke work-up and to explore the cause of the bruit on the right side of her neck. The fistula between the external carotid artery and internal jugular vein on the right side was an incidental finding.

Progressive cardiac failure in our patient was primarily attributable to her underlying cardiac dysfunction, and the contribution of the fistula to cardiac failure was difficult to assess. We offered our patient surgical ligation of the fistula as it was considered a small and relatively simple procedure because of the involvement of the external carotid and not the internal carotid artery.

Our patient had a poor ejection fraction, and the velocities in the carotid arteries were on the low side (right common carotid artery: 32/12 cm/s; right external carotid artery: 38/14 cm/s; right internal carotid artery: 36/18 cm/s). The venous pressure was presumably raised because of congestive cardiac failure. The fistula was small and originated from a very proximal external carotid artery (just distal to the carotid bifurcation). The combination of lower flow velocities on the arterial side and the relatively higher venous pressure caused turbulence in the right internal jugular vein during systole. The turbulence and Doppler flow patterns in the right internal jugular vein were not attributable to accentuated cardiac modulation by congestive cardiac failure because we did not see the any of these disturbances in the left internal jugular vein. We used a lower pulse repetition frequency (15 cm/s) to evaluate the low-velocity venous flow signals. Finally, the reported fistulous communication in our patient was visualized in both longitudinal and transverse views on the cervical duplex examination.

	Acknowledgments

 
Disclosures

None.

	References

Top References

 

1. Sharma VK, Pereira AW, Ong BKC, Rathakrishnan R, Chan BPL, Teoh HL. External carotid artery–internal jugular vein fistula: a complication of internal jugular cannulation. Circulation. 2006; 113: e722–e723.[Free Full Text]
   

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