A 58-year-old woman presented to the ICU with drug-induced liver failure and progressive renal dysfunction. Vascular access for haemodialysis was prepared using a 12 French haemodialysis catheter via a left internal jugular venous approach guided by ultrasound monitoring. Sonography presented a 12-o’clock configuration of the jugular-carotid anatomy. Vascular puncture appeared successful, and nonpulsatile dark-coloured blood was aspirated. After guide-wire insertion, puncture channel dilation and catheter insertion, pulsation of blood was visible immediately. Blood gas analysis revealed an arterial oxygen saturation. After consultation with a vascular surgeon, the haemodialysis catheter was removed and manual compression at the puncture site was applied for 30 min. Repeated sonography revealed a jugular-carotid fistula (JCF) confirmed by a pulsatile transjugular jet from the common carotid artery through the puncture channel into the sternocleidomastoid muscle. Manual compression was continued for another 60 min and vascular surgery was avoided. Within 24 h sonography and MRI confirmed a persisting JCF (contrast medium CT was avoided due to low thyrotropin levels and renal dysfunction). Consequently, an endovascular repair of the JCF was performed placing a covered Fluency-stent-graft into the common carotid artery under general anaesthesia. Neurological examination after the end of anaesthesia revealed no deficit. Written informed consent to publish this case was obtained from the patient's husband after progression and a fatal outcome to the liver failure.
Puncture-related injuries of the neck region after intended internal jugular venous access are serious incidents that may cause life-threatening conditions. They include Horner's syndrome, venous perforation, pneumothorax, cardiac tamponade, and thyroid injury or carotid artery lesion. If the arterial puncture is not recognised immediately and dilatation of the vessel and placement of the catheter follow, severe complications may result, such as arterial perforation, haemothorax, pseudoaneurysm and JCF.1 Although inadvertent carotid artery puncture accounts for the most frequent complication of jugular venous access, JCFs are rarely reported.2 Large-bore catheter devices, such as haemodialysis catheters, as reported in this case, are more likely to cause JCF than smaller catheters because vessel dilation and catheter placement may generate considerable injuries to vascular walls. JCFs commonly develop after removal of the catheter and persistence of the puncture channel. The transjugular jet of arterial blood can be limited to the jugular vein, but it can also spread into surrounding muscular and subcutaneous tissue, as in the case presented. The early repair of a JCF, either by an endovascular or surgical approach, is considered beneficial in the literature.2–4
The use of ultrasound for jugular venous access has recently been recommended to increase success rates and performance safety.5 There are numerous studies supporting the benefits of ultrasound use for vascular access.6,7 This case, however, illustrates that even under direct sonographic visualisation of the puncture process, misplacements of large-bore haemodialysis catheters are possible. We suggest that the JCF was caused by secondary vascular wall damage by the puncture needle while inserting the guide-wire. After successful puncture of the jugular venous wall, the operator requires both hands to fix the puncture needle and insert the guide-wire. This step is likely to be taken without ultrasound monitoring if a second person is not available to assist in keeping the ultrasound detector in place. Hence, the risk of secondary misplacement of the guide-wire increases despite an apparently correct position of the puncture needle. Depending on the location of neighbouring vascular structures and the angle of puncture direction, unintentional secondary perforation of jugular venous wall may be caused by slight movement of the puncture needle.8
The process of internal jugular vein catheterisation requires first, training, such as a simulation course (see, for instance, publications by Barsuk JH or Evans LV),9,10 and, second, expert knowledge to manage possible puncture-related complications.1,11 The effects of puncture-related complications may lead to further deterioration of the condition of patients requiring intensive care treatment. Consequently, the use of facilitating technologies, in particular ultrasound, should be standard in ICUs. However, some steps in the process of ultrasound-guided jugular vein catheterisation may be associated with a possible risk of secondary perforation of the vessel wall. Ultrasound guidance for vascular access is a valuable tool to increase patient safety but does not prevent all mechanical complications.
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