Central venous access in children via the external jugular vein

Sixty-two children undergoing cardiac surgery were surveyed for the presence of external jugular veins. When present, these were used as a route for central venous catheterisation using a 'J' wire Seldinger technique. Only 54% of attempted insertions were successful but the results support greater efficacy in older children.     

Percutaneous central venous catheterization through the external jugular vein in children: improved success rate with body maneuvers and fluoroscopy assistance

Background/Purpose

Central venous catheterization is among the most common procedures performed by pediatric surgeons. Significant morbidity and even mortality can ensue from the widespread approach to the deep veins of the neck and femoral region. The external jugular vein (EJV) is a low-morbidity alternative for percutaneous catheterization in children, but it has yielded a low success rate in previous reports .The authors show an improved success rate with this option.

Methods

We performed an analysis of 33 patients' charts in which central venous catheterization using Seldinger technique through the EJV was attempted in 2005. Age, diagnosis, maneuvers used for success, fluoroscopy usefulness, and types of inserted catheters were evaluated.

Results

The procedure was successful in 26 (78.8%) patients without complications. Diagnosis was neoplasia in almost half of the patients (42%). In half of the successful cases, body maneuvers were used, namely, twisting the head of the patient to the side of the vein and stretching the ipsilateral arm and shoulder. All but one procedure were completed under fluoroscopic guidance. In 6 (23%) patients, a long-term catheter was inserted.

Conclusions

The EJV is an excellent option for central venous catheterization in children. The execution of simple maneuvers along with fluoroscopic assistance might allow for an improved success rate not only for short-term but also for long-term catheter insertion.     

乳腺癌患者经颈外静脉置管送管困难的原因分析及对策

目的探讨经颈外静脉置入PICC送管困难的原因,提高送管成功率。方法总结分析12例患者置入PICC时发生送管困难的原因及对策。结果颈外静脉送管困难的原因在于颈外静脉的特殊解剖结构、血管变异及放化疗造成的血管损伤、血管痉挛、对血管的评估是否充分、血管的条件等。结论经颈外静脉置管作为PICC静脉置管的补救措施,应充分评估置管可能存在的困难,排除置管困难的因素,评估置管过程,做好调整导管的准备,确保置管成功。     

经颈内静脉完全植入式输液港在乳腺癌化疗中的应用

目的总结经颈内静脉放置全植入式输液港(TIVAP)作为乳腺癌化疗静脉输液通路的使用经验。方法对2013年6月~2015年12月486例行输液港植入术的乳腺癌化疗患者进行回顾性研究,观察其术后及远期并发症。结果全部病例均在术中成功完成输液港植入。l例出现心悸不适,2例穿刺点周围局部血肿,1例囊袋内港体周围血肿,2例气胸,3例导管相关性感染,2例导管堵塞,1例导管断裂。至末次随访,65例带管时间4~30个月,中位带管时间15个月。本组未出现导丝断裂、pinch-off综合征等严重并发症。结论经颈内静脉放置全植入式输液港是乳腺癌化疗安全、有效的输液途径。     

腔镜甲状腺手术CO_2气腹对颈内静脉压力及中心静脉压的影响

目的:探讨腔镜下胸乳入路甲状腺手术CO_2气腹对颈内静脉压力及中心静脉压的影响。方法:30例患者经胸乳入路行腔镜下甲状腺手术,分别于CO_2充气前,充气后10 min、20 min、40 min,关闭充气后5 min、20 min测量颈内静脉压力、中心静脉压,比较不同时点颈内静脉压力、中心静脉压的变化。结果:与充气前相比,充气后各时点的颈内静脉压力、中心静脉压显著上升(P0.05);解除充气后,逐渐下降,与充气前相比差异无统计学意义(P0.05);充气后三个时间点的颈内静脉压力均大于8 mmHg(P0.05),中心静脉压均小于8 mmHg(P0.05)。结论:经胸乳入路腔镜甲状腺手术中CO_2气腹会导致颈内静脉压力、中心静脉压显著升高,切除甲状腺中上部时无发生气体栓塞的可能,但切除甲状腺下部时有发生气体栓塞的可能。     

A randomized study of a new landmark-guided vs traditional para-carotid approach in internal jugular venous cannulation in infants

Background: Central venous catheterization is more difficult in infants than in adults. Ultrasound‐guided internal jugular venous cannulation may improve the accuracy of localization of the internal jugular vein (IJV), but ultrasound equipment is not universally available. The landmark technique remains essential in daily practice. Methods: One hundred and forty infants, aged 3–12 months, who were scheduled to undergo surgery for congenital heart disease, were randomly assigned to a new landmark‐guided group or traditional para‐carotid group. In the new landmark‐guided group, at the level of the cricoid cartilage, the carotid artery was marked, and the apex of the triangle formed by the two heads of the sternocleidomastoid muscle and the clavicle was also marked. The needle was inserted at the midpoint of the two marked points and advanced in the direction of the ipsilateral nipple. Seven cardiac anesthesia fellows participated in this study, and each fellow performed 10 central catheterizations in each group. The times to successful catheterization of the IJV were measured. Attempts at needle punctures for successful catheterization and procedural complications were counted. Results: The IJV was successfully punctured within three attempts in 74% of infants in the para‐carotid group, compared with 94% in the new landmark‐guided group (P = 0.001). The time to successful catheterization was significantly shorter in the new landmark‐guided group (P < 0.01). The incidence of arterial punctures in the para‐carotid group was 11%, compared with 3% in the new landmark‐guided group (P < 0.05). Conclusions: Compared with traditional para‐carotid approach, the new landmark‐guided approach for access of the IJV during teaching central catheterization significantly reduced carotid arterial puncture, provided a higher success rate and minimized procedure time in infants aged 3–12 months.     

Embolization of a fractured central venous catheter placed using the internal jugular approach

INTRODUCTIONFracture and embolization of central venous catheters placed via the subclavian approach is well recognized, but fractured catheters placed via the internal jugular vein are extremely rare.PRESENTATION OF CASEA 65-year-old man presented with a catheter embolus after placement of a central venous port using the internal jugular approach undertaken to administer adjuvant chemotherapy for colon cancer with lung metastases. Goose neck and conformational loop snares were successfully used to percutaneously retrieve the severed catheter, which had migrated to the right ventricle.DISCUSSIONCatheter fracture may occur even after placement via the internal jugular approach and may be underestimated because it is often asymptomatic. Interventional radiology techniques using goose-neck and conformational loop snares may be useful to retract an intravascular foreign body.CONCLUSIONImaging studies such as a chest X-ray are mandatory to check that the catheter tip is in the appropriate position during the entire follow-up period even if it was placed through the internal jugular vein.     

A dedicated consultant-led vascular access team significantly reduces out-of-hours and emergency permanent central venous access insertions

Purpose

The insertion of a permanent central venous access device (PCVAD i.e. Broviac or Hickman lines and vascuports) is often considered a low priority and performed as an emergency. In 2004, a vascular access team (VAT), responsible for all PCVAD insertions, was established in our institution to address this.

Methods

Data were collected retrospectively on all PCVAD insertions in 2 periods (January 2002-December 2003 and January 2005-December 2006). This included procedure, list type, surgeon grade, and operative time.

Results

During 2002 to 2003 and 2005 to 2006, 465 and 569 PCVADs were inserted, respectively (22% increase). After introduction of the VAT, the percentage of lines inserted during emergency lists fell from 24% (n = 112) to 13% (n = 72), and out-of-hours fell from 6% (n = 29) to 3% (n = 17; P < .05), respectively. Median time taken for PCVAD insertion in 2005 to 2006 was significantly less if using an elective list compared with insertions performed on an emergency list (elective, 67 [56-82] minutes vs emergency, 85 (65-110) minutes; P < .05).

Discussion

Introduction of a VAT has led to a significant decrease in emergency and out-of-hours PCVAD insertions, despite an increase in overall activity for the period. The median time taken for elective insertions is significantly less than emergency insertions, which has increased the efficiency of vascular access provision at our institution.     

颈外静脉切开置入带涤纶套中央静脉导管在特殊患者中的临床应用

目的 探讨颈外静脉切开置入带涤纶套中央静脉导管在特殊患者中的临床应用效果及评估其安全性.方法 将42慢性肾脏病（chronic kidney disease,CDK）5期并欲行带涤纶套中央静脉导管置入术的患者设为A组,以颈外静脉切开方法置管;同期选取36例已行右颈内静脉置入术的患者设为B组,置管方法为经皮穿刺右颈内静脉经撕脱鞘置入带涤纶套中央静脉导.观察术中、术后并发症.记录透析前后血肌酐、尿素氮变化以及透析中血流量、回血静脉压指标,计算尿素清除指数（Kt/V）值并比较.A组42例患者行颈外静脉切开置管患者根据原发病：糖尿病肾脏疾病、Ⅱ型心肾综合征进展至终末期肾脏疾病（end stage renal disease,ESRD）、慢性肾小球肾炎、强直性脊柱炎肾损害进展至终末期肾脏疾病、急性肾损伤,比较导管留存时间、导管中位留存时间.结果 2组患者Kt/V值均达标,血流量、回血静脉压无统计学差异（P＞0.05）,且透析前后血肌酐、尿素氮水平变化存在统计学差异（P＜0.05）.2组手术后未出现出血、血流量不佳导管相关性血流感染等并发症.A组中心肾综合征及急性肾损伤（acute kidney injury,AKI）患者导管留存时间与糖尿病肾脏疾病相比存在统计学差异（P＜0.05）.结论 尽管带涤纶套中央静脉导管置入方法推荐首选经典撕脱鞘置管,该方法安全成功率高,术后并发症少,但是经颈外静脉切开置入带涤纶套中央静脉导管术式在特殊患者中的临床应用中手术安全,能够保证透析充分性,并发症少,临床值得推荐.     

Life-threatening hemothorax resulting from right brachiocephalic vein perforation during right internal jugular vein catheterization

We present a life-threatening case of hemothorax resulting from right brachiocephalic vein perforation during right internal jugular vein catheterization. We considered that the guidewire had punctured the right brachiocephalic vein extraluminally and the catheter inserted over the guidewire had enlarged the size of the perforation. Despite the use of proper technique, an angle-tip guidewire may perforate the venous wall. Therefore, when there is negative aspiration after central venous catheterization, it is important to perform an emergency chest radiograph before proceeding with surgery; it is also important not to use an angle-tip guidewire.     

Venography at insertion of tunnelled internal jugular vein dialysis catheters reveals significant occult stenosis.

BACKGROUND: Tunnelled catheters are widely used to provide vascular access for haemodialysis. Percutaneous insertion of these catheters requires large calibre tissue dilators with the potential to cause trauma to central veins, particularly if anatomical abnormalities are present. METHODS: We evaluated the use of venography to identify central vein anatomical abnormalities in 69 consecutive patients undergoing percutaneous placement of tunnelled right internal jugular vein catheters. The internal jugular vein was entered under ultrasound guidance and venography was performed prior to insertion of a guide-wire. Images were evaluated on-screen by the operator and a decision made regarding the need for additional fluoroscopy during insertion of the catheter. RESULTS: In 29 cases (42%), venography showed evidence of unexpected stenosis and/or angulation of the central veins of sufficient severity to warrant additional fluoroscopy during insertion of the dilators, or abandonment of the procedure. Patients who had previously had tunnelled internal jugular catheters had more than double the incidence of such abnormalities than those who had not [15/23 (65%) vs 14/46 (30%); P = 0.009]. In two patients the procedure was abandoned due to severe stenosis. No patient suffered central vein trauma or pneumothorax. There were no adverse reactions to contrast injection. CONCLUSIONS: Venography performed immediately prior to tunnelled internal jugular dialysis catheter insertion detects unexpected, clinically significant anatomical abnormalities of the central veins in a substantial proportion of patients, particularly those with a history of previous tunnelled catheter insertion. We suggest that the use of venography may help to minimize the risk of complications from this procedure.     

经颈内静脉植入输液港:导管尖端处于不同位置时1年内并发症发生率与导管通畅率

目的 对比观察经颈内静脉（IJV）入路植入完全植入式静脉输液港（TIVAP）后,导管尖端处于不同位置时1年内并发症发生率及导管通畅率。方法 回顾性分析2 104例接受经IJV入路植入TIVAP的肿瘤患者,将接受经右IJV入路者（R组,n=1 903）分为导管尖端位于右心房上部［即上腔静脉（SVC）与右心房交界（CAJ）下方0.5～1.0 cm亚组（R1亚组,n=376）］与位于SVC下1/3至CAJ间亚组（R2亚组,n=1 527）,将接受经左IJV入路者（L组,n=201）相应分为L1亚组（n=64）及L2亚组（n=137）;记录2组内各亚组患者基本资料、植入TIVAP 1年内并发症发生率及导管通畅率,并进行亚组间比较。结果 2组内亚组间患者性别、年龄、临床诊断及肿瘤分期,以及气胸/血气胸、局部皮肤损伤、TIVAP感染、导管相关性血栓、药物外渗、导管移位及心律失常等并发症发生率差异均无统计学意义（P均＞0.05）。R1（94.15%）与R2亚组（93.78%）（χ²=0.069,P=0.793）、L1（98.44%）与L2亚组（89.78%）1年内导管通畅率差异均无统计学意义（Yates连续性校正χ²=3.563,P=0.059）。结论 经左或右IJV入路植入TIVAP后,导管尖端位于右心房上部与SVC下1/3与CAJ之间时,1年内并发症发生率及导管通畅率均无明显差异。     

Internal jugular vein versus external jugular vein anastamosis: implications for successful free tissue transfer

BACKGROUND: Microvascular free flaps are becoming the reconstructive option of choice for many head and neck defects. Many previous studies have examined factors predicting free flap survival. No study has compared differences in free flap survival when anastomosed to the internal or external jugular systems. METHODS: Retrospective review of all free flaps performed at an academic medical center by a single head and neck microvascular surgeon during the period July 1995 to December 1999. Flaps were closely monitored postoperatively and taken back to the operating room urgently for arterial insufficiency or venous congestion. RESULTS: On hundred fifty-six free flaps were performed during this time period. Sixty-five free flaps were anastomosed to the external jugular (EJ) vein and 86 to the IJ system (62 to the proximal common facial vein, 17 end-side on the IJ, and 7 to other branches). Five had either two venous anastomoses or were anastomosed to other veins and were excluded from statistical analysis. Six (4%) vascular thromboses occurred; 5 were venous and 1 arterial. Success by group was 99% for IJ anastomosis (1 arterial thrombosis) and 92% for EJ anastomosis (5 venous thromboses, p =.03). Urgent anastomotic revision and reperfusion salvaged 5 of the 6 flaps (overall success 99%). CONCLUSIONS: Although the overall success rate (96% success with 99% success with salvage) is comparable to other large series, microvascular free flaps anastomosed to the external jugular vein failed at a significantly higher rate than those anastomosed to the IJ system. This suggests that the IJ system should be used as a recipient vessel when feasible.     

Central venous cannulation in infants and children: a comparison of internal and external jugular vein approaches

We prospectively evaluated success rate and complications associated with 436 internal (IJ) and external (EJ) jugular approaches to central venous cannulation in 377 paediatric patients. Variables studied included the route of insertion, success rate, cannulation time, intraoperative and postoperative catheter-related complications. The overall success rate and the frequency of complications were higher with the IJ than with the EJ approach. Cannulation with the EJ approach was more successful in older patients than in younger ones, making EJ a more attractive route for central venous cannulation in older children. While the inconsistent final position of the catheter tip makes EJ a less reliable technique for central venous pressure monitoring, it does not limit its usefulness for infusion of vasoactive drugs. If monitoring of filling pressures is desired, the IJ approach is a better choice, despite its higher risk of complications.     

Right versus left internal jugular vein catheterization for hemodialysis: complications and impact on ipsilateral access creation

This study investigated whether the anatomical differences between right and left internal jugular vein catheterization (RJVC and LJVC) would lead to differences in the frequency of complications, in particular, central vein occlusion (CVO). A group of 479 jugular vein catheterizations, 403 RJVC and 77 LJVC done in 294 prevalent hemodialysis patients were analyzed. A right-sided carotid pseudoaneurysm was the only major puncture-related complication. A total of 78 RJVC and 17 LJVC were inserted more than once in the same position. Of the RJVC, 44 (10.9%) of 403 were removed because of infection compared with 16 (20.8%) of 77 LJVC (P < 0.02). The overall incidence of infections was 1.58 episodes of infection per 1000 catheter days, 1.57 for RJVC and 3.72 for LJVC, respectively. Catheter dwell times were not different. A group of 127 patients with former RJVC and 44 with LJVC had ipsilateral arteriovenous access (RJVC+ and LJVC+ group, respectively). Four diabetic LJVC+ developed severe arm swelling secondary to CVO leading ultimately to access ligation. The RJVC+ group had no access ligated. LJVC may cause CVO in diabetics.     

超声中线定位方法用于颈内静脉穿刺置管术的临床研究

目的比较两种超声定位方法与解剖定位方法行右颈内静脉(rIJV)穿刺置管的临床效果。方法择期手术患者120例,随机分为三组:解剖定位(AL)组,超声中线预定位(PU)组,超声中线实时定位(RU)组,每组40例。全麻气管插管后行rIJV穿刺置管,记录穿刺针入静脉的位置,穿刺、置管时间,穿刺次数,成功率及并发症。结果与AL组比较,PU组和RU组穿刺点距静脉中点距离明显缩短(P0.01),穿刺、置管时间明显减少(P0.01),穿刺次数明显减少(P0.01),静脉后壁穿透率明显降低(P0.05),一次成功率明显升高(P0.05)。AL组3例误穿动脉,2例血肿,PU组、RU组仅有1例误穿动脉。结论在行IJV穿刺置管过程中超声中线定位比解剖定位具有明显优势,且超声中线预定位和超声中线实时定位同样有效。     

特殊体位患者颈内静脉置管策略

目的探讨特殊体位患者行颈内静脉置管的可行性和临床效果。方法对47例特殊体位(被动体位9例,强迫体位38例)下行颈内静脉置管的患者作好物品与患者准备,根据不同体位确定穿刺步骤和固定导管。结果 47例颈内静脉置管均成功,其中一次置管成功38例。中心静脉置管留置4~151d,中位数22d。留置过程中无与置管相关的不良反应或并发症发生。结论对特殊体位患者行颈内静脉置管需重视各操作环节,尤其是穿刺点定位、穿刺方向、穿刺深度及角度,以提高置管成功率,减少置管相关并发症的发生。