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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
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carotid
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low
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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
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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!)