Color Doppler sonographic finding of retrograde jugular venous flow as a sign of innominate vein occlusion

Occlusion or stenosis of the superior vena cava, the innominate vein, or both is an important clinical problem that requires prompt diagnosis. To confirm a suspected occlusion, imaging studies revealing the obstruction and the presence of collateral venous routes are needed. Color Doppler sonography (CDUS) is widely used to evaluate suspected venous thrombosis and collateral pathways. We present the CDUS findings in 2 cases of innominate vein occlusion. In case 1, CDUS of the neck and left upper arm, which harbored a permanent hemodialysis access, showed engorged veins in the upper arm, a patent dialysis access, and some collateral veins in the axilla. The subclavian and internal jugular veins were patent, but the flow in the left internal jugular vein was reversed. The left innominate vein was occluded. In case 2, CDUS of the upper arms showed that the veins, the dialysis access in the left upper arm, and the subclavian and jugular veins were patent, but the flow in the left internal jugular vein and in the right subclavian vein was reversed. Collateral veins were seen in the right axillary region. Both innominate veins were occluded. The resulting collateral pathways, ie, retrograde flow in the ipsilateral jugular vein crossing to the contralateral jugular vein through dural sinuses, were confirmed by venography in both cases.     

Superior vena cava obstruction presenting as a complication of repeated central venous cannulations

Frequent use of central venous cannulations and dialysis catheters has led to increased complications like venous thrombosis and catheter-related sepsis. Superior vena cava subclavian obstruction secondary to extensive thrombosis of the central veins and internal jugular veins is presented. The risk factors, diagnostic modalities, and treatment options are discussed. The authors have stated that they do not have a significant financial interest or other relationship with any product manufacturer or provider of services discussed in this article. The authors do not discuss the use of off-label products, which includes unlabeled, unapproved, or investigative products or devices.     

Clinical review: Vascular access for fluid infusion in children

The current literature on venous access in infants and children for acute intravascular access in the routine situation and in emergency or intensive care settings is reviewed. The various techniques for facilitating venous cannulation, such as application of local warmth, transillumination techniques and epidermal nitroglycerine, are described. Preferred sites for central venous access in infants and children are the external and internal jugular veins, the subclavian and axillary veins, and the femoral vein. The femoral venous cannulation appears to be the most safe and reliable technique in children of all ages, with a high success and low complication rates. Evidence from the reviewed literature strongly supports the use of real-time ultrasound techniques for venous cannulation in infants and children. Additionally, in emergency situations the intraosseous access has almost completly replaced saphenous cutdown procedures in children and has decreased the need for immediate central venous access.     

Peripherally inserted central catheters--use in home care

Reliable vascular access is essential for any type of intravenous therapy. The movement of many intravenous therapies to the home setting has placed a greater burden on home care nurses to maintain reliable vascular access. In the past, when peripheral venous access became unmanageable, a central venous device such as a tunneled silastic catheter or a polyurethane subclavian line was placed. Peripherally inserted central venous catheters now offer an alternative to this type of device. These devices, nicknamed long-arm or long-line catheters, are providing reliable vascular access for many therapies. They are inserted by specially trained nurses in the home. They offer fewer complications, decreased cost and improved patient comfort. The phlebitis rate and other catheter-related complications are examined. Nurse training and insertion procedures are explored in this small pilot study.     

Temporary transvenous pacemaker placement in the Emergency Department

Emergency Department placement of a temporary transvenous cardiac pacemaker offers potential life-saving benefits, as the device can definitively control heart rate, ensure effective myocardial contractility, and provide adequate cardiac output in select circumstances. The procedure begins with establishment of central venous access, usually by a right internal jugular or left subclavian vein approach, although the femoral vein is an acceptable alternative, especially in patients who are more likely to bleed should vascular access become complicated. The indications for the procedure, as well as the equipment needed, are reviewed. Both blind and ECG-guided techniques of insertion are described. Methods of verification of pacemaker placement and function are discussed, as are the early complications of the procedure.     

Percutaneous innominate vein catheterisation: a new technique for venous access in the critically ill.

Venous access in the critically ill can be a major problem despite the wide variety of methods now available. A new technique is described involving percutaneous catheterisation of the innominate vein via a right second intercostal space approach. It has been successful in five patients over a four-year period. While there have been no major complications, it is advocated for use only when access is necessary for life-saving administration of fluids or drugs. Venous access can be obtained in the majority of patients by a variety of safe and accepted measures such as peripheral venepuncture, central vein catheterisation by the subclavian or internal jugular vein, or by a cutdown. There remains, however, a small subgroup of patients with venous thrombosis from a previous catheter insertion or intravenous drug abuse for whom a number of ingenious methods have been devised. These include cutdowns on the intercostal vein; the middle thyroid vein in infants; and on the inferior epigastric vein, the azygos vein, the iliac vein, and even the inferior vena cava in adults. Access for patients suffering from haemorrhagic shock can be facilitated by multiple catheters in one or more subclavian veins. Even more rarely, these methods may be unsuccessful or contraindicated because of vein thrombosis, infection overlying the insertion site, or patient instability. A new method has been developed allowing percutaneous catheterisation of the innominate vein.     

Permcath导管长期并发症研究

目的探讨长期血液透析留置双腔导管的效果和并发症,延长其使用期限。方法随访第二军医大学长海医院肾内科血液透析患者留置导管的使用情况和并发症,记录导管使用终点。结果共计106例患者,实施深静脉留置permcath导管112例次,6例次为再次置管;其中右颈内静脉置管术102例,左颈内静脉置管5例,锁骨下静脉3例,股静脉2例。导管平均使用时间为（10.6±8.9）个月,最长时间为52月。10例患者因栓塞拔管;6例患者因感染拔管;3例导管拔脱;11例患者接受肾移植;27例患者虽导管通畅,但患者因原发病等原因死亡;转入其他医院治疗及失访22例。结论深静脉留置permcath导管可长期保留,感染率低,栓塞率低,可满足透析要求,适合于用传统方法无法建立长期透析通路的患者和准备近期行肾移植的患者。     

An unusual case of the cephalic vein with a supraclavicular course

While the subclavian or axillary vein can be safely and successfully punctured in the majority of cases, some device implanters still prefer cut down to the cephalic vein as the initial approach to venous access for transvenous placement of pacemaker or defibrillator leads out of concern for the risk of pneumothorax, subclavian crush, and other possible complications. However, very occasionally, the cephalic vein crosses superficial to the clavicle to join the external jugular vein, making it rather unappealing for this purpose. Relying on a guide wire introduced through the cephalic vein to guide puncture of the subclavian vein is unlikely to be successful in such a situation and may cause accidental damage to the vital structures in the thoracic inlet region. Device implanters need to be aware of this anatomical anomaly because of the implications for transvenous lead placement.     

Ultrasonography as a guide during vascular access procedures and in the diagnosis of complications

Vascular access used in the treatment of patients involves central and peripheral vein accesses and arterial accesses. Catheterization of central veins is widely used in clinical practice; it is a necessary part of the treatment of patients in various settings. The most commonly involved vessels are the internal jugular, subclavian, and femoral veins. The mechanical, infectious, and thrombotic complications of central venous catheterization are markedly reduced when the procedure is performed with real-time ultrasound guidance or (to a slightly lesser extent) ultrasound assistance. Ultrasound guidance is also used to create peripheral venous accesses, for catheterization of peripheral veins and for peripheral insertion of central venous catheters. In this setting, it increases the catheterization success rate, especially during difficult procedures (e.g., obese patients, children) and reduces complications such as catheter-related infections and venous thrombosis. Arterial cannulation is used for invasive monitoring of arterial pressure and for access during diagnostic or therapeutic procedures. Ultrasound guidance reduces the risk of catheterization failure and complications. It is especially useful for arterial catheterization procedures performed in the absence of a palpable pulse (e.g., patient in shock, ECMO). Imaging support is being used increasingly to facilitate the creation of vascular accesses under difficult conditions, in part because of the growing use of ultrasonography as a bedside procedure. In clinical settings where patients are becoming increasingly vulnerable as a result of advanced age and/or complex disease, the possibility to reduce the risks associated with these invasive procedures should motivate clinicians to acquire the technical skills needed for routine use of sonographic support during vascular access procedures.     

Ultrasound‐guided subclavian venous catheterisation – is this the way forward? A narrative review

Central venous catheterisation is a commonly performed procedure in anaesthesia, critical care, acute and emergency medicine. Traditionally, subclavian venous catheterisation has been performed using the landmark technique and because of the complications associated with this technique, it is not commonly performed in the United Kingdom – where the accepted practice is ultrasound‐guided internal jugular vein catheterisation. Subclavian vein catheterisation offers particular advantages over the internal jugular and femoral vein sites such as reduced rates of line‐related sepsis, improved patient comfort and swifter access in trauma situations where the internal jugular vein may not be easily accessible. There is a growing body of evidence to suggest a potential emerging role for ultrasound‐guided subclavian vein catheterisation. Barriers to this approach include many physicians still believing that the clavicle obscures imaging of the vein. In this article, we review the evidence supporting ultrasound‐guided subclavian vein catheterisation and ask the question whether, in view of it potential advantages, it could be the way forward?     

Spontaneous correction of misplaced peripherally inserted central catheters

The purpose of the present study was to examine a new protocol involving the spontaneous correction of the misplaced tip of a peripherally inserted central catheter (PICC). Patients with PICCs misplaced in the jugular or contralateral subclavian veins were recruited. All patients underwent chest X-ray (CXR) after 3 days. In addition, those whose PICC tip still was misplaced and received another CXR after 4 days. The functions of the catheters, the subjective feelings of the patients, and local symptoms of the neck and upper anterior chest wall were recorded. Among 866 patients who had PICCs, we observed 22 PICC tips misplaced in the jugular, 3 tips misplaced in the contralateral subclavian vein, and 7 tips misplaced in other locations, which was confirmed by CXR. A total of 22 PICC tips automatically returned to the superior vena cava, which included all 3 tips in the contralateral subclavian vein and 19 tips in the jugular vein. All catheters functioned normally, and the patients had no complaints. In addition, we observed no local symptoms of the neck and upper anterior chest wall. For patients experiencing a PICC misplaced in the jugular and contralateral subclavian veins, there is no need to manually replace. In addition, the function of the catheter can remain normal.     

Doppler-guided cannulation of internal jugular vein,subclavian vein and innominate (brachiocephalic) vein—a case-control comparison in patients with reduced and normal intracranial compliance

Objective A case-control comparison of Doppler guidance on the success rate of central venous cannulation in patients with normal or reduced intracranial compliance.Design A single operator performed central venous access procedures with continuous wave Doppler guidance. It was used on patients on a ventilator. The position of patients with reduced intracranial compliance (RIC) was not changed for the procedure. Patients with normal intracranial compliance (NIC) were put in the Trendelenburg position.Setting We prospectively evaluated 249 Doppler-guided central venous access procedures performed over a 12-month period at our 10-bed neuro-intensive care unit at a university hospital.Patients and participants The group with RIC included 26 males and 35 females (n=61) aged 16–79 years. In this group 155 Doppler-guided cannulation procedures (62%) were performed. The group with NIC (n=52) comprised 29 males and 23 females aged 34–76 years; 94 Doppler-guided cannulation procedures (38%) were carried out.Measurements and results The veins cannulated in RIC and NIC, respectively, were: right innominate vein: 24/18, left innominate vein 26/12, right subclavian vein 12/7, left subclavian vein 25/14, and right internal jugular vein 33/18 and left internal jugular vein 35/24. The absence of one left internal jugular vein was identified in the NIC group. The success rate of first needle pass in patients with RIC was 92% and in patients with NIC 89%.Conclusions This study showed that Doppler guidance allows the cannulation of central veins in patients with RIC placed in head-up position. Cannulation can be ensured and first-pass needle placement maximised.All work was performed at the Intensive Care Unit of the Clinic for Neurology, University Hospital Hamburg-Eppendorf, Germany.There are no possible conflicts of interest, sources of financial support, corporate involvement, patent holdings etc. for any author.     

What is the best site for central venous catheter insertion in critically ill patients?

The choice of the best central venous access for a particular patient is based on the rate and the severity of failures and complications. Based on two recent papers, internal jugular access is associated with a low rate of severe mechanical complications in the intensive care unit as compared with subclavian access, and it is preferable for short-term access (<5–7 days) and for haemodialysis catheters. Subclavian access is associated with a lower risk for infection and is the route of choice, in experienced hands, if the risk for infection is high (central venous catheter placement >5–7 days) or if the risk for mechanical complications is low. The femoral route is associated with a higher risk for infection and thrombosis (as compared with the subclavian route). It should be restricted to patients in whom pneumothorax or haemorrhage would be unacceptable.     

78例血液透析病人颈内长期留置导管常见并发症观察与护理

目的:探讨血液透析病人颈内长期留置导管并发症的防治与护理,以延长导管留置时间。方法:对78例经皮下隧道颈内静脉长期留置导管病人进行回顾性分析,总结预防导管并发症发生的护理经验。结果:78例病人中,经颈内静脉入路74例(右71例,左3例),颈外静脉及锁骨下静脉各2例。除1例病人脑梗塞,1例肺部感染死亡,其余导管均正常使用。出现导管内血栓形成或流量不足11例,经溶栓、导管调整均再通;感染10例,发生率3.61例次/1000导管日,抗感染治疗后炎症消失。结论:血液透析护士执行各项护理时应严格无菌操作,掌握置入导管的常规护理,规范操作流程,注意心理护理及健康教育,减少导管并发症的发生。     

Value of postprocedural chest radiographs in the adult intensive care unit.

OBJECTIVE: To evaluate the necessity for postprocedural chest radiographs after catheterization of central veins, insertion of pulmonary artery catheters, and placement of endotracheal tubes. DESIGN: Prospective, controlled study. SETTING: Two academic tertiary adult ICUs. PATIENTS: Consecutive patients (n = 316) requiring central vein cannulation or endotracheal intubation in the ICUs. INTERVENTION: After each invasive procedure, the physician was instructed to complete a detailed evaluation sheet. Criteria based on the details of the procedure and immediate postprocedural clinical evaluation of the patient were used to determine the likelihood of a radiologically detectable complication. Actual radiologic findings were subsequently compared against clinical predictions. MAIN OUTCOME MEASUREMENTS: Ability of housestaff to correctly predict the absence of radiologically detectable postprocedural complications (predictive negatives). RESULTS: Ability to predict the absence of complications after cordis catheter insertions via the subclavian vein or internal jugular vein was very high (151/152; p < .001). Unsuspected complications were more frequent with central vein multilumen catheter insertions (3/24; p < .001). Ability to predict uncomplicated pulmonary artery catheterization was also high (110/111; p < .001). Physicians were unable to predict the majority of complications associated with endotracheal intubations (28/32; p > .50). CONCLUSIONS: The use of a protocol that includes an evaluation of the characteristics of the procedure and postprocedural physical examination can greatly reduce the need for routine chest radiographs after subclavian and internal jugular vein cordis catheterizations and pulmonary artery catheter placement. Chest radiographs should be performed after endotracheal intubation and multilumen catheter insertion.     

High-resolution real-time ultrasonography. Diagnosis and follow-up of jugular and subclavian vein thrombosis

Thrombosis of the internal jugular and subclavian veins was demonstrated by high-resolution real-time ultrasonography in eight patients. The sonographic findings were an intraluminal mass of low or mild amplitude echoes, loss of respiratory rhythmicity and venous pulsation, absence of vein response to respiratory maneuvers (Valsalva and sniff test) and incompressibility of the thrombotic jugular vein. Follow-up examinations after anticoagulant and local streptokinase therapy allowed monitoring of the treatment. High-resolution ultrasonography is a useful noninvasive technique for the diagnosis and follow-up of therapy in thrombosis of the jugular and subclavian veins.     

Surgical, infectious and thromboembolic complications of central venous catheterization

The authors have analysed the incidence of specific complications in a series of 420 intracaval catheters placed in 388 patients, using six transcutaneous puncture techniques: supraclavicular and infraclavicular subclavian, external and internal jugular, antecubital and brachiocephalic approaches.

Strict and moderate criteria were used to evaluate the frequency of complications. Using strict criteria, the lowest rate of surgical complications (5%) was found with the antecubital and external jugular approach, followed by infraclavicular (6.7%) and supraclavicular (9.3%) subclavian techniques; the highest rate was seen with internal jugular (10%) and brachiocephalic (15%) routes. As to inflammatory and infectious complications, the sequence was as follows: brachiocephalic (2.5%), infraclavicular (4.4%) and supraclavicular (5.3%) subclavian, and internal jugular (7%) veins; a 10% incidence was associated with external jugular and antecubital techniques. Manifest thromboembolic complications were observed only in the brachiocephalic and antecubital groups (2.5% and 10%, respectively), the overall incidence of pulmonary embolism being 0.2%. None of the approaches used can be recommended as an exclusive method of choice. The risks of central venous catheterization should be minimalized by adherence to strict principles of placing as well as care of the indwelling intravenous catheters.     

The innominate vein as alternative venous access for complicated implantable cardioverter defibrillator revisions

BACKGROUND: Venous complications of implantable cardioverter defibrillator (ICD) systems may cause significant problems when the need for system revision or upgrades arises. Such revisions require venous access close to the site of the previous ICD implantation. The internal and external jugular vein have disadvantages due to a long subcutaneous course crossing the clavicle and problems with lead extraction if infection occurs. METHODS: In seven patients with ICD revisions due to lead dysfunction (n = 4) and upgrade to a biventricular device (n = 2) and status after system removal due to infection with new device implantation (n = 1) conventional venous access could not be obtained. Intraoperative contrast venography demonstrated an occluded left subclavian and/or left innominate vein in all patients. In all patients, we gained venous access through puncture of the right innominate vein and tunneled the new lead subcutaneously to the ICD pocket on the left. RESULTS: No intraoperative complications were observed. All patients are followed in our ICD clinic. Mean follow-up is 16 +/- 4 months now. So far, no clinical or lead complications with this access have been observed. CONCLUSIONS: We have demonstrated that ICD lead placement through puncture of the right innominate vein is feasible. We propose the innominate vein as an alternative route for establishing venous access in patients requiring ICD revisions or upgrades who suffer from venous obstruction. ICD implanting physicians should acquaint themselves with the technique of right innominate vein puncture to use this vein as a bail-out strategy in patients with complicated venous access.     

246例次深静脉置管急诊血液透析治疗的安全性分析

目的 深静脉置管急诊血液透析是肾脏替代治疗的一种有效手段。本文通过对不同深静脉置管部位出现的并发症进行分析,以寻找最佳的深静脉置管急诊血液透析的方式。方法 本文分析了1993年1月至2000年6月期间,因急慢性肾功能衰竭行深静脉置管急诊血液透析治疗的住院患者。置管部位为股静脉、锁骨下静脉和颈内静脉。肝素封管方法为大剂量常规肝素一次性封管和小剂量肝素多次封管两种。结果 219例患者接受了246例次深静脉置管急诊血液透析治疗,平均置管保留时间为19.6天,合并症发生率为28.0％。股静脉置管平均保留时间为(16.89±8.11)天,合并症发生率为30.4％;锁骨下静脉置管平均保留时间为(19.85±12.10)天,合并症的发生率为38.9％;颈内静脉置管平均保留时间为(25.21±10.95)天,合并症的发生率为10.2％,与股静脉或锁骨下静脉置管相比有显著性差异(P<0.05)。结论 颈内静脉置管行急诊血液透析置管保留时间最长,合并症发生率最低,最为安全可靠,应为急诊血液透析治疗首选的临时血普通路。股静脉置管方法操作方便,相对安全,但影响患者活动。锁骨下静脉置管可出现较为严重的并发症,危险性较大,不建议作为急诊血液透析治疗时的临时血管通路。