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Cannulation of the Internal Jugular Vein Robert Cambria, MD he use of indwelling venous catheters has become T commonplace in the management of various medical conditions. Facilitated by Seldinger's 1 description of catheter exchange over a guidewire for access to the intravascular space and by advances in catheter technology, therapeutic alternatives, and the management of critically ill patients, access to the central venous system is practiced by a growing number of medical specialists. Indications for these types of procedures include administration of antibiotic or chemotherapeutic agents, invasive hemodynamic monitoring, total parenteral nutrition, hemodialysis, plasmapheresis, and insertion of caval filtering devices or transjugular intrahepatic portosystemic shunts. Before making any attempt to access the central veins, the clinician needs to be familiar with the patient's medical history, physical findings, and imaging studies. A history of bleeding disorders or coagulopathy should be obtained, and coagulation studies and platelet count should be within normal limits. Because many of these patients have chronic illness, a careful history of previous central lines or upper extremity swelling must be obtained. If there is a preexisting history of central access or of possible subclavian vein thrombosis, then a duplex ultrasound scan of the jugular and subclavian veins should be obtained. Preprocedural duplex examination revealed significant abnormalities in 35% of patients scheduled for dialysis access catheters, and more than 50% of these abnormalities occurred in patients who had been on dialysis for less than one year. 2 Finally, if there is a history of chest pathology, a preprocedural chest x-ray may be helpful in interpreting the x-ray following line placement. From the Division of Vasuiar Surgery, Medical College of Wisconsin, Milwaukee, WI. Address reprint requests to Robert Cambria, MD, Medical College ofWisconsin, Division of Vascular Surgery, 9200 West Wisconsin Ave, Milwaukee, Wl 53226. Copyright9 2001 by W.B. SaundersCompany 1524-153X/01/0304-0002535.00/0 doi:10.1053/otgn.2001.27733 Operative Techniques in General Surgery,Vol 3, No 4 (December),2001: pp 217-225 2 17 218 RobertCambria SURGICAL TECHNIQUE Percutaneous Access to the Internal Jugular Vein Performance of any percutaneous procedure demands strict attention to the regional surface anatomy and technical detail. Occasionally, the use of adjunctive imaging, such as ultrasound, for guidance can be helpful. In selected patients, ultrasound guidance may increase the rate of successful cannulation of the desired vein and decrease the incidence of injury to adjacent structures .3 J Clavicle" Clavicular head of sternocleidomastoid (SCM) muscle iS. Sternal head of SCM Manubrium of sternum 1 The SCM muscle and the distinction of its sternal and clavicular heads are of primary importance in the surface anatomy for internal jugular access. 219 Cannulation of the Internal Jugular Vein External Supraclavic Sternocleidornas ial jugular v. B 1 With the head turned to the opposite side, the internal jugular vein runs in a straight line from the pinna of the ear to the sternoclavicular joint, beneath the sternocleidomastoid muscle. The vein is located lateral to the common carotid artery in the base of the neck (B). 220 Robert Cambria Protection of carotid a. with medial retraction of it and sternal head of SCM by fingertips Point of insertion into jugular v. between heads of SCM <: j'/ Needle directed toward ipsilateral nipple ]: / 2 Needle inserted at angle 35 ~ - 45 ~ from horizontal plane into jugular v. between heads of SCM Medial head SCM (sternal) 3 See legend on opposite page. Cannulation of the Internal Jugular Vein 2 and 3 The patient is placed supine with the bed in Trendelenburg position and the head turned 45 degrees to the contralateral side. There are two common approaches to the internal jugular vein: the anterior approach (sometimes referred to as the central approach) and the posterior approach. For both approaches, the neck is prepped and draped following standard aseptic technique, with the angle of the mandible and jugular notch to be included in the operative field. Once the insertion site is selected as described below, local anesthetic is administered into the skin and subcutaneous area, withdrawing frequently to prevent inadvertent administration into the vascular space. For the anterior approach, the insertion site is located at the apex of the triangle formed by the two heads of the sternocleidomastoid muscle and the clavicle. The carotid pulse is palpated, and gentle traction is applied medially to the carotid artery. After the local anesthetic is administered, a 22-gauge finder needle on a syringe is inserted at the apex of the triangle with the bevel facing upward. The needle is advanced toward the ipsilateral nipple at a 45-degree angle to the skin for up to 3 cm, while gently aspirating. If no venous blood returns, then the needle should be slowly withdrawn while still aspirating. If still unsuccessful, then the needle should be directed 1-3 cm more laterally and a second pass made following the same procedure. If no venous blood returns, then a final pass directing the needle 1 cm medial to the ipsilateral nipple may be attempted, with care taken to maintain medial traction on the carotid artery to avoid inadvertent arterial puncture. If after three passes there is no venous blood return, then consideration should be given to using the posterior approach or a different access site. If at any point arterial blood or air is withdrawn into the syringe, then the procedure should be terminated and the complication managed as detailed below. Once venous return has been obtained with the finder needle, the angle of entry and direction should be committed to memory. The needle may then be removed, or the syringe detached and the needle left in place. An 18-gauge needle attached to a syringe is then inserted following the direction of the finder needle. After venous return is obtained, the syringe is removed and the hub of the needle occluded with a finger to prevent air embolism. A guidewire is inserted and advanced through the 18-gauge needle; it should pass with minimal resistance. If the wire does not pass easily, then it should be immediately withdrawn and the needle position verified by aspiration and free return of venous blood. The distance to the right atrium has been measured at less than 16 cm from the right side and less than 19 cm from the left, 4 and the guidewire should not be inserted beyond this distance to prevent atrial perforation or arrhythmia associated with irritation of the endocardium. After the wire has been inserted, the needle is removed, with control of the wire maintained at all times. Once wire access has been obtained, temporary catheters can be inserted directly over the wire, or sheaths can be advanced with dilators into the central venous system to permit placement of a more permanent device or insertion of other catheters such as a pulmonary artery catheter. Digital control of the wire must be maintained at all times to prevent loss into the intravascular space. Once the sheath or catheter has been positioned, the wire is withdrawn, and the device is secured to the skin with silk sutures. A sterile dressing is applied, and a chest x-ray should be obtained immediately to confirm appropriate placement and to assess for complications. 221 222 Robert Cambria ior ~ward 4 Sternal notch Needle lateral directe 4 and 5 For the posterior approach, the insertion site is located at the lateral border of the sternocleidomastoid muscle 1 cm above the external jugular vein. After a local anesthetic has been administered, a 22-gauge finder needle attached to a syringe is inserted with the bevel of the needle oriented laterally. The needle is advanced anteriorly along the undersurface of the muscle and toward the jugular notch of the sternum while aspirating. The jugular vein should be encountered within 5 - 6 cm with this approach. If it is not then the needle should be redirected more laterally, toward the ipsilateral sternoclavicular joint. Once blood return is obtained with the finder needle, the procedure continues as detailed for the anterior approach. Some data suggest that the posterior approach carries a higher success rate and a lower complication rate, s but this is largely dependent on individual operator experience and comfort. 223 Cannulation of the Internal Jugular Vein Operative Exposure of the Jugular Vein Clavicular head and origin of lateral SCM 6 Access to the internal jugular vein has become a percutaneous procedure in the vast majority of patients. Miniaturization of implantable devices and advances in catheter and sheath technology have made it possible to deliver even relatively large devices percutaneously. However, there remain several indications for operative exposure and insertion of devices under direct vision. In patients with coagulopathy or thrombocytopenia, open insertion of central lines may be preferable because of the increased risk of bleeding with percutaneous access. In patients whose anatomy is obscured by body habitus or regional disease, direct exposure of the venous access site minimizes the risk of technical misadventure. Although the internal jugular vein may not be the first choice for all patients who require direct exposure, it remains a viable and reliable option in some. The internal jugular vein lies laterally in the carotid sheath, beneath the sternocteidomastoid muscle. The vein can be exposed using an incision along the anterior border of this muscle in the midportion of the neck. Alternatively, the vein can be exposed at the root of the neck, between the heads of the sternocleidomastoid muscle, using a transverse supraclavicular incision. For both approaches, the patient is positioned supine with the head turned away from the side of the procedure. Using the incision anterior to the sternocleidomastoid muscle, the skin and subcutaneous tissues are divided. The platysma is incised, exposing the investing layer of the deep cervical fascia. The fascia is divided and the sternocleidomastoid muscle is reflected laterally, exposing the carotid sheath. The internal jugular vein can be isolated, taking care to preserve the vagus nerve, which also runs in the carotid sheath between the vein and the carotid artery. Tributaries of the jugular vein can be ligated with impunity, and if necessary, the jugular vein may be ligated when the contralateral vein is known to be patent. 224 Robert Cambria SCM ~dially ular v. J Laterat head of SCM partially divided 7 The supraclavicular incision should be placed 1-2 cm above the clavicle, beginning at the clavicular head and extending 5-7 cm laterally. The platysma is divided, and the sternal head of the sternocleidomastoid muscle is retracted medially. The clavicular head of the muscle can be retracted laterally or, if necessary, partially transected along its medial border. The carotid sheath with the internal jugular vein lies immediately beneath the muscle and can be isolated at this level. The vagus nerve and sympathetic chain course along the posteriolateral aspect of the carotid sheath and should be carefully avoided. If approaching from the left, the thoracic duct may also be visualized near its entry into the subclavian vein and should be preserved. 225 Cannulation of the Internal Jugular Vein Complications The complications associated with percutaneous access to the internal jugular vein fall into two broad areas: injury to adjacent structures during insertion and devicerelated complications. The most common complication of percutaneous internal jugular access is inadvertent puncture of arterial structures, usually the carotid artery, which has been reported in 2%-10% of attempts. If the procedure outlined above is followed and the carotid artery is punctured with a 22-gauge finder needle, then immediate withdrawal of the needle followed by digital compression is usually successful in managing this problem. If the carotid puncture is unrecognized and the artery is instrumented with a dilator or sheath, or if manual compression following needle puncture of the artery is unsuccessful and progressive hematoma develops, then surgical repair of the arterial injury is required. Late presentation of an arterial injury as a pseudoaneurysm or arteriovenous fistula has been described but occurs infrequently. Pneumothorax is a well-described complication of central venous access and can occur from any approach. Although most reports quote the incidence of pneumothorax following central line placement as 1% or less, some investigators have found an incidence as high as 2.5% following internal jugular access.6 The development of tension pneumothorax is even rarer, but necessitates immediate decompression to avoid hemodynamic compromise. Small collections of air in the thorax can be monitored or aspirated, but most patients with a significant pneumothorax require tube thoracostomy. Air embolism is an extremely rare but potentially lethal complication of central venous access. When recognized, any air that can be withdrawn from the catheter should be evacuated. If cardiopulmonary collapse ensues, then standard advanced cardiac life support measures should be initiated and consideration given to thoracotomy. Patients with lesser degrees of respiratory failure should be placed in the left lateral decubitus position with the head down to trap air in the right atrium. Air will eventually be dissolved in the blood, and chest x-ray can be used to monitor the air collection. Thrombosis of the central veins is the most common device-related complication, occurring in 4%-10% of patients. The incidence may be higher in selected populations (e.g., patients with malignancies known to be associated with hypercoagulable states), and some authors have suggested that small thrombi are associated with central lines in up to 50% of patients even when prophylactic anticoagulation is given. 7 Classic management of symptomatic central venous thrombosis involves removing the offending catheter and administering systemic anticoagulation. However, in selected patients with limited access options, preservation of the catheter may be possible with systemic anticoagulation or catheter-di- rected thrombolytic therapy to recanalize the central vein. s Prophylactic anticoagulation to prevent venous thrombosis in patients with central lines has been proven effective, but remains controversial. Thrombosis of the catheter itself can be treated by infusing thrombolytic agents directly into the occluded catheter. Although urokinase is not currently available in the United States, tissue plasminogen activator has been used successfully for this purpose. 9 Infectious complications of central lines remain problematic, occurring in 10%-30% of catheters. Strict adherence to aseptic technique during catheter placement and subsequent handling is the best means of prevention. The diagnosis of line infection can be difficult and usually relies on an increase in colony-forming units of cultures drawn through the catheter as compared to simultaneously drawn peripheral blood cultures. Suspicion of infection in temporary catheters can be managed by changing the line over a guidewire and culturing the tip. Attempts to sterilize infected permanent catheters or ports with systemic antibiotics can be successful, 1~ but failure to control the infection within 72 hours, recurrent line infection, or infection of the subcutaneous tunnel necessitate removal of the catheter. In general, muhilumen and external catheters are more susceptible to both thrombotic and infectious complications than totally implantable ports. REFERENCES 1. Seldinger SL: Catheter replacement of the needle in percutaneous arteriography. Acta Radiol 39:368, 1953 2. Forauer AR, Glockner JF: Importance of US findings in access planning during jugular vein hemodialysis catheter placements. J Vasc Interv Radiol 11:233-238, 2000 3. Fry WR, Clagett GC, O'Rourke PT: Ultrasound guided central venous access. Arch Surg 134:738-740, 1999 4. Andrews RT, Bova DA, Venbrux AC: How much guidewire is too much? Direct measurement of the distance from subclavian and internal jugular vein access sites to the superior vena cava-atrial junction during central venous catheter placement. Crit Care Med 28:138-142, 2000 5. Chudhari LS, Karmarkar US, Dixit RT, et al: Comparison of two different approaches for internal jugular vein cannulation in surgical patients. J Postgrad Med 44:57-62, 1998 6. Miller JA, Singireddy S, Maldjian P, et al: A reevaluation of the radiographically detectable complications of percutaneous venous access lines inserted by four subcutaneous approaches. Am Surg 65:125-130, 1999 7. Wu X, Studer W, Skarvan K, et al: High incidence of intravenous thrombi after short-term central venous catheterization of the internal jugular vein. J Clin Anesth 11:482-485, 1999 8. Haire WD, Lieberman RP, Lurid GB, et al: Obstructed central venous catheters: Restoring function with a 12 hour infusion of low dose urokinase. Cancer 66:2279-2285, 1990 9. Daeihagh P,JordanJ, ChenJ, et al: Efficacy of tissue plasminogen activator administration on patency of hemodialysis access catheters. AmJ Kidney Dis 36:75-79, 2000 10. Johnson L, Brown AE: Infections related to central venous access devices in patients with cancer. Infect Med 11:502-504, 1994