Duplex Ultrasound Diagnosis of an Arteriovenous Fistula between the Left Subclavian Artery and the Left Internal Jugular Vein after Attempted Central Venous Catheter Placement

Abstract

Introduction —An arteriovenous fistula between the subclavian artery and the internal jugular vein represents a rare iatrogenic injury that has almost exclusively been described on the right side. We describe the case of an arteriovenous fistula between the left subclavian artery and the left internal jugular vein after attempted central venous cannulation. The initial duplex ultrasound exam established the definitive diagnosis. Patient Description —A 72-year-old man had a central venous catheter inadvertently placed in the arterial system during attempted cannulation of the left internal jugular vein. After the catheter was removed, a duplex ultrasound exam of the left common carotid artery was requested to evaluate for injury. Methods —A carotid duplex ultrasound exam was performed using an Acuson Antares Ultrasound System with a VFX 9–4 MHz probe. The left common, internal, and external carotid arteries were evaluated with grayscale imaging; color Doppler, and spectral flow analysis. The left vertebral artery and subclavian arteries were also evaluated sonographically. Results —The duplex ultrasound did not detect an injury to the left common carotid artery; however, a color flow bruit was noted in the surrounding tissue. Further investigation clearly demonstrated a high-flow vascular communication between the left subclavian artery and the left internal jugular vein consistent with an arteriovenous fistula. The arteriovenous fistula was treated with an endovascular intervention that involved placing a stent graft in the left subclavian artery to cover the arterial origin of the arteriovenous fistula. The completion arteriogram and follow-up duplex ultrasound showed that the stent graft completely excluded the arteriovenous fistula. Conclusion —This case describes an extremely rare iatrogenic arteriovenous fistula between the left subclavian artery and the left internal jugular vein. The images obtained with duplex sonography were detailed enough to definitively diagnose the injury and plan for treatment.