Transcirculation Endovascular Trapping of a Traumatic Carotid-Jugular Fistula after Blast Injury

Abstract

Carotid-jugular fistulas are very rare lesions. They are usually acquired secondary to penetrating neck injuries or
iatrogenic after insertion of jugular central lines. These lesions might be asymptomatic or present with palpable neck
mass, audible thrill, tinnitus, headaches and even cardiac failure. Their management has radically changed from
open surgical repair to endovascular treatment in the recent years, mostly using intravascular stents to disconnect the
arterial-venous fistula. However, if this is not feasible alternative strategies should be sought obliterate the fistula.
We present a 17 year old man that suffered a blast injury while being a bus passenger in a war conflict zone. He had
multiple injuries including shrapnel wounds to the head and neck. He was airlifted in a delayed fashion to an outside
hospital for further treatment. A computed tomography of the neck was ordered prior to debridement of his wounds
which showed a large vascular lesion at the level of left skull base (Zone III). At arrival to our facility, the patient
was complaining of severe headache and tinnitus. A cerebral angiogram was performed that showed a high flow left
internal carotid to jugular vein fistula, both anterograde and retrograde, with reverse filling of the intracranial venous
sinuses. There was a complete occlusion of the intracranial left carotid at the level of the skull base. Due to the
anticipated difficulty to cross from the cervical to the intracranial carotid and to avoid possible embolic complications
of a stent placement, trapping of the fistulous connection was carried out. For that, the internal carotid was closed
with an Amplatz vascular Plug 4 and two coils (Ruby and Hydroframe) followed by a trans-circulation placement
of a MVP to the left petrous carotid. His headache and tinnitus resolved after surgery and he was repatriated with no
symptoms soon after the procedure.