Translumbar inferior vena cava access for Hickman line insertion

The procedure of translumbar inferior vena cava access and Hickman line insertion is described in a patient with acute myeloid leukaemia and thrombosis of the right internal jugular and right innominate vein. This is a useful technique for the interventionist offering a central venous access service.     

Translumbar placement of inferior vena caval catheters: a solution for challenging hemodialysis access

Access to the central venous circulation for hemodialysis has traditionally been achieved via the subclavian or jugular venous routes. With ongoing improvements in medical management, many hemodialysis recipients develop exhaustion of these routes and require alternative means of central venous access. Inferior vena caval (IVC) catheters have been placed with a percutaneous translumbar approach to allow central venous access for chemotherapy, harvesting of stem cells, and total parenteral nutrition. Translumbar placement of IVC catheters has become accepted by some as a useful and reliable alternative in patients who require long-term hemodialysis but have exhausted traditional access sites. IVC catheters have been placed in patients with IVC filters, and IVC filters have been placed in patients with IVC catheters. Complications include those associated with central venous catheters, for example, sepsis, fibrin sheaths, and thrombosis. A complication specific to placement of IVC hemodialysis catheters is migration of the catheter into the subcutaneous soft tissues, retroperitoneum, or iliac veins. Translumbar placement of IVC catheters is performed only in patients considered to have few or no other medical options and is not intended as a primary means of central venous access.     

Determination of optimum retrograde cerebral perfusion conditions

Retrograde cerebral perfusion through a superior vena caval cannula is a new technique used to protect the brain during operations on the aortic arch. We measured cerebral tissue blood flow, oxygen consumption, and cerebrospinal fluid pressure under various perfusion conditions in hypothermic (20 degrees C) mongrel dogs (n = 18, 12.8 +/- 0.6 kg) to determine the optimum conditions for retrograde cerebral perfusion. Retrograde cerebral perfusion was performed by infusion via the superior vena caval cannula and drainage via the ascending aortic cannula while the inferior vena cava and azygos vein were clamped. Retrograde cerebral perfusion was performed as the external jugular venous pressure was changed from 15 to 35 mm Hg in increments of 5 mm Hg. Cerebral tissue blood flow was measured by the hydrogen clearance method. Hypothermic retrograde cerebral perfusion with an external jugular venous pressure of 25 mm Hg provided about half the cerebral tissue blood flow of hypothermic (20 degrees C) cardiopulmonary bypass with a flow rate of 1000 ml/min (13.7 +/- 7.9 versus 32.7 +/- 8.5 ml/min per 100 gm). It decreased significantly as the external jugular venous pressure was decreased from 25 to 15 mm Hg but did not increase significantly as the external jugular venous pressure was increased from 25 to 35 mm Hg. Whole-body oxygen consumption during hypothermic retrograde cerebral perfusion with an external jugular venous pressure of 25 mm Hg was one quarter of that during hypothermic cardiopulmonary bypass (3.4 +/- 0.7 versus 12.7 +/- 5.6 ml/min) and varied in proportion to external jugular venous pressure. The cerebrospinal fluid pressure was a little lower than the external jugular venous pressure (19.2 +/- 4.5 mm Hg versus 24.8 +/- 2.4 mm Hg) but also varied with the external jugular venous pressure. The cerebrospinal fluid pressure remained lower than 25 mm Hg so long as the external jugular venous pressure remained lower than 25 mm Hg. High external jugular venous pressure was associated with high intracranial pressure, which restricts cerebral tissue blood flow and may cause brain edema. We believe that a venous pressure of 25 mm Hg is the optimum condition for retrograde cerebral perfusion.     

Ultrasound-guided cannulation versus the landmark-guided technique for acute haemodialysis access

BACKGROUND: The correct placement of large-bore venous catheters plays an important role in the management of haemodialysis patients. Whilst the procedure for landmark-based placement of these catheters is well known, the technique is not without significant morbidity and mortality. Complications include arterial puncture, haematoma, and pneumothorax. The procedure may be further complicated in these patients by venous thrombosis and abnormal vein position from multiple previous attempts at venous access. METHODS: Data on the use of ultrasound guidance versus anatomical landmarks for the placement of internal jugular vein (n = 69) and femoral vein (n = 30) dialysis access was retrospectively analysed over a 13-month period. Data collected included age, sex, duration on dialysis, number of vein cannulation sets required, number of attempts for successful cannulation, salvage of failed cannulation using landmark-based technique by ultrasound guidance, and the complication rate. RESULTS: Internal jugular vein cannulation using ultrasound was ultimately successful in 96.7% compared to 82% in the landmark group. The vein was entered on the first attempt in 83.3% of patients with ultrasound compared to 35.9% of the landmark group (P < 0.0001). Seven patients in whom the landmark technique was unsuccessful had access placed under ultrasound guidance. There were fewer carotid artery punctures in the ultrasound group (7.7 versus 0%, P = n.s.). In the femoral vein group, the vein was entered on the first attempt in 85.7% of patients with ultrasound compared to 56.25% of the landmark group (P = n.s.). CONCLUSIONS: The use of ultrasound guidance is associated with fewer complications and is more likely to lead to cannulation of the vein at the first attempt in haemodialysis patients.     

Selective transvenous embolization of dural fistulas without occlusion of the dural sinus

Two patients with dural arteriovenous fistulas (DAVFs) and unsuccessful transarterial embolizations were treated with a technique for selective transvenous embolization. A 5F catheter was advanced from a femoral vein access into the internal jugular bulb and a catheter was navigated through the sinus lumen into the involved cortical veins or the parasinusal venous draining channels of the DAVFs. The venous recipients at the nidal level of the DAVFs were occluded by fibered platinum coils. Complete angiographic cure was effected in both patients, with occlusion of the venous recipients and the nidus, although the sinus segments next to the nidus of the DAVFs remained patent. Placement of coils in a transsinusal route into the venous channel of a DAVF yet outside the sinus lumen can result in complete obliteration of the fistula without damage to the physiological function of the dural sinuses.     

Aortic arch anomalies associated with chromosome 22q11 deletion (CATCH 22)

Subcutaneous infusion ports (SIPs) represent a valid method for long-term chemotherapy. The SIPs have several advantages over other methods of venous access: they are easy to implant under local anaesthesia, have less discomfort for the patients, allow low costs, can be implanted in day hospital, and can be managed ambulatorily. However, SIPs have delayed complications, frequently related to clinical conditions of the neoplastic patients, and immediate complications, often due to the placement technique. From March 1992 to March 1997 we placed, under local anaesthesia and under fluoroscopic control, 102 SIPs in 99 general oncology patients for long-term chemotherapy (88% solid, 12% haematological tumours). The percutaneous venous access devices were in the subclavian vein in 96% of the cases and in the internal jugular vein in 4% of them. Immediate complications were: 1 haemopneumothorax, which required thoracic aspirations and two blood transfusions, 1 loop of the tunneled part of the catheter without alterations in SIP function, and 1 left jugular thrombosis in a patient with subclavian veins already thrombosed. The venous access was in the subclavian vein in the first 2 cases, and it was not necessary to suspend the therapeutic program. In the third instance, implanted in jugular vein, it was necessary to remove the SIP. Delayed complications were: 1 necrosis of the skin over the port, 1 infection of subcutaneous pocket, 2 infections of the system, 1 catheter deconnection, and 3 catheter ruptures with embolization of the catheter tip. The SIPs were removed in all cases but 1 in whom infection was successfully treated by appropriate antibiotic therapy. Embolization of the catheter required removal from the pulmonary artery under fluoroscopic guidance in the cardiac catheterization laboratory. In conclusion, infection and thrombosis are the two major complications of SIP in general oncology patients. In these cases it is not necessary to remove systematically the system, but a correct therapy (antibiotic, fibrinolytic agents) can be utilized with good results. The catheter rupture is often due to the wear over the costoclavicular angle. The interventional radiology is the method of choice in the treatment of the catheter embolization by rupture or dislocation. The experience of the surgical and nursing staff is probably the most important factor in decreasing the total rate of complications.     

Pulse-spray treatment of subclavian and jugular venous thrombi with recombinant tissue plasminogen activator

PURPOSE: To evaluate the efficacy of recombinant tissue plasminogen activator (rtPA) injected by pulse-spray in lysing subclavian and jugular venous thrombi. MATERIALS AND METHODS: Twelve patients with symptomatic, venogram-confirmed, occlusive thrombi of the subclavian-axillary or jugular veins were treated with one or two daily 15-minute injections of rtPA delivered directly into the clots with pulse-spray catheters. Twenty-four hours after each treatment, repeated venograms were obtained to assess venous patency. Successful thrombolysis was defined as antegrade flow through the previously occluded segments with minimal collateral venous flow. Continued patency was assessed with repeated venograms obtained after 1 and 2 months of oral anticoagulation. RESULTS: The 15-minute rtPA injections successfully lysed thrombi in eight of the 12 patients. Hypofibrinogenemia developed in only one patient. The technique had a high success rate with thrombi less than 2 weeks old (seven of eight) regardless of the length of the clot, but had limited success with thrombi more than 2 weeks old (one of four). Continued patency over a 2-month interval was documented in four of the eight patients whose thrombi were successfully lysed. However, patency could be maintained in only one of the four patients who retained a venous access device in the treated vein. CONCLUSION: Pulse spray rtPA is an effective, safe, and practical alternative to continuous infusions of thrombolytic agents to treat upper extremity venous thrombi.     

Ruptured vertebrobasilar junction aneurysm associated with basilar artery fenestration

BACKGROUND: The goal of the study was to measure the blood flow parameters of the fetal internal jugular vein during the second half of normal pregnancy using Doppler ultrasound. METHODS: Jugular blood flow was analyzed in 95 normal singleton fetuses between 20 and 42 weeks gestation. Color and pulsed Doppler ultrasound was used to obtain jugular venous waveforms at the level of the mid-neck. Peak velocities, ratios of velocities, and time-averaged maximum velocities were measured. RESULTS: Jugular venous waveforms in healthy fetuses consist of three phases--the first forward peak occurs during ventricle systole; the second forward peak occurs during early diastole and the third peak occurs during atrial contraction. Forty-eight percent of the fetuses demonstrated absent flow during atrial contraction; 32% of fetuses demonstrated forward flow during atrial contraction and finally 20% of fetuses demonstrated flow reversal during atrial contraction. CONCLUSIONS: The reported jugular venous profile may serve as a foundation for future studies of jugular blood flow in high risk fetuses.     

Use of jugular venous blood, compared with mixed venous blood, for measurement of venous oxygenation indices in a porcine model of endotoxic shock

OBJECTIVE: To evaluate the reliability of oxygen saturation and oxygen content values measured from jugular venous blood in estimating values measured from mixed venous blood during endotoxic shock. ANIMALS: 14 random-bred 10- to 15-kg Yorkshire pigs. PROCEDURE: 60 pairs of heparinized blood samples were simultaneously collected from the pulmonary artery and right jugular vein during an independent study, using a porcine model of endotoxic shock. Endotoxic shock was induced by infusion of Escherichia coli endotoxin. Eighteen of the sample pairs were obtained from pigs prior to infusion of endotoxin or from control pigs. Oxygen saturation and venous oxygen content were measured by direct oximetry. Analysis of bias and precision was used to compare jugular venous blood values with values obtained from mixed venous blood. Samples from endotoxemic pigs were subclassified on the basis of abnormal states of global oxygen imbalance associated with septic shock. RESULTS: Indices of venous oxygenation measured from jugular venous blood were an imprecise method of estimating values measured from mixed venous blood. There was no significant difference in bias between nonendotoxemic and endotoxemic pigs, regardless of abnormal hemodynamic states. CONCLUSION: Jugular venous blood oxygen saturation and oxygen content values should not be used to assess global oxygen transport during endotoxic shock.     

Totally implantable systems in oncology: the cephalic vein as an elective access port

The use of totally implantable systems (TIS) has noticeably reduced risks and enhanced quality of life for cancer patients undergoing long-term chemotherapy. One aspect remains open to discussion: site of venous access and placement procedure. Opinions are divided between two techniques: percutaneous access by direct puncture of the subclavian vein or surgical access through the veins afferent to the subclavian: the cephalic, the jugular, or other minor veins. We report our experience with 63 patients undergoing surgical placement of TIS through the cephalic vein. The operatory procedure is divided into four phases: 1) Preparation of vein and cannulation; 2) X-ray control; 3) creation of subcutaneous sheath; 4) reconstruction. None of the 63 patients developed immediate complications. 46 patients are currently using TIS for a period ranging from 17 to 1862 days. 16 patients died during the time their TIS was in place. In only one patient was the TIS removed after treatment was completed. From our results it is clear that the surgical access through the cephalic vein is the most reliable method of TIS placement, with fewer risks concerning immediate and post operatory complications.     

Diagnosis of traumatic carotid-cavernous sinus fistula by monitoring venous oxygen saturation in the jugular bulb: report of two cases

OBJECTIVE AND IMPORTANCE: A traumatic carotid-cavernous sinus fistula (CCF) is rarely diagnosed early and may sometimes be missed until clinical signs and symptoms appear. The continuous monitoring of cerebral venous oxygen saturation may reveal the presence of a CCF by means of a fiberoptic catheter that records very high oxygen saturation values when positioned in the jugular bulb. CLINICAL PRESENTATION: We report two cases of early diagnosis of CCFs unexpectedly revealed by monitoring the jugular bulb for venous oxygen saturation values that approximated arterial saturation values. One case was diagnosed on Day 3 after admission, and the other was diagnosed shortly after cannulation of the ipsilateral jugular bulb. INTERVENTION: Confirmation of the diagnosis of CCF was obtained by angiography. Intravascular treatment was performed in one case. CONCLUSION: These cases add another diagnostic role to cerebral venous oxygen saturation monitoring. When high cerebral venous oxygen saturation values rapidly or abruptly reach arterial oxygen saturation, the presence of a CCF must be considered and confirmed by arterial angiography.     

Complications of internal jugular vein catheterization

Percutaneous cannulation of the internal jugular vein has become a widely accepted method for monitoring central venous pressure, hyperalimentation, and rapid fluid administration. Although complications from this procedure have been rare, many unusual case reports are found in the literature. Three cases of otolaryngologic importance are presented. A revised technique of the internal jugular vein catheterization is described.     

Initial experience in vascular plastic surgery in the surgical treatment of metastases of laryngopharyngeal cancer

The paper concerns conduction of the internal carotid artery and internal jugular vein reconstruction in 3 and 2 patients, respectively, operated for metastases of laryngopharyngeal carcinoma. 4 patients are still alive, 1 died on postoperative day 6. Bilateral one-stage Crile operation with application of autograft venous reconstruction of the internal jugular vein is detailed. Further research in this field is necessary.     

Intraoperative jugular desaturation during surgery for traumatic intracranial hematomas

Traumatic intracranial hematomas which are present on hospital admission or which develop during the hospital course are associated with a worse neurological outcome than diffuse injuries. The purpose of this study was to monitor jugular venous oxygen saturation (Sjvo2) during surgery for evacuation of traumatic intracranial mass lesions, to determine the incidence and the causes of jugular venous desaturation, and to assess the usefulness of Sjvo2 monitoring in this setting. Twenty-five severely head injured patients were monitored during 27 surgical procedures. At the start of the surgical procedure, the median Sjvo2 was 47% (range 25%-89%). Seventeen (63%) of the patients had a Sjvo2 less than 50%. Five patients had extremely low Sjvo2 values (< or = 30%). Upon evacuation of the intracranial hematoma, there was a significant (P < 0.001) increase in the median Sjvo2 to 65% (range 50%-88%). Intracranial hypertension was the primary cause of the low Sjvo2, as confirmed by the response to surgical evacuation. Hypotension (mean arterial pressure < 80 mm Hg) was a contributing factor in seven of the cases of jugular desaturation. The definitive treatment of a traumatic intracranial hematoma is surgical evacuation. However, during the period prior to evacuation of the hematoma, jugular venous desaturation was common, suggesting that monitoring Sjvo2 might provide useful information about the adequacy of cerebral perfusion.     

Jugular venous and arterial concentrations of serum S-100B protein in patients with severe head injury: a pilot study

The objective of this study was to analyse the temporal course of the jugular venous-arterial gradient of S-100B protein after severe head injury and the correlation between the absolute concentrations of serum S-100B protein and outcome, CT findings, and clinical variables. Fifteen patients were included in this pilot study. All patients were treated according to a standard therapy protocol targeted to maintain cerebral perfusion pressure. The serum concentration of S-100 protein was measured daily for five consecutive days after injury by a monoclonal two site immunoluminometric assay. Nine patients showed favourable and six unfavourable outcome after 6 months with a mortality rate of 33% (five patients). The mean gradient between jugular venous and arterial blood was 8.2% (p<0.05). Patients showing an unfavourable outcome had significantly higher jugular venous or arterial S-100 values compared with those with a favourable outcome (jugular venous S-100B 2.78 microg/l v 1.22 microg/l, p<0.05; arterial S-100B 2.48 microg/l v 1.19 microg/l, p<0.05). All patients with an initial or secondary increase in S-100B value of >2 microg/l were found to have an unfavourable outcome. S-100B was found to be an independent predictor of outcome after severe head injury. The persisting increase of S-100B for three to five days even in patients with favourable outcome and no signs of secondary insults might reflect continuing damage to the blood-brain barrier or ongoing glial cell death.     

Jugular venous desaturation and outcome after head injury

Early experience with continuous monitoring of jugular venous oxygen saturation (SjvO2) suggested that this technology might allow early identification of global cerebral ischaemia in patients with severe head injury. The purpose of the present study was to examine the relationship between episodes of jugular venous desaturation and neurological outcome. One hundred and sixteen severely head-injured patients had continuous monitoring of SjvO2 during days 1-5 after injury. Episodes of jugular venous desaturation (SjvO2 < 50% for more than 10 minutes) were prospectively identified, and the incidence of desaturation was correlated with neurological outcome: 77 episodes of desaturation occurred in 46 of the 116 patients; 27 had one episode and 19 had multiple episodes of desaturation. The causes of these episodes were systemic (n = 36), cerebral (n = 35), or both (n = 6). Most of the episodes were less than 1 hour in duration, and it is probable that many of them would not have been detected without continuous measurement of SjvO2. Episodes of desaturation were most common on day 1 after injury, and were twice as common in patients with a reduced cerebral blood flow as in patients with a normal or elevated cerebral blood flow. The occurrence of jugular venous desaturation was strongly associated with a poor neurological outcome. The percentage of patients with a poor neurological outcome was 90% with multiple episodes of desaturation and 74% in patients with one desaturation, compared to 55% in patients with no episodes of desaturation. When adjusted for all co-variates that were found to be significant, including age, Glasgow coma score, papillary reactivity, type of injury, lowest recorded cerebral perfusion pressure, and highest recorded temperature, the incidence of desaturation remained significantly associated with a poor outcome. Although a cause and effect relationship with outcome cannot be established in this study, the data suggest that monitoring SvO2 might allow early identification and therefore treatment of many types of secondary injury to the brain.     

An Anglo-American comparison of the scaling of life events

Exact placement is an essential prerequisite for long-term use of a central venous catheter. Reported data show an extremely wide range of catheteral misplacements: from less than 1% to more than 60%. Some approaches appear to be less advantageous than others, but the highest rates of misplacement occur in the cubital, external jugular and saphenous veins. A series is presented of 378 radiographically controlled central venous catheters analysed for aberrant placement and loop formation. The total occurrence of faulty positioning and coiling reached 5.3%, while the respective incidences were 30% for the external jugular vein, 5.7% for the internal jugular vein, 5.5% for the infraclavicular technique of subclavian venepuncture, 5.3% for the innominate vein and 1.4% for the supraclavicular approach of subclavian venepuncture. The total frequency for pure loop formation was 2.9%. The authors discuss numerous reported data on catheter malpositioning, according to the specific techniques used, and compare them with thier own results. The relatively low incidence in the present series is possibly due to the high proportion of cases where the supraclavicular subclavian approach was used, the omission of the sphrenous/femoral and cubital techniques, and to pre-determining the length of the inserted catheteral segments.     

Cannulation of neonates for venovenous extracorporeal life support

Venovenous access via a double-lumen cannula in the right internal jugular vein is the extracorporeal life support mode of choice for neonates with respiratory failure. We report a simplified method of cannulation. The advantages of this "semi-Seldinger" method include the ability to cannulate without ligating the internal jugular vein, and to adjust the position of the cannula and decannulate without re-exploring the wound.     

Mechanism of bioactive substance release and the response to various drugs

Jugular plebectasia is rare, and most patients present in childhood. We describe a thrombotic episode within an external jugular venous aneurysm in an adult. This has not previously been described in the medical literature.     

Importance of eliminating portal flow to produce large intrahepatic lesions with interstitial laser coagulation

The objective of this study was to determine the incidence of internal jugular vein thrombosis in patients undergoing free flap reconstruction and simultaneous neck dissection. Patients underwent Doppler ultrasound examination of their internal jugular veins on postoperative days 1 and 7 after functional neck dissection and free flap transfer. Long-term follow up was obtained at a minimum of 3 months. The incidence of internal jugular vein thrombosis in patients undergoing free flap reconstruction with simultaneous neck dissection is similar to that of patients undergoing just neck dissection. A significant number of these veins recanalize and have excellent long term patency. There does not seem to be a correlation between venous thrombosis and free flap survival.