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• W2077394520 abstract "We recently treated a cardiac transplant recipient who developed an arteriovenous fistula between the right subclavian artery and external jugular vein following placement of a central venous catheter. The fistula was percutaneously repaired via the right femoral route using interventional radiology. Previous reports have described an arteriovenous fistula between the right subclavian artery and external jugular vein as a complication of percutaneous central venous catheterization, but not in a cardiac transplant patient. In the present case, the cause of the patient's continued cardiac failure was not understood until the accidental discovery of higher oxygen saturation in the superior vena cava during routine posttransplant myocardial biopsy. Iatrogenic arteriovenous fistula formation is a rare but potentially serious complication of central venous catheterization. High-output congestive heart failure (HF) is a well-documented sequela of this condition. Although there have been several reports in the literature of coronary artery fistulae draining directly to the right ventricle or a fistulous connection between the posterior descending branch of the right coronary artery and the middle cardiac vein in the cardiac transplant patient population, to our knowledge this article represents the first report of arteriovenous fistula formation following central venous catheterization in a cardiac transplant recipient.1 In August 2004, a 57-year-old man with a history of ischemic cardiomyopathy after aortocoronary bypass in 2000 presented with severe HF. A Jarvik 2000 (Jarvik Heart, Inc, New York, NY) left ventricular assist device was implanted as a bridge to cardiac transplantation, which took place the following April. After the transplant, the patient experienced right ventricular dysfunction. Serial postoperative 2-dimensional (2D) echocardiography revealed depressed left ventricular function. Several right heart catheterizations performed before the diagnosis of arteriovenous fistula showed a cardiac index ranging from 4.2 to 4.4 L/min. During a routine surveillance endomyocardial biopsy, the right internal jugular vein was accessed using the Seldinger technique, and bright red blood was withdrawn from the catheter. Oxygen saturation of the blood was 92%. Pressures recorded from the catheter were compatible with venous pressures. With the appropriate venous access confirmed, a flow-directed pulmonary catheter was then placed. Pulmonary hemodynamic readings were within normal limits. Cardiac output as established by the Fick method was 8.6 L/min, with a cardiac index of 4.2 L/min. The high cardiac output and oxygen concentration were compatible with an arteriovenous fistula. Saturations at multiple levels were obtained. In the pulmonary artery and right ventricle, saturation was 76%. Saturation was 78% in the right atrium and 89% in the superior vena cava, mid superior vena cava, and lower internal jugular vein. The upper internal jugular vein had a saturation of 92%. Thus, a left-to-right shunt proximal to the venous access site was present, likely secondary to previous venous catheterizations. The possibility of cardiac allograft rejection was ruled out by endomyocardial biopsy. Angiography of the aorta and its major branches revealed a substantial high-flow fistula between the proximal right subclavian artery and the right external jugular vein (Figure 1). The diagnosis of the subclavian external jugular arteriovenous fistula was delayed because previous surveillance endomyocardial biopsies had been performed via femoral access. After the correction of the arteriovenous fistula, the cardiac index ranged from 2.5 to 3.1 L/min and pulmonary artery saturation, right atrial saturation, and superior vena cava saturation were 77%, 77%, and 69%, respectively. Selective injection of the right internal jugular vein shows stenosis at the point of the fistula, with dye dilution at the confluence of the right jugular and innominate veins. The patient underwent percutaneous stenting of the fistula under general anesthesia. A catheter was advanced into the right subclavian artery and through the fistula into the external jugular vein. A wall-covered stent graft (12 mm in diameter, 4 cm long) was deployed at the site of communication and dilated to 10 mm in diameter. Subsequent right innominate arteriography revealed complete cessation of arteriovenous shunting (Figure 2). After placement of a covered stent at the confluence of the right jugular and innominate veins, an arteriogram of the innominate vein shows closure of the arteriovenous fistula. High-output failure due to an arteriovenous fistula is uncommon after cardiac transplantation and infrequently reported; sepsis is a more common etiology. However, as the patient described here demonstrates, arteriovenous fistula is an important etiology to consider when evaluating new HF symptoms in cardiac transplant recipients. Careful treatment of fistulae is required in these immunosuppressed patients. We treated the arteriovenous fistula with covered stent-graft placement because of the increased risk of mortality and morbidity associated with surgical repair. Congestive HF from an arteriovenous fistula is usually of the high-output type and, as in this case, can be easily reversed by correcting the defect. It is also possible that failure to diagnose and correct the defect early may lead to irreversible depression of left ventricular function that does not respond to surgical correction of the defect. Thus, a thorough search for all possible causes of high-output HF is imperative. Arteriovenous fistulae that cause HF are most commonly congenital, including hemangioendotheliomas of the liver and hereditary telangiectasia (Osler- Weber-Rendu disease). However, these fistulae may also be iatrogenic following catheterization or posttraumatic secondary to a penetrating injury of an artery or vein in close proximity.2 Central venous cannulation is a common procedure performed in the critical care setting and after cardiac transplantation. Complications associated with the procedure are not uncommon and may include arterial puncture, hematoma, pneumothorax, hemothorax, chylothorax, catheter malposition, arrhythmia, air embolism, arteriovenous fistula, and brachial plexus injury. Incidence of these complications ranges from 0.58% to 10%.3 Several randomized controlled clinical trials have compared 2 methods of central venous catheter placement: the anatomic landmark technique and real-time ultrasonography (either Doppler or external 2D). These studies have consistently shown that ultrasonic guidance significantly reduces the rate of complications and the number of attempts needed to place the catheter. Using ultrasound also increases the speed of placement and the success rate.4 Guidelines for the use of ultrasound for central venous catheterization have been published in both the United Kingdom and in North America.5 In the United Kingdom, the National Institute for Clinical Excellence recommends that ultrasonic guidance be used for central venous cannulation placement in adults and children in all elective central venous catheterizations and in most emergency cases.6 Although many of the reported complications of central venous cannulation are relatively minor or easily treated, they can have a huge effect on patient mortality and length of stay. Therefore, it is important to ensure that these procedures cause minimal pain and discomfort to patients." @default.
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• W2077394520 date "2007-07-01" @default.
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• W2077394520 title "High Cardiac Output Due to Fistula After Cardiac Transplantation" @default.
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• W2077394520 doi "https://doi.org/10.1111/j.1527-5299.2007.06571.x" @default.
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