Simplified technique for retrograde cerebral perfusion during repair of distal aortic arch and proximal descending thoracic aorta

Lesions of distal aortic arch and proximal descending thoracic aorta require a posterolateral thoracotomy approach and total circulatory arrest. Retrograde cerebral perfusion through the superior vena cava is technically difficult in such situations. We describe a simplified technique for delivery of retrograde cerebral perfusion through the left internal jugular vein.     

Selective jugular cannulation for hypothermic retrograde cerebral perfusion in thoracic aortic operations (reverse over the wire-catheter method)]

We have employed hypothermic retrograde total body perfusion via the caval cannulae as a supportive measures to protect the brain and other systemic organs in operations for aortic arch aneurysms or acute aortic dissection. But occasionally unsatisfactory results ensued, because competent valves located in the internal jugular vein near the jugulo-subclavian junction may block retrograde blood flow to the brain from the caval cannula. To cope with this problem, we designed an easy and safe method to cannulate the internal jugular vein transatrially utilizing guidewire and central venous catheter, and thereafter we have used this technique clinically and obtained good results.     

Percutaneous cannulation of the internal jugular vein

Two simple techniques for central venous cannulation by percutaneous puncture of the right internal jugular vein are described. They have been employed routinely for the last six months in all patients requiring central venous cannulation. No serious complications or difficulties have been encountered in a series of two hundred cases. The method allows free movement of the limbs postoperatively and avoids the painful thrombotic sequelae associated with the use of superficial veins for long-term cannulation.     

A randomized study of left versus right internal jugular vein cannulation in adults

STUDY OBJECTIVE: To compare the success rate and incidence of complications of right internal jugular vein (RIJV) versus left internal jugular vein (LIJV) cannulation using external landmarks or surface ultrasound guidance. DESIGN: Prospective randomized study. SETTING: Operating room of a university-affiliated hospital. PATIENTS: 120 adult patients scheduled for elective abdominal, vascular, or cardiothoracic procedures with general anesthesia and mechanical ventilation in whom central venous cannulation was clinically indicated. INTERVENTIONS: Patients were randomized to four groups for RIJV cannulation using the landmark approach (Group 1) or surface ultrasound (Group 2) versus LIJV cannulation with the landmark approach (Group 3) or ultrasound (Group 4). MEASUREMENTS AND MAIN RESULTS: The data collected included time from first puncture to guidewire insertion, number of attempts, and associated complications. If conversion to the ultrasound technique was required, the number of crossover patients and reasons for failure were recorded. Cannulation of the LIJV was more time consuming; it required more attempts; and it was associated with a greater number of complications when compared to the right side (p < 0.05). CONCLUSIONS: Left IJV cannulation is more time consuming than RIJV cannulation and is associated with a higher incidence of complications. The use of ultrasound improves success rate and decreases the number of complications during IJV cannulation.     

Ultrasound guidance for internal jugular vein cannulation: Continuing Professional Development

Purpose

The objective of this continuing professional development module is to describe the role of ultrasound for central venous catheterization and to specify its benefits and limitations. Although ultrasound techniques are useful for all central venous access sites, the focus of this module is on the internal jugular vein approach.

Principal findings

In recent years, several studies were published on the benefits of ultrasound use for central venous catheterization. This technique has evolved rapidly due to improvements in the equipment and technology available. Ultrasound helps to detect the anatomical variants of the internal jugular vein. The typical anterolateral position of the internal jugular vein with respect to the carotid is found in only 9-92% of cases. Ultrasound guidance reduces the rate of mechanical, infectious, and thrombotic complications by 57%, and it also reduces the failure rate by 86%. Cost-benefit analyses show that the cost of ultrasound equipment is compensated by the decrease in the expenses associated with the treatment of complications. In this article, we will review the history of ultrasound guidance as well as the reasons that account for its superiority over the classical anatomical landmark technique. We will describe the equipment needed for central venous catheterization as well as the various methods to visualize with ultrasound.

Conclusion

To improve patient safety, we recommend the use of ultrasound for central venous catheterization using the internal jugular approach.     

Impact of retrograde cerebral perfusion on aortic arch aneurysm repair

OBJECTIVE: Protection of the brain is a primary concern in aortic arch surgery. Retrograde cerebral perfusion is a relatively new technique used for cerebral protection during profound hypothermic circulatory arrest. This study was designed to compare, retrospectively, the outcome of 109 patients undergoing aortic arch operation with and without the use of retrograde cerebral perfusion. METHODS: Fifty-five patients had profound hypothermic circulatory arrest alone, and 54 patients had supplemental cerebral protection with retrograde cerebral perfusion. Mean age was 61 +/- 13 years and 58 +/- 14 years, respectively (mean +/- standard deviation). Twenty-two preoperative and intraoperative characteristics, including age, sex, acuity, presence of aortic dissection, and aneurysm rupture, were similar in the 2 groups (P >.05). RESULTS: Mean circulatory arrest times (in minutes) were 30 +/- 19 in the group without retrograde cerebral perfusion and 33 +/- 19 in the group with retrograde cerebral perfusion, respectively. chi(2) Analysis revealed that patients operated on with the use of retrograde cerebral perfusion had significantly lower hospital mortality (15% vs 31%; P =.04) and in-hospital permanent neurologic complications (9% vs 27%; P =.01). Retrograde cerebral perfusion failed to reduce the prevalence of temporary neurologic dysfunction (17% vs 18%; P =.9). Stepwise multiple logistic regression revealed that extracorporeal circulation time, age, and lack of retrograde cerebral perfusion were statistically significant independent risk factors for hospital mortality. The same analysis revealed that lack of retrograde cerebral perfusion was the only significant independent risk factor for permanent neurologic dysfunction. CONCLUSION: Retrograde cerebral perfusion decreased the prevalence of permanent neurologic complications and the hospital mortality in patients undergoing aortic arch operations.     

超声引导在患儿颈内静脉穿刺置管中的应用

目的 比较超声引导与传统体表标志定位在患儿颈内静脉穿刺置管中的差异.方法 将53例行心脏外科或消化道手术的患儿(0～36个月)随机分成超声引导组(U组,28例)和体表定位组(L组,25例).前者在超声引导下行颈内静脉置管术,后者使用传统的体表标志定位法行颈内静脉置管术.记录两组成功率、穿刺时间、试穿次数及并发症.结果 U组一次成功率为96.43％,明显高于L组的80％ (P＜0.05);穿刺相关并发症U组仅3.57％,明显低于L组28％(P＜0.01),同时U组穿刺时间明显短于L组(P＜0.05),穿刺次数明显少于L组(P＜0.05).结论 超声引导应用于患儿颈内静脉穿刺置管可提高置管成功率,减少并发症的发生.     

Optimal arterial cannulation technique for selective cerebral perfusion in thoracic aortic surgery

Despite advances in surgical procedures, anesthetic management, and cardiopulmonary bypass, brain injury remains a major source of morbidity and mortality in patients undergoing operations on the thoracic aorta. Here, we report our experience with arch vessel cannulation for selective cerebral perfusion in 32 consecutive patients with thoracic aneurysms who underwent total arch replacement between 1998 and 2000. The innominate vein was divided, and intraoperative epiaortic echography was performed to identify the least atherosclerotic site on brachiocephalic and left carotid arteries before establishment of cardiopulmonary bypass. There were no in-hospital deaths, and only 1 patient (3.1%) had a perioperative stroke. Identifying the least atherosclerotic site in cephalic branches is important for safely establishing selective cerebral perfusion and for preventing perioperative cerebral embolism during total arch replacement.     

Comparison of three techniques for internal jugular vein cannulation in infants

Central venous cannulation allows accurate monitoring of right atrial pressure and infusion of drugs during the anaesthetic management of infants undergoing cardiopulmonary bypass. In this prospective, randomized study, we compared the success and speed of cannulation of the internal jugular vein in 45 infants weighing less than 10 kg using three modes of identification: auditory signals from internal ultrasound (SmartNeedle, SM), external ultrasound imaging (Imaging Method, IM) and the traditional palpation of the carotid pulsation and other landmarks (Landmarks Method, LM). The cannulation time, number of attempts with LM and SM techniques were greater than those with IM technique. The incidence of carotid artery puncture and the success rate were not significantly different among the three groups. In infants, a method based on visual ultrasound identification (IM) of the internal jugular vein is more precise and efficient than methods based on auditory (SM) and tactile perception (LM).     

A simple method for percutaneous cannulation of the internal jugular vein

A safe and rapid technic for internal jugular vein cannulation is described. The success rate is almost as high and the serious complication rate is much lower than subclavian vein cannulation.     

Competence of the internal jugular vein valve is damaged by cannulation and catheterization of the internal jugular vein

BACKGROUND: Experimental results suggest that the competence of the internal jugular vein (IJV) valve may be damaged when the IJV is cannulated for insertion of a central venous catheter. It has further been hypothesized that the risk of causing incompetence of the proximally located valve might be reduced by using a more distal site for venous cannulation. The present study evaluated these hypotheses in surgical patients. METHODS: Ninety-one patients without preexisting incompetence of the IJV valve were randomly assigned to undergo distal or proximal IJV cannulation (> or = 1 cm above or below the cricoid level, respectively). Color Doppler ultrasound was used to study whether new valvular incompetence was present during Valsalva maneuvers after insertion of a central venous catheter, immediately after removal of the catheter, and, in a subset of patients, several months after catheter removal, when compared with baseline findings before cannulation of the IJV. RESULTS: Incompetence of the IJV valve was frequently induced both by proximal and distal cannulation and catheterization of the IJV. Its incidence was higher after proximal than after distal cannulation (76% vs. 41%; P < 0.01) and tended to be so after removal of the catheter (47% vs. 28%; P = 0.07). Valvular incompetence persisting immediately after removal of the catheter did not recover within 8-27 months in most cases. CONCLUSIONS: Cannulation and catheterization of the IJV may cause persistent incompetence of the IJV valve. Choosing a more distal site for venous cannulation may slightly lower the risk of causing valvular incompetence but does not reliably avoid it.     

A complication of percutaneous cannulation of the internal jugular vein

Reviews of the use of the technique of percutaneous cannulation of the internal jugular vein for central venous pressure monitoring have indicated that it is free from serious complications. A patient is reported here in whom the ascending cervical artery was damaged during attempted cannulation of the internal jugular vein prior to aortic valve replacement. Haemorrhage from this site after the operation led initially to an extrapleural haematoma and soon afterwards to a haemothorax, which proved fatal despite immediate resuscitation and exploration.