Innovation under pressure: Managing a complex carotid-jugular fistula in a war-zone limited-resources area.

Abstract

Background: Arteriovenous fistula (AVF) constitutes a pathological direct connection between an artery and a vein without an intervening capillary bed with a spectrum of high to low-grade malformation. Here, we present an unusual case of congenital neck AFV managed in a resource-limited setting in a war-zone area.

Case description: A 43-year-old man presented with neck swelling and tinnitus since childhood with no history of trauma or surgical procedure. He was found to have reduced ejection fraction heart failure and atrial fibrillation and started on medications. Examination and bedside Gray scale and color Doppler ultrasound revealed a pulsatile high-flow vascular lesion around the left mandibular angle with thrill and dilated neck veins. A left external carotid artery catheter angiogram showed a large AVF hole with fast arteriovenous shunting distal to the origin of the facial artery draining into a venous sac and then to multiple superficial draining veins emptying into the anterior and external jugular veins. Multiple closure attempts at the fistula point using detachable coils and vascular plugs were unsuccessful. As a result, we treated the fistula surgically by disconnecting the draining veins and the presumed fistula and then resection of the venous sac guided by an intraoperative ultrasound. The patient tolerated the procedure, the tinnitus disappeared, and the heart failure improved at the 8-week follow-up echocardiogram. He developed local neurogenic pain that improved with 2 weeks of carbamazepine. Immediate postoperative neck computed tomography angiography confirmed fistula obliteration.

Conclusion: This case demonstrates the ability to consider patient and setting-tailored treatment options in managing complex carotid-jugular fistula and the utility of adjunctive intraoperative ultrasound in these procedures.