Iatrogenic left common carotid artery to right internal jugular vein arteriovenous fistula

A 47-year-old female patient presented with a palpable right-sided neck thrill, dyspnea, and dysphagia 14 days after discharge from a 102-day hospitalization for COVID-19 pneumonia. Computed tomography angiography (CTA) of the neck demonstrated an unusual left common carotid artery to right internal jugular vein (IJV) arteriovenous fistula (AVF) with aneurysmal dilatation of the fistulous tract of up to 2.8 cm, causing mass effect on the proximal trachea and esophagus, which led to her experience of dysphagia and palpable thrill. Coronal maximum intensity projection CTA images of the neck (A) were used for three-dimensional cinematic rendering to create a photorealistic representation of the fistula (B/Cover). The image was subsequently enhanced with postprocessing filters to generate an artistic digital recreation of the left common carotid artery to right internal jugular vein fistula. We presume that this large AVF involving vessels on both sides of the neck is iatrogenic. A possible source of vascular injury is right IJV and right femoral venovenous extracorporeal membrane oxygenation she underwent for 79 days. The patient was extremely deconditioned after her hospitalization with poor ventilatory capacity requiring 2 L of oxygen at rest and up to 5 L with exertion. To avoid open surgery, the patient and a multidisciplinary team with cardiology, vascular surgery, and interventional radiology elected to embolize the AVF using an endovascular plug (Amplatzer Duct Occluder II; Abbott Cardiovascular). The Amplatzer Duct Occluder II was originally designed to treat patent ductus arteriosus endovascularly. The procedure was performed under general anesthesia with electroencephalogram monitoring to detect any neurovascular events. Vascular access was obtained through ultrasound guidance into the right IJV and right common femoral artery. The operation was successful, verified by postoperative CTA demonstrating thrombosed AVF and successful plug placement (C). There were no intraprocedural neurologic or postprocedural neurologic/access site complications. Informed consent was obtained from this patient for this publication.