An Unusual Cause of HD Catheter Dysfunction

Dear Editor,Internal jugular vein (IJV) catheterization is the most preferable intervention for acute hemodialysis (HD) treatment, particularly in the last decade [1]. Although it is a simple application in experienced hands it can be associated with many complications, one of which is carotid artery-IJV fistula, a rare complication that has been described in the literature [2,3]. Herein, we report a case with carotid artery-IJV fistula who presented with catheter dysfunction and interruption of HD treatment.A 78-year-old woman with end-stage renal disease was referred to our clinic with a vascular access problem. She had been receiving HD treatment via a right brachiosephalic arteriovenous fistula (AVF) for 4 years which became silent 2 days before admission. A standard non-tunneled double-lumen 14-Fr/15-cm catheter was inserted for HD treatment to the right IJV using the Seldinger technique. At the visit on the 10th day of intervention, there was no problem with HD therapy, but the pressure of the venous line had risen above 150 mm Hg when the blood pump rate was 200 ml/min at the end of the second week. The pressure continued to increase gradually and catheter dysfunction occurred on the 20th day of intervention. Poor blood flow of the venous line with normal arterial line function was detected. The catheter was removed. After the IJV puncture for new HD catheterization using real-time ultrasonography (USG), the syringe filled easily, reflecting the high central vein pressure. The image of the finding needle and also the guidewire was detected in the IJV with USG and a catheter was inserted over the guidewire in the usual manner. When checking the catheter patency, pulsatile blood was aspirated through the venous line of the catheter in the operating room. USG of the vascular structures confirmed the catheter was in the IJV, not in the carotid artery in the operating room. AVF was supposed after these findings. The catheter was removed and a constant murmur was detected on auscultation of the neck, supporting the diagnosis. Radiological evaluation with Doppler USG revealed the diagnosis of carotid-IJV fistula (fig. 1).IJV catheterization can be associated with many well-documented complications [4,5,6,7,8], but AVF between the carotid artery and IJV is rare [2,3,4]. In a minority of cases it develops from the carotid arterial puncture (CAP), and CAP is a frequent complication because of the anatomic relation of the two vessels with an incidence of 2–9.9% [9]. AVF evolution is frequently insidious, needs several months and sometimes years. It can lead to a variety of well-known clinical presentations such as cerebrovascular steal syndrome, systemic embolization, infection and congestive heart failure [1,2,10]. However, catheter dysfunction that is caused by AVF has not been described in the literature before.In our case, carotid artery-IJV fistula was the cause of poor blood flow on the venous line during HD. A gradual increase of venous pressure with a normal arterial line flow may be a specific sign for AVF in patients who have been receiving HD via a catheter. Nephrologists should consider AVF as another reason of catheter dysfunction, especially the existence of the findings described above. This approach will provide early detection of AVF and protect the patient from chronic complications.