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Cardiac Internal Catheterization throUgh the Jugular Vein in Pediatric Patients* An Alternative to the Usual Femoral Vein Access 1t2010 Guccione, M.D.; M. Giulia Gagliardi, M.D.; Maurizio Bevilacqua, M.D.; Francesco Parisi, M.D.; Bruno The percutaneous for cardiac femoral vein may be impossible it inferior vena cava or inconvenient endomyocardial biopsies. 160 cardiac is used routinely vein or due to previous cardiac as for right ventricular the period In between 1982 right ventricular or catheterizations biopsies were performed in 102 in age between 2 months and (mean, 3.8 years) and in weight from 3.2 to 57.3 14.4 kg). Indications for the internal jugular vein were as follows: (1) thrombosis of the inferior vena to previous cardiac catheterization in 42 patients endomyocardial Patients ranged cent); cardiac (2) right transplant ventricular or bidirectional Mustard’s arteries and children. 17 years kg (mean, tral cava due after indicate (3) control can with classic femoral venous approach Homer that Cc = cardiac IvC he percutaneous femoral vein approach’ is used routinely for cardiac catheterization (CC) in pediatric age patients, but in some children, it may be for congenital inferior vena absence ofthe hepatic segment cava (IVC) or impossible for occlusion ofthe iliac vein or the inferior vena cava due to previous CC.2 In other instances, this approach may be inconvenient, as for myocardial biopsy. Alternative approaches approach3 include and a percutaneous through the that often require a cutdown. zation of the internal jugular widely accepted method pressure or rapid fluid and children, approach for CC of this report but the is to describe CCs subclavian vein or axillary vein Percutaneous catheterivein (IJV) has become for monitoring administration in children number of pediatric approach. brachial experience is limited.7 our experience using a central venous both in infants with The the IJV purpose in a large the percutaneous IJV *From the DepartmentofPediatricCardiologyand Cardiac Surgery, Bambino Ges#{252} Hospital, Rome, Italy. Manuscript received October 9-, revision accepted December 2. Reprint requests: Dr. Guccione, Ospedale Bambino Gesii, Deportmeat ofCardiology, Rome, Italy 09165 1512 A patient developed another patient a cen- developed syndrome. Accidental carotid without consequences. cardiac = infarior in infants catheterization be performed safely through a high success rate and T difficult of the attackand complications. (6 in six patients occurred. ischemic in five patients occurred anastomosis in 16 patients (4) superior vena cava obstruction Ibilowing procedure in 14 patients (14 percent); (5) failed percutaneous transient a persistent (41 per- following complications major approach biopsy (19 percent); of the pulmonary cavopulmonary catheterization (16 percent); endomyocardial in 19 patients and (6) absence of the hepatic segment of the inferior vena cava in Ibur patients (4 percent). The right or left internal jugular vein could be entered in all but three procedures (98 percent). Seventeen patients had more than one procedure through the same internal jugular vein and the vein was found patent in all. A complete right heart cardiac catheterization was per&wmed using this mute. Right ventricular endomyocardial biopsy and interventional procedure were performed through this mute. Two percent); age but in some as in the case ofiliac thrombosis catheterization, 1990, approach in the pediatric catheterization children, and M.D. Marino, (Chest catheterization; vena cava and the internal a low IJV puncture Our data children jugular vein, incidence of 1992; 101:1512-14) internal jugular major vein; METHODS Stud Ibpulation In the eight-year period between 1982 and 1990, 3,303 CCs were performed in 2,130 pediatric patients; the IJV approach was used in 160 CCs (4.8 percent) and 102 patients (4.7 percent). Patients ranged in age between 2 months and 17 years (mean, 3.8 years) and in weight from 3.2 to 57.3 kg (mean, 14.4 kgJ. Indications for the liv approach included the following: (1) thrombosis of the inferior vena cava due to previous CC in 42 patients (41 percent); (2) right ventricular endomyocardyal biopsy after cardiac transplant in 19 patients (19 percent); (3) control catheterization of the pulmonary arteries following classic or bidirectional cavopulmonary anastomosis in 16 patients (16 percent); (4) superior vena cava obstruction following Mustard’s procedure in 14 patients (14 percent); (5) failed femoral venous approach in six patients (6 percent); and (6) absence of the hepatic segment of the inferior vena cava in four patients (4 percent). Technique Patients were not allowed to eat or drink for 8 to 12 h before the procedure. All were premedicated with mefedine (1.5 mg/kg,J and promethazine hydrochloride (1.5 mg/kgj and received mask inhalationanesthesiawith halothane(Fluothane). Continuous electrocar. diographic monitoring was maintained. In each patient, we tried to use the right IJV rather than the left because this is a more direct route to the heart. The patient’s head was turned contralateral to the side ofthe catheterization, the shoulders were slightly elevated, and the arms were placed parallel to the body. The neck was sterilized using the standard technique. The site of puncture was Cardiac Catheterization Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21647/ on 05/04/2017 k Pediatric Patients(Gucclone eta!) located medial 3 cm above the superior border ofthe clavicle, between the and lateral bellies of the sternocleidomastoid muscle. A 19gauge, 3.75-cm needle was then advanced at an angle 30#{176} to 40#{176} caudad from the vertical and 20#{176} to 30#{176} toward the patient’s right. Continuous suction was applied to the needle with#{225}8-l syringe. If a vein could not be cannulated with this technique, the needle was angled first more laterally and then medially to reduce the chance ofcarotid artery puncture. Ifthe vein was not entered after several attempts, the left IJV approach was undertaken. After the IJV was successfully probed, a guide wire was advanced to the right atrium under fluoroscopic visualization, the needle was removed, and an appropriate wire size sheath (5F to 7F) was advanced along the IJV Cardiac catheterization and angiocardiography were performed with balloon-lipped catheters (Berman) and an endomyocardial biopsy specimen was obtained with GU guide through the bioptome. RESULTS The 1W could (98 percent). dures in all but three right IJV was utilized (91 percent) and the left IJV (9 percent). same be entered The IJV procedures in 145 proce- was utilized cava obstruction route. Howmore diffi- from the femoral vein atrium catheterization septal defect was more and of pulmonary cava-pulmonary Right formed ing the Two performed from the IJV relief of superior vena in five patients after artery stenosis artery anastomosis Mustard technique major described complications surgery after superior vena in two patients. ventricular endomyocardial biopsy in 19 children, without complications, by Mason8 occurred was perfollow- in adults. (1.3 showed region, ax; area probably patient with a congenital shunt developed but the computed of decreased density due to paradoxic symptomatology manifested after heart a transient tomogram in the embolism. several frontal The attempts to the IJ\ immediately following the introduction of the sheath, and before the insertion of the catheter. The patient was not heparinized. A 19month-old patient, weighing 12 kg, developed a percannulate manent right Homer’s syndrome. In this patient, the right 1W could not be cannulated after several attempts with the formation ofa large hematoma on the right side of the puncture occurred neck. in five procedures) formation with Accidental carotid patients (3. 1 percent of a small artery of the hematoma consequences. percent DIsCuSSIoN The Seldinger catheterization femoral vein awkward. Interventional procedures entry were balloon dilatation One and right-to-left ischemic attack in 15 procedures through the same IJV The IJV was found patent in all patients who had more than one procedure through the same IJV A complete right heart cathe- cult from the IJV than that approach; in particular, left even in a patient with an atrial procedures). defect central without Six patients had two CCs through the five had three CCs, and six had four or more terization could be performed using this ever, catheter manipulation was somewhat the of technique’ for percutaneous has been widely applied in infants and children and vessel using it the remains the first approach for CC in patients with congenital heart defects. However, in some cases, the femoral venous approach is impossible. The occlusion rate of the inferior vena cava in patients through the femoral vein during of life can be as high through the femoral pulmonary arteries cavopulmonary ization of the difficult as severe plete SVC usually Furthermore, patients of the (Fig 1) and cava (SVC) heart from In other conditions, as endornyocardial biopsy,8 preferred. access to the bidirectional the cathetercan be very after Mustard surgery with In these conditions, a corn- obstruction. catheterization precluded. ventricular as 16 percent.2 vein, there is no in case of previous anastomosis9 superior vena in who underwent CC the first six months Alternative venous the groin is in case of right IJV approach is approach such Ftcuii 1. Angiography in a patient following anastomosis. vein close in the internal jugular vein bidirectional cavopulmonary The catheter is in the internal jugular to its confluence with the subclavian vein. CHEST Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21647/ on 05/04/2017 I 101 I 6 I JUNE, 1992 1513 as antecubital or axillary may be used, a cutdown. Multiple cutdowns the sources ofaccess to the heart who tions. may require other The IJV route critical information series in a group catheterizations for central care on its use ofl4 patients venous of infants require limit of patients and Latson series ofthis opera- our experience complications ofIJV puncture,6 nerves,’2 ture.6 cations and injury to the In the present was 5 percent. Although subclavian femoral can a high our data et al. without confirms vagus, series, Our REFERENCES 1 Seldinger neous the performed major complicathese data. Many are reported, such thoracic duct and others carotid punc- phrenic, incidence of compli- suggest as a first indicate rate that safely and low a percutaneous alternative to the CC in infants through incidence and the IJ\ of major caval JF, Lang of the needle technique. Acta in percouta- Badiol 1953; 39:368- Cardiol after cardiac 1980; 1:257-61 LockJE. Manual vessel entry and KE, in congenital J, Fyler DC. Iliac vein-inferior catheterization in infancy. Pediatr P. Newburger thrombosis 3 KeaneJF, technique catheter Diagnostic heart disease. 11-31 1976; 46:362-64 5 Belani KG, Buckley ofcardiac catheterization: In: Lock manipulation. eds. 1987; 4 Prince of the ology and interventional Boston: Martinus JE, Keane JF, catheterization Nijhoff Publishing, SR. Sullivan RL, Hackel A. Percutaneous catheterization internal jugular vein in infants and children. Anesthesi- cervical internal central and JJ, Gordon venous external line jugular JR. Castaneda W. Percutaneous placement: a comparison of the vein routes. Anesth Anaig 1980; 59:40-44 6 BaOTLK, WongAY, Salem MR. A new approach to percutaneous catheterization ofthe internaijugular vein. Anesthesiology 1977; 46:362-64 LA, Kugler PJ. Percutaneous vein in infants JD, cardiac and Cheatham JP, Gumbiner catheterization children. Cathet CH, Hofschire via the internal Cardiovasc Diagn jugular 1984; 10:593-95 and left ventricular endomyo1978; 41:887-92 9 Mazzera E, Corno A, Picardo S, et al. Bidirectional cavopulmonary shunt: clinical application as staged or definitive pallialion. Ann Thorac Surg 1989; 47:415-20 10 Chaara A, Zniber L, El Haitem N, Benomar M. Percutaneous balloon valvuloplasty via the right internal jugular vein for 8 Mason vardial valvular ACKNOWLEDGMENTS: We acknowledge and appreciate the assistance of Luigi Ballerini, M.D., Giuseppe De Simone, M.D., Roberto Di Donato, M.D., Salvatore Giannico, M.D. , and Luciano Pasquini, M.D. We thank Giuseppe Bolla for technical assistance and the nurses and technicians of the catheterization laboratory at the Bambino Gesu Hospital for their excellent work. replacement a new 76 7 Latson complications. CC through the IJV may become a good alternative approach in children with congenital heart defects who are candidates for repetitive CCs. 1514 SI. Catheter arteriography: Fellows experience confirms accidental the be performed success to the angioplasty from other authors vein approach3 vein, children CC is limited hydrothorax,” and hematoma used but catheterization pneumothorax is widely children, of patients procedure. Percutaneous transluminal through the IJV is reported tions’#{176}and line and in pediatric from based on a larger feasibility and safety with but they progressively 2 Keane in the as will JW. Techniques biopsy. Am pulmonic for right J Cardiol stenosis with severe right ventricular failure. Am Heart J 1988; 117:684-85 11 English DCW, Frew RM, Pigott JJ. Percutaneous catheterization ofthe internal jugular vein. Anaesthesia 1969; 24:521-31 12 BriscoeCA, BushmanjA, McDonaldWl. Extensive neurological damage after cannulation ofthe internaijugular vein. BMJ 1974; 1:314 Cardiac Catheterizahon Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21647/ on 05/04/2017 in Pediatric Patients (Gucc!one eta!)