Percutaneous cannulation of the internal jugular vein in infants and children.

A technique for percutaneous catheterization of the internal jugular vein in infants and children was used since January 1975 in 206 patients ranging in age from a few hours to 12 years old. The series included 31 premature infants weighing less than 2,500 grams and 107 babies weighing less than 4,000 grams. Five attempts at cannulation failed. Each catheterization procedure required an average of 1.8 needle insertions before the vein was entered. In 129 patients, the first attempt was successful. Sixteen complications related to the procedure occurred early in our experience, seven of which were life threatening. One death was directly ascribed to the actual insertion of the catheter and mediastinal extravasation of infusion material. Most of the early complications probably could have been injected through the catheter immediately after cannulation, in addition to aspirating the blood and lowering the infusion bottle. The 22 late complications were related to infection; one infant died because of catheter sepsis. To minimize septic complications, an arbitrary limit of seven days was set, after which the catheter was replaced. Cannulation of the internal jugular vein in infants and children should be regarded as a serious surgical procedure to be performed by a trained team and only when properly indicated.     

Right atrial catheter insertion through the external jugular vein.

The external jugular vein may be used to place a right atrial catheter if the cephalic veins are not suitable for cannulation. Atrophy or sclerosis of the cephalic vein is seen in some patients with malnutrition or a malignant lesion. Some women patients also have cephalic veins of rather small caliber. In these patients, the insertion of the right atrial catheter, using the external jugular vein, may be warranted. The external jugular vein approach is recommended because of its easy accessibility and the lower risk involved than with the internal jugular or cephalic vein approach.     

Ultrasonographic guidance for central venous access during pregnancy

Real-time ultrasonographic imaging of vascular and anatomic neck structures allows easy visualization of the right internal jugular vein and carotid artery. Application of this technology during pregnancy may reduce potential complications encountered with central venous monitoring and will be especially useful in cases of difficult anatomy.     

Percutaneous insertion of subclavian venous catheters in infants and children

All attempts at subclavian venous catheterization by the Pediatric Surgery Service done during a one and one-half year period at the Children's Hospital of Los Angeles were prospectively studied. Catheterization was attempted in 107 patients with a mean age of 9.8 years. Cannulation of the vein was successful 89 times (71 per cent) with the major complications being arterial puncture (8.0 per cent), pneumothorax (2.4 per cent) and abnormal position (12.8 per cent). Fluoroscopy was a valuable adjunct when used, resulting in an 86 per cent success rate. The serious complication rate was similar between left and right-sided attempts, but more catheters were abnormally positioned during right-sided attempts (15.7 versus 5.2 per cent). Percutaneous insertion of subclavian venous catheters can be accomplished in infants and children with low morbidity. Cannulation of the left subclavian vein can be accomplished with a similar success rate and a lower malposition rate than the right side. Fluoroscopy is a useful tool to assist in the correct placement of the catheter.     

Tunneled central venous catheters in a gynecologic oncology service: operative and short-term complications

PURPOSE: To determine the difference in the immediate complication rate between placement of long-term central venous catheters (LTCVCs) by the percutaneous versus jugular venous cutdown method. METHOD: Case lists were examined to determine the number of LTCVCs placed during the designated time period. Medical records, operative reports, and chest roentgenograms were examined to extract pertinent information. Immediate complications included complications occurring in the operating room until 30 days postoperatively. Complications included misplacement of the catheter requiring an adjustment or a repeat procedure, pneumothorax, hydrothorax, or hemothorax, operative site or tunnel infection, and line migration requiring removal. RESULTS: Five hundred and one patients had LTCVCs placed during the period of this study. This included 399 totally implantable venous access devices (TIVADs) and 102 free access venous access devices (FAVADs) with 163 placed percutaneously into subclavian veins and 338 placed by cutdown into jugular veins. There was a significant increased risk in the overall immediate complication rate for the percutaneous placement compared to venous cutdown (p < 0.001). Also, pneumothorax was more common with the percutaneous approach compared to the venous cutdown approach (p < 0.001). CONCLUSIONS: Immediate complications, especially pneumothorax, were more common when placing catheters by the percutaneous approach as compared to the venous cutdown approach.     

Management options for penetrating injuries to the great veins of the neck and superior mediastinum

Between January 1984 and January 1986, 74 patients were treated for stab or gunshot injury to the great veins in the neck and superior mediastinum. Veins involved in the neck were the subclavian and internal jugular and in the mediastinum, the brachiocephalic and subclavian vein and the superior vena cava. Most patients presented in a state of shock. Twenty-nine were bleeding too rapidly to resuscitate adequately and required emergency operation while in a moribund state. Twenty-five had arteriovenous fistulas and were hemodynamically stable. Direct venous repair was attempted if simple lateral suture or end to end anastomosis could be rapidly done. If complex repairs were required, ligation was performed. Fifty-five veins were ligated on this basis, including 14 brachiocephalic trunks, nine proximal subclavian veins and one superior vena cava cephalad to the azygos. Nineteen were repaired. Two patients died after ligation and one patient after repair, all as a result of the effects of massive hypovolemia. Edema of the upper limb developed in two patients in each treatment group in whom the distal part of the subclavian vein had been involved. The edema resolved within five to seven days. Chronic venous stasis problems did not develop in any patient during the two to 26 month follow-up period.     

Phrenic nerve damage in the tiny infant during vein cannulation for parenteral nutrition

An infant weighing 740 gm at birth underwent right internal jugular venous cannulation for the administration of parenteral nutrition at age 17 days. The roentgenogram obtained to assess catheter placement revealed a high right diaphragm for the first time in the course of the infant. The phrenic palsy was incurred during the cutdown in the neck of the tiny, then 650 gm, infant. Two similar patients are mentioned in the literature. The phrenic palsy appeared to delay improvement in the respiratory status of this infant. This patient illustrates the fact that phrenic nerve palsy is a potential complication of central line placement in the neck of a very low birthweight infant.     

Management of Pelvic Venous Stenosis with Intravascular Stainless Steel Stents

Patients with gynecologic malignancies may develop stenosis of the large pelvic veins as a result of their disease or its treatment. The percutaneous insertion of a stainless steel vascular stent is a novel approach to the management of an extrinsically compressed vein. The objective of this study was to review the results of treating lower extremity edema secondary to a pelvic venous stenosis through the percutaneous insertion of a stainless steel vascular stent. A retrospective review was performed on gynecologic oncology patients who presented with an edematous lower extremity and underwent an evaluation to diagnose proximal venous stenosis. The evaluation included sonography, venography, and balloon angioplasty prior to the percutaneous insertion of a stainless steel vascular stent. If a venous thrombosis was documented, thrombolysis with urokinase was performed prior to evaluation for venous stenosis. Records were reviewed for the etiology of the venous stenosis, the location and type of stent inserted, and the ability of the stent to maintain patency and provide symptomatic relief. Patency was evaluated at 1-week and then at 1-, 3-, and 6-month intervals. The probability of vascular stent patency was calculated using life table analysis. Ten patients with cervical (n = 4), corpus (n = 3), ovarian (n = 1), vulvar (n = 1), and vaginal (n = 1) cancer had one or more vascular stents inserted for the treatment of a stenosed pelvic vein. The etiologies of venous stenosis were radiation fibrosis and surgery (n = 5), postoperative fibrosis (n = 3), and metastatic tumor (n = 2). The stented vessels were the left common (n = 5) or left external (n = 4) iliac veins, the right common (n = 1) or right external (n = 3) iliac veins, and the right common femoral vein (n = 1). The median follow-up was 21 months. All patients had subjective resolution of their edematous extremity while the stents were patent. The interval probability of patency of stented veins was greater than 85% at each evaluation interval. Patency was 100% for patients beyond 6 months of follow-up. There were no major complications. The percutaneous intravascular insertion of a stainless steel stent was safe and subjectively effective in the management of venous stenosis associated with a gynecologic cancer. A prospective trial with objective endpoints may be warranted.     

Echocardiographic assessment of total anomalous pulmonary venous connections in pediatric patients.

BACKGROUND AND PURPOSE: Cardiac catheterization can be superfluous and risky for sick babies, infants, and young children with total anomalous pulmonary venous connection (TAPVC). This study assessed the accuracy of echocardiography in the clinical assessment of pediatric patients with TAPVC before cardiac surgery. PATIENTS AND METHODS: A total of 15 consecutive patients with TAPVC treated between July 1, 1993, and December 31, 1999, were included in this retrospective study. Patients with TAPVC with heterotaxy syndrome were excluded. We assessed this cardiac anomaly preoperatively using plain chest roentgenograms, echocardiography, and magnetic resonance imaging. A combination of suprasternal, parasternal, subcostal, and apical four-chamber views and their tilting scans were employed for diagnosis and to trace the course of the anomalous pulmonary venous connection. RESULTS: Interatrial right-to-left shunt via atrial septal defects were documented by two-dimensional echocardiography with color Doppler mapping in all 15 patients. Patent ductus arteriosus was found in six patients. Cardiomegaly with enlargement of the right atrium and the right ventricle could be seen on plain chest roentgenograms and by echocardiography in all but two patients with infracardiac TAPVC. In all patients, the left innominate vein, coronary sinus or right atrium, and portal vein were the draining sites of supracardiac, cardiac, and infracardiac TAPVC, respectively. A pattern of continuous flow without phasic variation, which is suggestive of stenosis of the pulmonary vein, was found in two patients with infracardiac TAPVC with obstruction. The surgical findings were reviewed and correlated well with those of the echocardiography. CONCLUSIONS: In infants and children with TAPVC, the drainage sites and flow profiles of the pulmonary veins can be exactly determined by Doppler echocardiography preoperatively, which makes cardiac catheterization and angiocardiography unnecessary.     

Central venous cannulation in neonates

A modified technique for central venous cannulation for parenteral nutrition in neonates has been developed. The internal or external jugular veins are cannulated and the catheter is tunneled out onto the anterior part of the chest wall through a long subcutaneous tunnel. Fixation of the catheter is accomplished by gluing two small pieces of Silastic sheeting to the catheter and then suturing this sandwich to the skin. Over 150 central venous catheters for total parenteral nutrition have been placed using this method. The reduced rate of catheter-related complications and improved ease of nursing care have provided excellent results.     

Simplified insertion of central venous catheter in infants

A technique for insertion of central venous catheters in infants is described. A needle is percutaneously positioned into the subclavian vein. Through this, a guide wire is passed and a catheter introduced over the wire. This method has proved to be safe and effective in over 100 infants.     

Cyproterone acetate- and ethinyloestradiol-containing oral contraceptive as a risk factor for upper extremity deep venous thrombosis–a case report

Deep venous thrombosis of the upper extremity (UEDVT) is a rare variety of deep venous thrombosis. Compared to lower-extremity deep venous thrombosis, less is known about the risk factors for primary UEDVT. We report on a 27-year-old woman with UEDVT extending from the jugular and subclavian veins to the elbow. The thrombosis was possibly provoked by a shoulder trauma, in combination with heterozygosity for the prothrombin G20210A mutation and a protein S-deficiency, which may have been induced by the use of a cyproterone acetate- and ethinyloestradiol (CPA/EE)-containing oral contraceptive.     

Dural arteriovenous malformation of the transverse sinus with sinus occlusion: report of a case.

We report a case of dural arteriovenous malformation (AVM) of the transverse sinus with sinus occlusion. This 49-year-old man developed right parietal lobe dysfunction with acute onset. Computed tomography and magnetic resonance imaging (MRI) showed a non-hemorrhagic venous infarct in the subcortical white matter of the right parietal lobe, and diffusely dilated subcortical veins. Thrombosis of the right internal jugular bulb was also revealed on MRI. Cerebral angiography showed a dural AVM in the posterior fossa with occlusion of the right transverse sinus and retrograde venous drainage into the superior sagittal sinus, causing diffuse engorgement of the superficial cortical and the deep intramedullary veins. The focal neurologic deficits in this case were due to a non-hemorrhagic venous infarct in the subcortical white matter of the right parietal lobe secondary to retrograde cortical venous drainage.     

An unusual case presentation: pericardial tamponade complicating central venous catheter

The use of central venous catheters in very low birthweight infants to provide adequate calories for growth is an integral part of the care of the high-risk neonate. The use of surgically placed Broviac catheters has been associated with infectious and mechanical complications. Recently, there has been increasing use of silastic central venous catheters inserted through a peripheral vein and advanced to the right atrium. These catheters have a reported low rate of complications. However, we report a case of a very low birthweight infant in whom a peripherally inserted silastic catheter perforated the wall of the right atrial appendage and led to fatal pericardial tamponade. This is a very rare but nearly always fatal complication. It is potentially avoidable by careful placement of the tip of the central venous catheter, so that it is not impinging on a wall of the heart. Serial venograms may be useful to reconfirm the position of the catheter.     

Internal jugular vein blood flow in normal and growth-restricted fetuses

OBJECTIVE: To assess internal jugular vein blood flow patterns during the second half of pregnancy in normal and growth-restricted fetuses. METHODS: We did Doppler ultrasound studies of internal jugular veins and the inferior vena cavas longitudinally on 21 normal singleton fetuses from 20 weeks to term, and on eight growth-restricted fetuses with absent end-diastolic flow at the umbilical artery (UA). The three components of the venous flow velocity waveforms were used to calculate peak velocity ratio: Peak systolic velocity (S wave) minus reverse peak velocity (R wave) divided by peak velocity during early diastole (D wave) and velocity time integral ratio: systolic velocity time integral minus reverse velocity time integral divided by velocity time integral during early diastole. Statistical analysis of longitudinal measurements used K-related samples Friedman test; groups were compared with Mann-Whitney U test and chi(2) test. RESULTS: In normal fetuses we found significant increases in peak velocity ratio and velocity time integral ratio of internal jugular veins and the inferior vena cavas throughout gestation. The mean +/- standard deviation (SD) of the internal jugular veins peak velocity ratio (1.12 +/- 0.4 versus 1.46 +/- 0.15, P <.05) and velocity time integral ratio (1.1 +/- 0.2 versus 1.55 +/- 0.17, P <.05) were significantly lower in growth-restricted fetuses compared with normal fetuses at 28-32 weeks' gestation but inferior vena cava indices were not. None of the eight growth-restricted fetuses had umbilical venous pulsations or changes in inferior vena cava or ductus venosus blood flow patterns. All had arterial pH above 7.15 at birth. CONCLUSION: Growth-restricted fetuses with absent end-diastolic velocity in the UA have changes in internal jugular vein blood flow patterns that probably indicate increased cerebral blood flow, more evidence of redistribution of blood flow in growth-restricted fetuses that can be used to maintain them.     

Simple technique for long term central venous access in the patient with thrombocytopenic carcinoma

A technique for the insertion of a central venous access device in the patient with thrombocytopenia is described. Using the Seldinger technique, a wire is placed into the internal jugular vein. A catheter tunneled from the anterior part of the chest is inserted through a peel-away sheath into the central venous system. The incision is then closed.     

Sonographic visualization of ovarian veins during the puerperium: an assessment of efficacy

OBJECTIVE: The purpose of this study was to determine the ability to visualize ovarian veins by sonography in postpartum patients as well as to assess the frequency of ovarian vein thrombosis in these patients. STUDY DESIGN: Seventy subjects were recruited from either the postpartum ward or labor and delivery unit after vaginal delivery between November 1, 2000, and March 1, 2001. Patients were excluded if they had a previous or current history of venous thrombosis or recently underwent cesarean delivery. Demographic data were recorded. Transabdominal ultrasonography was performed with gray scale or color Doppler imaging for visualization of the right and left ovarian veins. Either power Doppler or pulsed Doppler imaging with spectral analysis was used for verification of the ovarian veins. Logistic regression was used for univariate analysis. RESULTS: Of the 70 parturients studied, both ovarian veins were visualized in 55 women (78.6%). Of the remaining subjects, either the right (n = 6) or the left (n = 6) ovarian vein could not be visualized. In 3 subjects, neither ovarian vein could be visualized (4.3%). An isolated, asymptomatic right ovarian vein thrombus was identified in one subject (1/55, 1.8%) after bilateral tubal ligation was performed. Maternal age, parity, body mass index, gestational age, spontaneous versus operative vaginal delivery, neonatal sex, or sonographer (radiologist versus perinatologist) did not correlate with ability to visualize the ovarian veins; however, increasing birth weight tended positively toward significance (P =.064). CONCLUSION: Most ovarian veins can be visualized sonographically during the early puerperium. Additional imaging studies should be considered when a diagnosis is unclear. The presence of an asymptomatic ovarian vein thrombus is unusual and is of uncertain importance.     

Internal jugular venous autograft in extrahepatic portal hypertension.

A 26 year old female with repeated episodes of upper gastrointestinal bleeding, secondary to extensive extrahepatic portal and superior mesenteric venous obstruction, was surgically treated by interposing an internal jugular vein autograft between a collateral channel and the inferior vena cava. The follow-up observation during a seven and one-half year period has shown no recurrence of bleeding, disappearance of esophageal varices and a widely patent graft with normal portal vascular pressures. The internal jugular vein is a readily accessible autogenous graft of adequate caliber that can maintain patency under rigorous conditions. Its use is recommended in constructing portal-systemic venous shunts in those instances of extrahepatic portal hypertension in which conventional shunts cannot be established or, if they can be established, are liable to closure.     

Percutaneous central venous catheters in neonates

Fifty-six percutaneous central venous catheters were inserted over a six-month period in 41 term and preterm infants who required long-term venous access. The mean birth weight and gestational age for the study population was 1,281 g and 30.5 weeks, respectively. A cross-case analysis of data revealed information concerning duration of percutaneous central venous catheter therapy, weight gain or loss during therapy, and incidence of catheter-related complications. No complications were observed in 52% of the subjects; the remaining 48% of infants experienced problems with clotting, leaking fluids, and peripheral edema. There was one positive blood culture. As the insertion procedure and nursing management plan became standardized with experience over time, the incidence of complications sharply decreased. The use of percutaneous central venous catheter therapy in neonatal care promises to be a cost-effective nursing technique that will be advantageous for care providers, sick infants, and their parents.     

Persistent right umbilical vein associated with complex congenital cardiac malformation

Umbilical venous catheterization is frequently used for vascular access during neonatal resuscitation. The differentiation between umbilical artery and vein, specifically during the resuscitation procedure, is clinically neither always easy nor unambiguous. A preterm infant of 35 weeks of gestational age was born after an uneventful course of his mother's pregnancy. Severe postnatal cyanosis led to the placement of presumed arterial and venous umbilical catheters. Chest x-ray was suggestive of the presence of a persistent right umbilical vein (PRUV). Echocardiography showed a double outlet right ventricle with mitral atresia and a levo-atrial cardinal vein draining the left atrium into the azygos vein. The foramen ovale was firmly closed and conventional balloon atrioseptostomy failed. Several attempts of transseptal puncture and subsequent creation of an atrial septal defect were unsuccessful and the infant eventually died. There is an association of PRUV and congenital cardiac malformation. PRUV can be diagnosed prenatally if specifically looked for. The presence of PRUV can be the only clue prenatally alerting to the presence of congenital heart disease. Postnatal diagnosis of PRUV may justify echocardiography and cardiologic assessment even in the absence of clinical cyanosis.