INTRODUCTION: Many intensive care unit patients require long term intravenous (IV) access. Complications related to these devices occur frequently. Venous wall perforation and/or fistula formation is an uncommon complication. We present a patient with a venobronchial fistula as a delayed complication of a central catheter.
CASE PRESENTATION: 53 year old female presented to her primary care physician with dry, intermittent, paroxysmal cough of two month duration. A Hickman catheter had been placed through the left subclavian vein a year ago. Use of the catheter was followed recently by episodes of coughing. She denied having fevers but complained of a sensation of drowning after catheter use. Past history included several abdominal surgeries, adhesions, multiple episodes of partial small bowel obstruction and dehydration, requiring hospital admissions. The catheter had been placed for administration of IV anti-emetics and IV fluids. She was sent to the emergency room for evaluation of a possible pneumonia. Examination showed a pulse oximetry of 96% on room air with no other abnormalities and laboratory data was unremarkable. Chest X ray showed infiltrates in the right middle lobe. Computerized tomography showed contrast infiltration into the same area. A diagnosis of a fistula between the azygous vein and lung parenchyma was made. The catheter was removed and the fistula embolized with gelfoam. This was associated with an episode of severe coughing and small amount of hemoptysis. Subsequent course was uneventful.
DISCUSSIONS: Fistula formation is a rare but significant complication of long-term venous access catheters. Complications of long term venous access are early and delayed. Early complications include arterial or bronchial perforation, pneumothorax, venous laceration, or obstruction. Delayed complications include infections, venous thrombosis, “pinch-off” syndrome, and venobronchial fistula. Friction of the catheter tip across the vessel wall, suction on the vessel walls when withdrawing blood, and vessel wall irritation with chemotherapy are possible causes for fistulization (1). Predisposing factors for azygous fistula might be low blood flow and anatomy of the azygous vein and superior vena cava (1). Proximity of the azygous vein and the right main stem bronchus also favors development of fistulae. Classic symptoms are cough and a drowning sensation. Contrast injection through can delineate the extent of the fistula although Ananian et al do not recommend this, as it can increase infections and worsen symptoms (2), and instead recommend aspirating the catheter for air in order to secure the diagnosis. Most complications in their review were associated with left sided lines (2). In our case, we hypothesize that the catheter tip might have been placed or could have migrated into the azygous vein, from where it eroded into the lung tissue. Our patient never received radiation therapy, chemotherapy through the line and did not obtain regular blood draws. This suggests that even without usual risk factors, long term central venous access is not without problems. Lines should be removed as soon as they are not needed. Access catheters should be routinely checked for potential complications.
CONCLUSION: Prevention of venobronchial fistulae related to long-term central venous catheterization is a difficult task. Correct placement should be confirmed by radiology. In patients receiving chemotherapy a high index of suspicion should be maintained, especially for left sided lines. Periodic assessment of device function and placement should be done and lead to catheter removal whenever persistent malfunction is noticed. Finally, device should be removed as soon as it is no longer needed.
DISCLOSURE: Muhammad Ali Javed, No Financial Disclosure Information; No Product/Research Disclosure Information