Migration of a distal ventriculoperitoneal shunt catheter into the internal jugular vein and heart through the external jugular vein: case report

A 6-year-old boy had undergone ventriculoperitoneal (VP) shunt for acute hydrocephalus because of a brain tumor at the age of 11 months, and presented with vomiting and somnolence after the shunt malfunctioned 6 days after VP shunt reconstruction, during which the right external jugular vein was injured during the tunneling process and the peritoneal catheter was not fixed to the peritoneum with a purse string suture. Radiography revealed an abnormal route of the peritoneal catheter, suggesting that the distal VP shunt catheter had migrated into venous vasculature through the right external jugular vein. Computed tomography revealed that the peritoneal catheter had migrated into the internal jugular vein and the right atrium. At surgery, the peritoneal catheter was exposed through a small incision on the subclavicular region, was easily extracted from the internal jugular vein and the heart as there was no coiling or adhesion of the distal catheter to the vascular tissues, and was repositioned into the peritoneum with weak fixing between the subcutaneous tissues of the right subclavicular region and the right abdominal rectus muscle fascia as a temporary emergency measure. Peritoneal shunt migration into the internal jugular vein and the heart through the external jugular vein can be lethal because of pulmonary infarction or arrhythmia, and must be detected as soon as possible. Periodic follow-up radiography should be scheduled after VP shunt placement, even in the absence of symptoms.     

Prediction of a small internal jugular vein by external jugular vein diameter

The relationship between internal jugular vein diameter as measured with an ultrasound imaging machine (SiteRite, Dymax) and external jugular vein diameter was studied in 50 anaesthetised patients undergoing elective cardiac surgery. There was an inverse correlation between external jugular vein diameter and internal jugular vein diameter ( r  = −0.47, p < 0.001). All patients with an external jugular vein diameter of 7 mm or greater had an internal jugular vein diameter of less than 15 mm. No patient with an external jugular vein diameter of less than 7 mm had an internal jugular vein diameter of less than 20 mm. No other patient dimension (height, weight, body mass index, neck circumference) predicted internal jugular vein size. These results suggest that a large external jugular vein (i.e. 7 mm or greater in external diameter) may be associated with a small internal jugular vein. A size 5.0-mm internal diameter tracheal tube may be used to provide a rapid assessment of external jugular vein diameter.     

Internal jugular vein occlusion test for rapid diagnosis of misplaced subclavian vein catheter into the internal jugular vein.

BACKGROUND: During subclavian vein catheterization, the most common misplacement of the catheter is cephalad, into the ipsilateral internal jugular vein (IJV). This can be detected by chest radiography. However, after any repositioning of the catheter, subsequent chest radiography is required. In an effort to simplify the detection of a misplaced subclavian vein catheter, the authors assessed a previously published detection method. METHODS: One hundred adult patients scheduled for subclavian vein cannulation were included in this study. After placement of subclavian vein catheter, chest radiography was performed. While the x-ray film was being processed, the authors performed an IJV occlusion test by applying external pressure on the IJV for approximately 10 s in the supraclavicular area and observed the change in central venous pressure and its waveform pattern. The observations thus obtained were compared with the position of catheter in chest radiographs, and the sensitivity and specificity of this method were evaluated using a 2 x 2 table. RESULTS: In 96 patients, subclavian vein cannulation was successfully performed. In four patients, cannulation was unsuccessful; therefore, these patients were excluded from the study. There were six misplacements of venous catheters as detected by radiography. In five (5.2%) patients, the catheter tip was located in the ipsilateral IJV, and in one (1.02%), the catheter tip was located in the contralateral subclavian vein. In the patients who had a misplaced catheter into the IJV, IJV occlusion test results were positive, with an increase of 3-5 mmHg in central venous pressure, whereas the test results were negative in patients who had normally placed catheters or misplacement of a catheter other than in the IJV. There were no false-positive or false-negative test results. CONCLUSION: The IJV occlusion test successfully detects the misplacement of subclavian vein catheter into the IJV. However, it does not detect any other misplacement. The test may allow avoidance of repeated exposure to x-rays after catheter insertion and repositioning.     

Neurologic complications during the placing of a catheter into the internal jugular vein

Attempted puncture of the internal jugular vein in a 53 year old patient was followed by a reversible hemisyndrome. Therapy and course are described. Neurological complications caused by puncture of the jugular internal vein and measures for prevention are discussed.     

Case of meningioma with extracranial extension through the internal jugular vein

We report a case of posterior fossa meningioma extending into the cervical jugular vein, which was successfully resected. A 57-year old male with ataxia and mild hypogeusia was admitted to our hospital. MRI demonstrated a well-circumscribed large posterior fossa mass with extracranial extension through the internal jugular vein. Two-staged surgical treatment was then performed. The mass in the posterior fossa was removed at the first operation. The tumor was invading into the sigmoid sinus which was filled with tumor. The second operation for extracranial mass was performed 1 month later. Transcervically, the internal jugular vein obstructed by tumor was successfully removed. The post-operative course was uneventful and histopathological examination revealed the fibrous meningioma in the posterior fossa, but the intravenous portion of the tumor showed more atypical findings. Such a case is quite uncommon and the mechanism of tumor extension with different histological features is discussed.     

Cannulation of the internal jugular vein

A new approach to internal jugular vein catheterisation in the neck (the 'very high' approach) was used in 335 patients over a 12-month period. The success rate was 100% and there were no complications. It proved to be an easy technique to learn and may be particularly useful in difficult and emergency situations.