External Carotid Artery–Internal Jugular Vein Fistula
A Complication of Internal Jugular Cannulation
A 75-year-old female patient was admitted to our hospital after an episode of transient right-sided weakness. Her medical history was significant for ischemic heart disease, with coronary artery bypass grafting having been performed 4 years previously. She had experienced progressive dyspnea and decreased effort tolerance in the preceding 2 years, with 2 admissions due to congestive heart failure in the past year despite medical treatment.
The physical examination was remarkable for a raised jugular venous pressure on the right side, bilateral ankle edema, and basal crackles in the lungs. A right carotid bruit was heard on auscultation during systole, although no thrill was palpable. There was no significant arterial occlusive disease detected by cervical duplex ultrasonography and transcranial Doppler methods. Transthoracic echocardiography revealed dilated cardiomyopathy, with an ejection fraction of 24%. Her transient ischemic attack was therefore believed to have been cardioembolic in origin.
Duplex ultrasonography of the neck incidentally revealed a fistula on the right side between the external carotid artery and an enlarged internal jugular vein. Color Doppler investigation demonstrated blood flow from the external carotid artery into the internal jugular vein, causing turbulence in the latter during systole (Figure 1) but not during diastole (Figure 2). Doppler examination of the internal jugular vein revealed an abnormal flow pattern with high pulsatility (Figure 3).
We later confirmed that central venous cannulation of the right internal jugular vein had been performed during the coronary bypass operation 4 years previously. The patient recalled experiencing intermittent vague pain and swelling over the right side of the neck 1 year after the operation. The patient declined further investigation with contrast angiography and operative repair of the fistula. She was discharged after her dyspnea had improved with diuretic therapy.
Carotid-jugular fistula is a known complication of central venous cannulation of the internal jugular vein. The common carotid and the internal carotid arteries are more commonly involved compared with the external carotid artery because of their smaller caliber, as well as the more medial location of the latter at the carotid bifurcation in most subjects. Carotid-jugular fistula should therefore be considered in patients presenting with carotid bruit, worsening heart failure, and a history of internal jugular cannulation, as in this patient. Color flow duplex ultrasonography is a reliable screening examination for this relatively rare condition.