Iatrogenic central arterio-venous fistula—case report

Abstract

Iatrogenic complications provide insight into the limitations of procedures. Complications associated with insertion of permanent dialysis catheter are numerous but central arterio-venous fistulas (cAVF) are a rarity. Our case reports a cAVF between the innominate vessels post insertion of a tunneled hemo-dialysis central venous catheter (HD-CVC) via left internal jugular vein (IJV) in a 43-year-old female. She presented with progressive swelling in the left side of the neck and fullness of the left supra-clavicular fossa and supra-sternal notch with dyspnea upon exertion. High output cardiac failure was noted. Due to the impending rupture status at the catheter insertion site, surgery was expedited. The sternum was split and the communication between the arterial and venous system successfully ligated. Patient was discharged after a week. Literature search culminated in describing this first innominate arterio-venous fistula (AVF) post HD-CVC insertion case and its management.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-025-01951-6.

Introduction

Dependency of chronic kidney disease patients on hemodialysis necessitates a tunneled cuffed central venous catheter or a peripheral arterio-venous fistula (pAVF) for long-term hemo-dialysis. Dialysis catheters are stiff and need manipulation which can injure/puncture adjoining structures. This case report of a fistulous connection between the innominate vessels post insertion of a cuffed tunneled hemodialysis catheter is first of a kind to the best of our knowledge as it has not been described in the literature.

Medical Subject Headings (MeSH) words—Central Arteriovenous fistula (AVF), Innominate / Brachio-cephalic artery, Innominate / Left brachio-cephalic vein AVF, Iatrogenic, Hemodialysis Central Venous Catheter (HD CVC), surgical ligation, congestive heart failure. Search engines—Pubmed, Science direct, Google scholar.

Case report

A 43-year-old female was referred with a progressive swelling in the left side of neck and fullness of left supra-clavicular fossa and supra-sternal notch and dyspnea with New York Heart Association (NYHA) class 3. She was a diagnosed case of chronic kidney disease (CKD) on regular hemo-dialysis, on hypertension medications and a history of failed pAVFs. History of insertion of a tunneled cuffed hemodialysis catheter (Arrow Teleflex^R) 9 months back via the left internal jugular vein coincided with the onset of symptoms. Due the gradual onset of symptoms, the swelling was ignored and hemodialysis was continued via the same catheter, delaying the referral. There were signs of impending rupture at the puncture site, i.e., left internal jugular vein (Fig. 1) along with dilated veins and a palpable thrill in the left supra-clavicular fossa and supra-sternal notch. High output cardiac failure status was noted. Clinically diagnosis was a left common carotid artery to left internal jugular vein (IJV) fistula.

Fig. 1.

Impending rupture in left internal jugular vein (IJV) puncture site (red arrow) with the HD catheter tunneled from IJV to left upper chest

Computed tomography (CT) aortogram done elsewhere confirmed the central AVF with the feeding vessel being the innominate artery to the innominate vein. Since the images and compact disc were not issued and as it was impending rupture requiring emergency intervention, decision was made to directly take her up for digital subtraction angiography (DSA) with emergency endovascular covered stenting.

DSA was conducted with the right trans-femoral access under ultrasound guidance. A 7 Fr femoral sheath was placed. Initially, 5 Fr multi-purpose catheter and 0.035″ Terumo wire were taken until the arch, later changed over to 5 Fr pigtail catheter and 5 Fr Simmons no. 1 catheter. The intention was to delineate the AVF site since CT images were not available and we wanted to confirm the diagnosis and do an endovascular covered stenting. We noted the AVF communication to be between the innominate artery at the origin (Fig. 2). No communication noted with left common carotid artery (Videos 1 and 2). Since the lesion was at the origin of the innominate artery, it was not amenable for endovascular covered stenting (Fig. 5). We decided to go ahead with emergency open repair keeping cardiopulmonary bypass (CPB) as back up. A femoral HD catheter was inserted prior to procedure.

Fig. 2.

Digital subtraction angiogram (red arrow showing blush at the base of innominate artery and dye moving into the tortuous innominate vein—blue arrow)

Fig. 5.

Schematic representation showing the AV fistula site

Careful median sternotomy was performed and incision was extended above the supra-sternal notch. The thymus was dissected to expose the dilated innominate vein. The pericardium was opened and a monitoring line was placed into the arch of aorta for invasive monitoring. Meticulous dissection with looping of the base of innominate artery and innominate vein was performed using subtraction method. Fistula was noted from the anterior aspect of the base of innominate artery to the posterior aspect of dilated pulsatile innominate vein. Central AVF was doubly looped (Fig. 3). Due to persistence of thrill post ligation of the central AVF with no. 1 silk, the innominate vein was looped proximal and distal to the fistula. With proximal and distal controls on both the vein and artery near the fistula, venotomy revealed the fistulous communication in the innominate artery. The HD catheter was cut and the proximal end was removed. Using 5-0 Polypropylene suture, the opening in the innominate artery was closed. Venotomy was closed using 5-0 Poly propylene (Fig. 4). The distal half of HD catheter along with the cuff was dissected out along with debridement of the left 95 IJV area. A schematic representation is provided in Fig 5 for the ease of understanding and the complexity involved with the procedure. Immediate post op had no signs of facial puffiness with complete resolution of symptoms. Patient was doing well upon follow up after 6 months.

Fig. 3.

Intra-operative picture showing looped central arterio-venous fistula (red) and a dilated innominate vein (blue)

Fig. 4.

Post arterio-venous fistula ligation—note the collapsed vein (blue arrow)

Discussion

A peripheral AVF is created as long-term treatment plan in chronic kidney disease patients for hemodialysis. Although AVFs are the gold standard, the need for a central venous catheter (CVC) arises to temporarily initiate hemodialysis or when fistulas are dysfunctional [1].

Iatrogenic AVFs are uncommon complications of procedures such as CVCs insertion for vascular access and percutaneous pacemaker lead extraction [2]. A majority of the complications can be attributed to vascular access, i.e., insertion of CVCs. In some instances, endo-venous thermal ablation for percutaneous lead extraction can cause AVF. Risk factors are large needle gauge, arterial hypertension, female sex, peri-procedural anticoagulation, and anti-platelet therapy [3]. Inculcating image guidance into routine practice reduces the complication rates but not to zero [4].

Due to the ease of access, internal jugular or subclavian veins are routinely used for long-term hemo-dialysis. The concept of tunnelling and cuffing theoretically acts as a barrier against infection when long-standing catheters are in situ [4].

Hemo-dialysis CVCs inserted via left IJV have to negotiate two bends, one at IJV-innominate vein junction followed by innominate vein-superior vena cava (SVC) junction with the catheter tip ending in inferior vena cava (IVC). As depicted in Fig. 2, the catheter is tunnelled to the final infra-clavicular site after IJV access. Stiff guide wires, dilators, excess forward pressure while guiding the large stiff catheters, and tips of catheters are etiology to most complications as they can injure the vein wall during the catheter placement.

Literature provides insight into a traumatic innominate AVF but the iatrogenic cause for an innominate AVF due to HD-CVC is not reported. Neck vessels, i.e., carotid artery, subclavian artery, vertebral artery, and transverse cervical artery, providing inflow to the fistulas can be explained when the needle tip traverses the veins, breaching the intima of arterial wall so as to cause a hematoma. When endothelization and fibrosis occur, the fistula matures. Time frame of maturation to onset of symptoms varies from 24 h to years [5].

Probable cause of the fistula at a site distant from the puncture site got us guessing. In the tortuous path from left IJV to the IVC, there is a possibility for the dilator to push the mid portion of the guide wire, creating a loop that could perforate the side wall of the central vein and artery [6]. Or the curvature of the HD-CVC in the innominate vein being close the base of the innominate artery, with the pulsations hitting the stiff catheter overtime, may have caused this fistula. This can be avoided by direct fluoroscopic visualization during passage of all dilators and sheaths over the wire [6].

The larger the diameter of the feeding vessels, the earlier the presentation to the hospital with symptoms of dilated pulsating veins, strange noise (murmur), and overtime heart failure [7]. Our patient presented after 9 months post procedure not for heart failure symptoms but for an abnormal protruding neck mass.

Without treatment prognosis is grim for central AVFs. Endovascular procedures are preferred modality offering less morbidity and early recovery. Frequently, coiling of the fistulous communication or covered stents are used for obliteration of the fistula [6]. In our case, the lesion was not amenable for endovascular therapy. The vicinity of AVF evoked sternotomy. Fibrosis of the wall of AVF allows for ligation as the initial surgical step. Persistence of murmur post ligation, as in our case, needed closure of the mouth of AVF. In the case of hemodynamic instability due to a bleeding central AVF, use of CPB is justified.

Ultrasound guidance will help to improve the efficiency and safety during CVC insertion. It will reduce the incidence of immediate complications and is recommended to use for CVC as first-line procedure in all puncture sites [8].

Conclusion: central message

Due to its nature and rarity, high index of suspicion, early detection, and prompt management is necessary for treating central AVF. Open repair is advised when endovascular modality is not feasible with CPB as backup.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contribution

– Dr. P Poornima and Dr. Chandra Sena M have contributed to the conceptuality and design, data collection, data analysis, interpretation of data, drafting the work, revising the work, and approving the final version.

– Dr. N Muralikrishna and Dr. Seetharama Bhat P S have contributed to the supervision and approving the final version.

– Dr. Vinay K S and Dr. Narendra Davu have contributed to the resources, and were scrubbed in for the case.

Funding

None.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article and/or its supplementary materials.

Declarations

Ethical approval and informed consent

The Institutional Review Board (IRB) or equivalent ethics committee of the Sri Jayadeva Institute of Cardiovascular Sciences and research approval not applicable as this is a case report/study. The subject provided informed written consent for the publication of the study data.

Conflict of interest

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.