Central Venous Catheterization - Anatomical Review - Internal Jugular Vein

Prévia do material em texto

REVIEW
Central Venous Catheterization—An
Anatomical Review of a Clinical Skill,
Part 2: Internal Jugular Vein via the
Supraclavicular Approach
J.M. BOON,1{ A.N. VAN SCHOOR,1* P.H. ABRAHAMS,1,2,3 J.H. MEIRING,1 AND T. WELCH4
1Department of Anatomy, University of Pretoria, Pretoria, South Africa
2Girton College, Cambridge, United Kingdom
3Institute of Clinical Education, Warwick Medical School, Coventry, United Kingdom
4Queen’s College, Cambridge, United Kingdom
The safe and successful performance of a central venous catheterization (CVC)
requires a specific knowledge of anatomy in addition to a working knowledge.
Misunderstanding the anatomy may result in failure or complications. This
review aims to aid understanding of the anatomical framework, pitfalls, and
complications of CVC of the internal jugular veins. CVC is common practice
amongst surgeons, anesthesiologists, and emergency room physicians during
the preparations for major surgical procedures such as open-heart surgery, as
well as for intensive care monitoring and rapid restoration of blood volume.
Associated with this technique are certain anatomical pitfalls and complications
that can be successfully avoided if one possesses a thorough knowledge of the
contraindications, regional anatomy, and rationale of the technique. Clin. Anat.
21:15–22, 2008. VVC 2007Wiley-Liss, Inc.
Key words: clinical procedures; central venous catheterization; anatomy; pit-
falls; complications; internal jugular vein
INTRODUCTION
Central venous catheterization (CVC) is a common
practice amongst surgeons, anesthesiologists, and
emergency room physicians, during the preparations
for major surgical procedures (Chudhari et al.,
1998). CVC can serve as a means for parenteral
nutrition, administration of drugs and fluids, and
allowing for invasive monitoring of cardiac parame-
ters (Luckraz, 2003).
However, serious complications can occur when
the clinician lacks a sound understanding of the
anatomy that plays a vital role in the safe and
successful performance of CVC (Abrahams and
Webb, 1975; McMinn et al., 1984; Beahrs et al.,
1986; Crisp, 1989; Ger, 1996; American Association
of Clinical Anatomists (AACA, EAC), 1999; Cottam,
1999; Boon et al., 2001). A lack of anatomical
knowledge can also prolong a procedure, which will
inevitably lead to increased morbidity and mortality
(Beahrs et al., 1986; Graney, 1996). Competency to
perform clinical procedures such as CVC only exists
when a practitioner has sufficient knowledge and
manual skills required to perform the procedure
safely and successfully.
Therefore, an important part of competency is a
sufficient and updated knowledge base, which is
necessary to perform a safe and successful proce-
dure. Recognition of the relevant anatomy to any
specific procedure remains the important basis of
{Deceased.
*Correspondence to: A. van Schoor, Department of Anatomy,
Section of Clinical Anatomy, School of Medicine, Faculty of Health
Sciences, University of Pretoria, Pretoria 0001, South Africa.
E-mail: albert.vanschoor@med.up.ac.za
Received 4 November 2005; Revised 20 July 2007; Accepted 7
October 2007
Published online 3 December 2007 in Wiley InterScience (www.
interscience.wiley.com). DOI 10.1002/ca.20563
VVC 2007 Wiley-Liss, Inc.
Clinical Anatomy 21:15–22 (2008)
this knowledge. Phillips (1987) points to the impor-
tance of identifying those features of anatomical
relationships that are of special interest to clinicians
performing CVC.
This article reviews the clinical anatomy of CVC of
the internal jugular vein (IJV). It starts with a step-
by-step description of the different procedures and
then focuses on the anatomical pitfalls and complica-
tions.
STEP-BY-STEP PROCEDURE
1. Place the patient in a supine position, at least
158 head down (Trendelenburg’s position), to
distend the veins in the neck and prevent the
possible occurrence of an air embolism. Only if
the cervical spine has been cleared radiograph-
ically can the patient’s head be turned away
from the puncture site (Shimada and Sato,
1997).
2. Sterile preparation of the skin and drape the
area. Sterile gloves should be worn during the
procedure.
3. Use a local anesthetic if the patient is awake. This
is not necessary if the patient is under general
anesthesia.
4. Locate the carotid artery by palpation in the
space between the trachea and sternocleido-
mastoid (SCM). Thereafter do not palpate the
carotid pulse again (Bazaral and Harlan, 1981).
The vein is located immediately lateral to the
carotid pulse (Ellis and Feldman, 1997).
Anterior Approach (see Fig. 1)
5. Introduce a large caliber needle attached to a
syringe into the center of the triangle formed
by the sternal and clavicular heads of SCM and
the clavicle (Sedillot’s triangle).
6. Direct the needle inferiorly, parallel to the sag-
ittal plane, 30–458 posterior to the frontal
plane. The needle should be advanced inferi-
orly and slightly laterally toward the anterior
end of the first rib behind the clavicle.
7. Slowly advance the needle while gently with-
drawing the plunger of the syringe.
8. When free flow of blood appears, remove the
syringe and occlude the needle with a finger to
prevent air embolism.
Posterior Approach (Paschall and Mandel,
1983) (see Fig. 2)
5. Find a point one-third of the distance along the
line between the sternal head of the clavicle
and the mastoid process, just lateral to SCM
(Paschall and Mandel, 1983). At this point, the
external jugular vein (which should not be used
because of its valves) crosses over SCM.
6. Introduce the needle and cannula at an angle
of 30–408 to the skin, deep to SCM and
advance inferiorly and medially toward the
suprasternal notch until entering the IJV at a
depth of 2–3 cm (Abrahams and Webb, 1975).
7. The needle is hence advanced through skin,
superficial fascia, platysma, and deep cervical
fascia.
8. Insert the guidewire and remove the needle.
Then insert the catheter over the guidewire.
Anterior and Posterior Approaches
9. Remove the guidewire and connect the cathe-
ter to the intravenous line.
10. Fix the catheter in place.
11. Attach the central venous pressure setup to
the intravenous tubing and adjust the manom-
eter to level zero with the level of the patient’s
right atrium.
12. Obtain a chest X-ray to identify the position of
the tip of the catheter and a possible pneumo-
thorax.
13. Obtain free flow intravenous fluid with gravity
and flow of blood through the catheter tubing
on lowering the intravenous fluid bag below
the level of the patient.
Direction of the Needle
The needle is inserted at the apex of the triangle
formed by the sternal and clavicular heads of SCM.
The apex is situated *5.0 cm superior to the clavi-
cle. The vein lies at a depth of 1.0–1.5 cm below the
skin between SCM and the cervical pleura. The nee-
dle should be directed in a caudal direction at an
angle of 30–458 to the frontal plane, keeping the
needle parallel to the sagittal plane. This ensures
that the needle is directed along the central axis of
the vein (AACA, EAC, 1999).
Bazaral and Harlan (1981) suggests a needle
insertion at or above the cricoid cartilage. The needle
should be inserted at a 30–408 angle to the skin,
expecting the IJV 1.0–2.0 cm inferior to the cricoid
cartilage ring at a depth of 1.0–1.5 cm. The head
should not be extremely rotated, which may cause
SCM to overlie the vein.
Correct Placement of Catheter Tip
The catheter tip should be placed 3.0–4.0 cm
above the junction of the superior vena cava and the
right atrium (Blitt, 1985).
Equipment Selection and Ultrasound
Guidance
The choice of equipment depends greatly on what
the clinician is trying to accomplish, what equipment
is available to him, or what equipment he feels most
comfortable using.
It should be noted that in a study conducted by
Onders et al. (2006), they found that more difficulty
was associated with the insertion of a larger triple-
lumen catheter when compared with the smaller
single lumen catheter (31% vs. 11%, respectively;
P <0.009). Although Lakhal et al. (2006) concluded
that central venous pressure (CVP) measurement
made at the distal ports of a multi-lumen catheter
16 Boon et al.
Fig. 1. Surface anatomy of the
neck indicating the procedure for
inserting a CVC into the IJV via the
anterior approach. The circle indi-
cates location for needle insertion
and the arrow represents the direc-
tion in which the needle should be
inserted. (1) Sternal head of SCM,
(2) clavicular head of SCM, (3)
manubium, (4) right brachiocephalic
vein, (5) right subclavian vein, (6)
right IJV, (7) sternal notch, and (8)
clavicle.
Fig. 2. Surface anatomy of the
neck indicating the procedure for
inserting a CVC into the IJV via the
posterior approach. The dotted line
indicates a line between the sternal
head of the clavicle and the mastoid
process. The circle indicates location
for needle insertion and the arrow
represents the direction in which
the needle should be inserted. (1)
Sternal head of SCM, (2) clavicular
head of SCM, (3) manubium, (4)
right brachiocephalic vein, (5) right
subclavian vein, (6) right IJV, (7)
sternal notch, and (8) clavicle.
17Internal Jugular Vein Catheterization
are not influenced by high flows through the proxi-
mal ports. The advantage of inserting a multi-lumen
catheter is that it is therefore not necessary
to discontinue the fluid infusion during a CVP
measurement.
Ultrasound guidance is useful in helping to locate
the subclavian vein (SCV) for CVC and it decreases
the complications that may occur (i.e., pneumo-
thorax and arterial puncture). However, it does not
decrease the technical difficulties that may occur
(Hind et al., 2003). According to both Bold et al.
(1998) and Lefrant et al. (1998), ultrasound guid-
ance does not have a significant effect on improving
the success rate of CVC during clinical trials and that
the anatomical landmark-based technique remains
reliable.
PATIENT POSITION
The patient should be positioned in the Trendelen-
burg position. This facilitates filling of the vein and
decreases the risk of air embolism (Mathers et al.,
1992).
Brederlau et al. (2004) conducted a study on 64
ventilated ICU patients (14 female, 50 male) with a
median age of 52 years (range, 18–85 years), need-
ing central venous cannulation for insertion of a
central venous catheter, haemodialysis, or pulmo-
nary artery catheter. The majority of patients pre-
sented with risk factors for a difficult cannulation and
catheterization was performed using real-time ultra-
sound guidance with all patients positioned in 308
dorsal elevation. Despite a high incidence of anoma-
lous anatomy (39%) no injury to the carotid artery
occurred and all attempts were successful. The
authors concluded that ultrasound-guided cannula-
tion of the IJV can be performed successfully with
the patient positioned in 308 dorsal elevation. Poten-
tially deleterious position changes can thus be
avoided in high-risk patients.
Turning of the Head
Turning the head should only be done if a possible
neck injury has been excluded. Although anatomical
studies have not confirmed the benefit of turning
the head away from the site of catheter insertion
(Jesseph et al., 1987), it may decrease the risk of
contamination and patient anxiety during the proce-
dure (Dronen and Younger, 1994).
Jesseph et al. (1987) stated that by turning the
head the acuteness of the angle of the SCV and IJV
is increased. They suggest a position of lying supine
with the head and shoulders in a neutral position.
This is a favorable position considering the fact that
many patients needing a central venous catheter in
the emergency department have suspected neck
injuries where manipulation of the head is totally
contraindicated.
The angle of the SCV with the IJV is more or less
908 (Jesseph et al., 1987), and increases when the
head is turned to one side. This suggests that turn-
ing the head away from the side of the puncture may
in fact promote malpositioning in the IJV. Turning
the head toward the site where the procedure is per-
formed may prevent the advancing catheter from
moving into the IJV.
ANATOMICAL PITFALLS
The following anatomical pitfalls, associated with
inserting a CVC via the IJV, is essentially the same
to that of inserting a CVC via the SCV (see Part 1:
Subclavian vein, Clin Anat 20:602–611): Superior
vena cava, phrenic nerve, vagus nerve, thoracic
duct, right lymphatic duct, apex of the lung, and the
cervical pleura.
Internal Jugular Vein
The IJV is most frequently used for CVC (Mathers
et al., 1992). It lies in a straight line connecting the
mastoid process and the medial end of the clavicle
and is more distensible than the SCV. This is shown
by narrowing of the diameter of the vein with pro-
longed palpation of the carotid pulse (Armstrong et
al., 1994). The diameter of the internal jugular ves-
sel is greatest below the cricoid cartilage, where it
may reach 2.0–2.5 cm (Bazaral and Harlan, 1981).
The transverse process of the atlas, the cervical
plexus in the upper neck, and the anterior and mid-
dle scalene lie posterior to the IJV. More inferiorly
the phrenic nerve, thyrocervical trunk, and first part
of the subclavian artery are found posterior to the
IJV. The common carotid artery and vagus nerve are
found medial to the IJV (Bazaral and Harlan, 1981).
As the vein approaches the supraclavicular junction
with the SCV, it takes a more medial position in the
triangle between the two heads of SCM.
A head-down tilt of 158 (Trendelenburg position)
causes significant distension of the vein. Both exten-
sive palpation of the neck and rotation of the head
increase the difficulty to cannulate the vein. Exten-
sive palpation of the carotid artery may distort the
anatomy. Therefore, Bazaral and Harlan (1981) rec-
ommend that after locating the artery, palpation
should be discontinued.
The IJV is more collapsible compared to the SCV
(AACA, EAC, 1999). This may complicate catheteri-
zation. The advancing needle may press the anterior
wall of the vein against the posterior wall. This may
result in passing the needle through both walls with-
out locating the lumen. If no blood is found after
advancing the needle at a depth of 2.0–2.5 cm, the
needle should be withdrawn and therefore reestab-
lishing a lumen by drawing the anterior wall from the
posterior wall.
The right IJV is preferred because of its straight
course into the superior vena cava and right atrium,
which facilitates successful and correct placement of
the catheter (Mathers et al., 1992).
An anatomical study conducted by Botha et al.
(2006) showed that the IJV lies directly posterior to
the apex of the triangle, formed when the sternal
and clavicular heads of SCM merge (Sedilott’s trian-
gle), in 78.79% of the cases on the left and 97.14%
of the cases on the right.
18 Boon et al.
External Jugular Vein
The external jugular vein crosses over SCM at a
point one third of the distance along the line between
the sternal head of the clavicle and the mastoid pro-
cess. It is separated from the sternomastoid by the
cervical fascia and often has one or more sets of
valves in its course through the neck (Abrahams and
Webb, 1975; Cobb et al, 1987; Mathers et al.,
1992).
Common Carotid Artery
The common carotid artery usually lies medial to
the IJV (Edwards and Morgan, 1989). In a study
conducted by Denys and Uretsky (1991), they found
that in about 92% of cases (n ¼ 200 patients) the
IJV was antero-lateral to the common carotid artery.
In 1% the IJV was more than 1.0 cm lateral from the
common carotid artery. The IJV can lie antero-medi-
ally to the common carotid artery in about 2% and in
5% of cases the IJV lies totally out of the path that
was predicted by the external surface landmarks.
ANATOMICALLY RELEVANT
COMPLICATIONS
The following anatomically relevant complications,
associated with inserting a CVC via the IJV, is essen-
tially the same to that of inserting a CVC via the SCV
(see Part 1: Suclavian vein, Clin Anat 20:602–611):
Venous air embolism, cardiac tamponade, dysrhyth-
mias,pneumothorax, hydrothorax, thrombosis, cath-
eter related infection, and catheter embolization.
Arterial Puncture
With CVC of the IJV, arterial puncture usually
involves the common carotid artery, because of its
close anatomical relationship to the IJV (Caridi et al.,
1998; Chudhari et al., 1998; Denys and Uretsky,
1991). Yeum et al. (2001) retrospectively analyzed
the data on 150 IJV catheterization attempts on 132
patients. Arterial puncture of the common carotid
artery occurred in 11.3% of cases.
The direct result of puncturing either the subcla-
vian artery or the common carotid artery is the for-
mation of a hematoma (Chudhari et al., 1998). Mild
to severe thrombosis may also occur, especially in
long-term catheterization (Chudhari et al., 1998;
Iovino et al., 2001; Schummer et al., 2003), result-
ing in the possible compression of the surrounding
structures.
Arterial pseudo-aneurysms have also been reported
to occur after puncturing the common carotid artery or
the thyrocervical trunk (Luckraz, 2003).
Wisheart et al. (1972) reported a case of lacera-
tion of the ascending cervical artery, with massive
hemothorax, after inserting a catheter via the IJV.
Schummer et al. (2005) recently reported a case
where intra-arterial misplacement was confirmed
using a pressure transducer, after attempting an IJV
catheterization. Surgical exploration of the neck
showed that the carotid artery remained uninjured;
however, the introducer sheath had completely
punctured the right IJV and entered the inferior thy-
roid artery.
Puncturing the pulmonary artery has also been
documented in the literature (Rosen and Latto,
1992). One study reported the puncturing of the
ascending aorta (Childs and Wilkes, 1986), within
the pericardial reflection causing a fatal hemoperi-
cardium. The patient reported by Childs and Wilkes
(1986) had gross abdominal distension, causing
superior movement of the intrathoracic structures
and therefore changes in the classical anatomical
landmarks.
Failure to Locate the IJV
Locating the IJV becomes more difficult after com-
mon carotid arterial puncture because of venous
compression from hematoma formation due to arte-
rial leakage. (Armstrong et al., 1994).
The anterior wall of the vein may also, due to the
collapsible nature of the vein, be pushed against the
posterior wall by the needle. The needle may there-
fore puncture both walls without reaching the lumen.
Withdrawal of the needle at this point may draw the
anterior wall away from the posterior wall and with
aspiration the lumen of the vein may so be encoun-
tered (AACA, EAC, 1999). According to Chudhari
et al. (1998), venous pseudo-aneurysms are a com-
mon occurrence when multiple attempts at punctur-
ing the IJV have been attempted.
Hemothorax
The development of a hemothorax is similar to
complications discussed in Part 1: Subclavian vein in
Clin Anat 2007;20.
Lovell and Baines (2000) reported a fatal case of
hemothorax in a child, following the attempted
placement of a cannula in the left IJV. Extravasation
of blood products via the cannula resulted in haemo-
thorax, hypotension, and eventual brain death.
Brachial Plexus Injury
Injury of the brachial plexus may occur when the
correct technique is not followed and the needle is
not directed correctly. The brachial plexus lies poste-
rior to the subclavian artery posterior to anterior
scalene and both cross the first rib only 2.0 cm lat-
eral to the SCV (Smith et al., 1965). Therefore,
brachial plexus injuries are more common with the
catheterization of the SCV and is usually associated
with a subclavian artery puncture.
Paschall and Mandel (1983), however, comments
on upper root brachial plexus injury after IJV cannu-
lation. The patient complained of sensory loss over
C5/C6 distribution and loss of motor function of the
muscles around the shoulder joint. The upper trunk
of the brachial plexus (C5, C6) lies at the level of the
cricoid cartilage, close to the puncture site of the
IJV. The upper trunk lies in the posterior triangle of
the neck and the IJV in the anterior triangle. There-
fore, when using the posterior access route to the
vein at the junction of the middle and lower thirds of
19Internal Jugular Vein Catheterization
SCM, aiming at the suprasternal notch, the upper
trunk of the plexus may be injured if the needle is
slightly posterior when entering the posterior triangle
(Paschall and Mandel, 1983).
Although this complication is rare for CVC of the
IJV, several cases of brachial plexus injury have
been reported recently (Tarng et al., 1998; Del
Rosario Usoles et al., 2004; Tajiri et al., 2004) and
one should be aware of the possibility of injury to the
upper trunk of the brachial plexus when using the
posterior approach to the IJV.
Phrenic Nerve Injury
Vascular lesions due to IJV puncture may result in
the formation of a hematoma, which is usually clini-
cally evident. Although mostly benign, some of these
hematomas may cause compression of the surround-
ing structures, i.e. the phrenic nerve (Depierraz
et al., 1989).
Damage to the phrenic nerve is also possible
when placing an IJV catheter, because of the close
relationship between the IJV and the phrenic nerve
behind SCM. As opposed to compression of the phre-
nic nerve by a hematoma, or transient blockade fol-
lowing local anaesthetic infiltration, direct injury may
be irreversible (Armengaud et al., 1991).
Horner’s Syndrome
Horner’s syndrome has been reported to occur
either due to lesions of the sympathetic chain or as a
complication secondary to hydromediastinum (Milam
and Sahn, 1988).
Extensive neurological damage has been reported
with IJV catheterization. This includes damage to a
phrenic nerve, the sympathetic chain on the left,
cranial nerves IX, X, XI, and XII, and the anterior
branches 2nd, 3rd, and 4th cervical nerves (Briscoe
et al., 1974).
More recently Taskapan et al. (2001) reported
three cases of patients that developed Horner’s syn-
drome following repeated attempts for catheteriza-
tion of the IJV for hemodialysis.
Hoarseness
Theoretically the vagus nerve may be injured
when the IJV is cannulated, by injuring the vagus
nerve and therefore the recurrent laryngeal branch
posterior to the IJV (Moosman, 1973).
Chylothorax
Injury to the thoracic duct and possible chylo-
thorax is a rare complication that may occur when
placing a central venous catheter into the IJV on the
left side (Kwon et al., 2001).
Hsu et al. (1997) reported a case in which a left
chylothorax developed 2 days after IJV catheteriza-
tion. The complication was managed successfully by
continuous drainage of the pleural space, oral
administration of a low-fat, high-carbohydrate and
high protein diet, and application of positive end-
expiratory pressure.
Hydromediastinum
Valat et al. (2002) described the first case of
infected mediastinitis associated with central venous
catheter insertion into the IJV. The symptoms (chest
pain and dyspnoea) were not specific and chest
X-ray and computerized tomography was used to
show the presence of a hydromediastinum and pleu-
ral effusion.
Accidental Mediastinal Entry
Albertson et al. (1985) reported on two cases,
and Tong et al. (2004) reported a case of cannula-
tion of the left IJV with mediastinal entry, and
warned of the need for extreme caution when using
this vein. This may be explained by a venous anom-
aly: The most common variant of systemic venous
drainage is a persistent left superior vena cava. It
occurs in 0.3% of persons with otherwise normal
hearts, and in 4.3% of patients with congenital heart
disease (Godwin and Chen, 1986). It may also be
due to cannulation of the left pericardiophrenic vein,
and subsequently entering the mediastinal space as
reported by Weeden and Abel (1982).
Malpositioning of Catheter Tip
Most malpositioned catheters occur in the follow-
ing locations: IJV (43.4%), contralateral brachioce-
phalic vein (11.2%), and right atrium (9.8%) (Lum
and Soski, 1989). Unusual chest pain syndromes
may indicate central venous cathetermalposition
(Webb et al., 1986). Webb et al. (1986) described
this phenomenon in three incidents involving cannu-
lation of the left internal thoracic vein. Malpositioning
of catheters via the IJV appears to be more common
via the left. This is due to the left brachiocephalic
vein being longer and its oblique course. Further-
more, the left brachiocephalic vein has frequent
small tributaries, e.g., the left internal thoracic vein,
pericardiophrenic vein (Weeden and Abel, 1982; Van
Haeften et al., 1988), and left superior intercostal
vein (Webb et al., 1986).
PREVENTION OF COMPLICATIONS
To keep complications to a minimum, the follow-
ing basic factors need to be observed (Hegarty,
1977):
� The indications for CVC should be carefully con-
sidered.
� Thorough acquaintance of the clinical anatomy
of the SCV and IJV as well as their neighboring
structures. Meticulous technique should be fol-
lowed.
� There is no substitute for experience. Most com-
plications are found in the hands of inexper-
ienced operators.
� Awareness of the complications, their frequency,
and reason for occurrence is very important.
The reason for the complications can in almost
every instance be explained by the regional
anatomy.
20 Boon et al.
ADVANTAGES OF USING THE IJV OVER
THE SCV
� Slightly fewer complications compared to the
subclavian route, but a slightly higher incidence
of failure (Sterner et al., 1986; Dronen and
Younger, 1994).
� Chest compressions during CPR can continue.
� Bleeding complications are more easily detecta-
ble and compression can be applied. Pressure
can be applied to the IJV in the case of bleeding.
It is more difficult to apply pressure to the SCV
or adjacent artery, following a puncture,
because of the overlying clavicle.
� Less risk of a pneumothorax.
� Malpositioning is rare (almost a straight course
to the superior vena cava on the right) (Ruesch
et al., 2002).
CONCLUSION
CVC of both the SCV (see Part 1: Subclavian vein,
Clin Anat 20:602–611) and the IJV is often per-
formed by surgeons, anesthesiologists, and emer-
gency room physicians, during the preparations for
major surgical procedures.
Irrespective of which approach is used the safe
and successful performance of CVC demands a work-
ing and specific knowledge of the anatomy surround-
ing these procedures, a thorough knowledge of the
indications and contraindications, as well as the ana-
tomical pitfalls and complications associated with the
procedure.
Only with this knowledge and with a high degree
of experience can a clinician become confident in
safely performing CVC.
REFERENCES
Abrahams PH, Webb P. 1975. Clinical Anatomy of Practical Proce-
dures. London: Pitman Medical. p 32.
Albertson TE, Fisher CJ Jr, Vera Z. 1985. Accidental mediastinal
entry via left internal jugular vein cannulation. Intensive Care
Med 11:154–157.
American Association of Clinical Anatomists, Educational Affairs
Committee. 1999. The clinical anatomy of several invasive pro-
cedures. Clin Anat 12:43–54.
Armengaud MH, Trevoux-Paul J, Boucherie JC, Cousin MT. 1991.
Diaphragmatic paralysis after puncture of the internal jugular
vein. Ann Fr Anesth Reanim 10:77–80.
Armstrong PJ, Sutherland R, Scott DH. 1994. The effect of position
and different manoeuvres on internal jugular vein diameter size.
Acta Anaesthesiol Scand 38:229–231.
Bazaral M, Harlan S. 1981. Ultrasonographic anatomy of the inter-
nal jugular vein relevant to percutaneous cannulation. Crit Care
Med 9:307–310.
Beahrs OH, Chase RA, Ger R. 1986. Gross anatomy in medical edu-
cation. Am Surg 52:227–232.
Blitt CD. 1985. Monitoring in Anaesthesia and Critical Care Medicine.
Central Venous Pressure Monitoring. New York, NY: Churchill
Livingstone. p 121–165.
Bold RJ, Winchester DJ, Madary AR, Gregurich MA, Mansfield PF.
1998. Prospective, randomized trial of Doppler-assisted subcla-
vian vein catheterization. Arch Surg 133:1089–1093.
Boon JM, Meiring JH, Richards PA, Jacobs CJ. 2001. Evaluation of
clinical relevance of problem-oriented teaching in undergraduate
anatomy at the University of Pretoria. Surg Radiol Anat 23:57–
60.
Boon JM, Van Schoor AM, Abrahams PH, Meiring JH, Welch T, Sha-
nahan D. 2007. Central venous catheterization – An anatomical
review of a clinical skill – Part 1: Subclavian vein via the infracla-
vicular approach. Clin Anat 20:602–611.
Botha R, van Schoor AN, Boon JM, Becker JH, Meiring JH. 2006.
Anatomical considerations of the anterior approach for central
venous catheter placement. Clin Anat 19:101–105.
Brederlau J, Greim C, Schwemmer U, Haunschmid B, Markus C,
Roewer N. 2004. Ultrasound-guided cannulation of the internal
jugular vein in critically ill patients positioned in 30 degrees dor-
sal elevation. Eur J Anaesthesiol 21:684–687.
Briscoe CE, Bushman JA, McDonald WI. 1974. Extensive neurologi-
cal damage after cannulation of the internal jugular vein. Br Med
J 1:314.
Caridi JG, Hawkins IF Jr, Wiechmann BN, Pevarski DJ, Tonkin JC.
1998. Sonographic guidance when using the right internal jugular
vein for central vein access. AJR Am J Roentgenol 171:1259–1263.
Childs D, Wilkes RG. 1986. Puncture of the ascending aorta-a com-
plication of subclavian venous cannulation. Anaesthesia 41:331–
332.
Chudhari LS, Karmarkar US, Dixit RT, Sonia K. 1998. Comparison of
two different approaches for internal jugular vein cannulation in
surgical patients. J Postgrad Med 44:57–62.
Cobb LM, Vinocur CD, Wagner CW, Weintraub WH. 1987. The central
venous anatomy in infants. Surg Gynecol Obstet 165:230–234.
Cottam WW. 1999. Adequacy of medical school gross anatomy edu-
cation as perceived by certain postgraduate residency programs
and anatomy course directors. Clin Anat 12:55–65.
Crisp AH. 1989. The relevance of anatomy and morbid anatomy for
medical practice and hence for postgraduate and continuing
medical education of doctors. Postgrad Med J 65:221–223.
Del Rosario Usoles E, De Andrés Ibáñez J, Higueras Castellanos R.
2004. Prolonged interscalene block to treat postoperative brach-
ial plexopathy. Rev Esp Anestesiol Reanim 51:213–216.
Denys BG, Uretsky BF. 1991. Anatomical variations of internal jugu-
lar vein location: impact on central venous access. Crit Care Med
19:1516–1519.
Depierraz B, Essinger A, Morin D, Goy JJ, Buchser E. 1989. Isolated
phrenic nerve injury after apparently atraumatic puncture of the
internal jugular vein. Intensive Care Med 15:132–134.
Dronen SC, Younger JG. 1994. Central catheterization and central
venous pressure monitoring. In: Pfenninger JL, Grant CF, edi-
tors. Procedures for Primary Care Physicians. St. Louis, London:
Mosby. p 270.
Edwards N, Morgan GA. 1989. How to insert a central venous cathe-
ter. Br J Hosp Med 42:312–315.
Ellis H, Feldman S. 1997. Anatomy for Anaesthetists. 7th Ed.
Oxford: Blackwell Science. p 359–363.
Ger R. 1996. Basic surgical training. IV. American and British scenes
compared. Clin Anat 9:173–174.
Godwin JD, Chen JT. 1986. Thoracic venous anatomy. AJR Am J
Roentgenol 147:674–684.
Graney DO. 1996. Letter to the editor. Clin Anat 9:61.
Hegarty MM. 1977. The hazards of subclavian vein catheterization:
Practical considerations and an unusual case report. S Afr Med J
52:240–243.
Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C,
Thomas S. 2003. Ultrasonic locating devices for central venous
cannulation: Meta-analysis. BMJ 327:361.
Hsu LH, Lien TC, Wang JH. 1997. Chylothorax: A complication of
internal jugular vein catheterization. Zhonghua Yi Xue Za Zhi
(Taipei) 60:57–61.
Iovino F, Pittiruti M, Buononato M, Lo Schiavo F. 2001. Central ve-
nous catheterization: Complications of different placements. Ann
Chir 126:1001–1006.
Jesseph JM, Conces DJ Jr, Augustyn GT. 1987. Patient positioning
for subclavian vein catheterization. Arch Surg 122:1207–1209.
Kwon SS, Falk A, Mitty HA. 2001. Thoracic duct injury associated
with left internal jugular vein catheterization: anatomic consider-
ations. J Vasc Interv Radiol 13:337–339.
21Internal Jugular Vein Catheterization
Lakhal K, FerrandièreM, Lagarrigue F, Mercier C, Fusciardi J, Laffon
M. 2006. Influence of infusion flow rates on central venous pres-
sure measurements through multi-lumen central venous cathe-
ters in intensive care. Intensive Care Med 32:460–463.
Lefrant JY, Cuvillon P, Bénézet JF, Dauzat M, Peray P, Saı̈ssi G, de
La Coussaye JE, Eledjam JJ. 1998. Pulsed Doppler ultrasonogra-
phy guidance for catheterization of the subclavian vein: A
randomized study. Anesthesiology 88:1195–1201.
Lovell M, Baines D. 2000. Fatal complication from central venous
cannulation in a paediatric liver transplant patient. Paediatr
Anaesth 10:661–664.
Luckraz H. 2003. Venous pseudo-aneurysm as a late complication
of short-term central venous catheterisation. Cardiovasc Ultra-
sound 1:6.
Lum PS, Soski M. 1989. Management of malpositioned central ve-
nous catheters. J Intraven Nurs 12:356–365.
Mathers LH Jr, Smith DW, Frankel L. 1992. Anatomic considerations
in placement of central venous catheters. Clin Anat 5:89–106.
McMinn RMH, Hutchings RT, Logan BM. 1984. A Colour Atlas of
Applied Anatomy. London: Wolfe Medical Publications.
Milam MG. Sahn SA. 1988. Horner’s syndrome secondary to hydro-
mediastinum. A complication of extravascular migration of a
central venous catheter. Chest 94:1093–1094.
Moosman DA. 1973. The anatomy of infraclavicular subclavian vein
catheterization and its complications. Surg Gynecol Obstet
136:71–74.
Onders RP, Shenk RR, Stellato TA. 2006. Long-term central venous
catheters: Size and location domatter. Am J Surg 191:396–399.
Paschall RM, Mandel S. 1983. Brachial plexus injury from percuta-
neous cannulation of the internal jugular vein. Ann Emerg Med
12:58–60.
Phillips LG Jr. 1987. Anatomy: How much or how little and taught
by whom? Am Surg 53:540–542.
Rosen M, Latto P. 1992. Handbook of Percutaneous Central Venous
Catheterization. 2nd Ed. London: WB Saunders Company.
Ruesch S, Walder B, Tramèr MR. 2002. Complications of central ve-
nous catheters: Internal jugular versus subclavian access—A
systematic review. Crit Care Med 30:454–460.
Schummer W, Schummer C, Hoffmann E. 2003. Chylothorax after
central venous catheterization. Considerations to anatomy, dif-
ferential diagnosis and therapy. Anaesthesist 52:919–924.
Schummer W, Schummer C, Paxian M, Fröber R, Settmacher U.
2005. ECG recording of central venous catheter misplaced in
inferior thyroid artery. Br J Anaesth 94:296–299.
Shimada K, Sato I. 1997. Morphological and histological analysis of
the thoracic duct at the jugulo-subclavian junction in Japanese
cadavers. Clin Anat 10:163–172.
Smith BE, Modell JH, Gaub ML, Moya F. 1965. Complications of sub-
clavian vein catheterization. Arch Surg 90:228–229.
Sterner S, Plummer DW, Clinton J, Ruiz E. 1986. A comparison of
the supraclavicular approach and the infraclavicular approach for
subclavian vein catheterization. Ann Emerg Med 15:421–424.
Tajiri O, Tateda T, Sugihara H, Yokoyama H, Nishikido O, Mukumoto
C. 2004. Brachial plexus neuropathy following open-heart sur-
gery. Masui 53:407–410.
Tarng DC, Huang TP, Lin KP. 1998. Brachial plexus compression
due to subclavian pseudoaneurysm from cannulation of jugular
vein hemodialysis catheter. Am J Kidney Dis 31:694–697.
Taskapan H, Oymak O, Dogukan A, Utas C. 2001. Horner’s syn-
drome secondary to internal jugular catheterization. Clin Nephrol
56:78–80.
Tong MK, Siu YP, Ng YY, Kwan TH, Au TC. 2004. Misplacement of a
right internal jugular vein haemodialysis catheter into the medi-
astinum. Hong Kong Med J 10:135–138.
Valat P, Pellerin C, Cantini O, Jougon J, Delcambre F, Morales P,
Janvier G. 2002. Infected mediastinitis secondary to perforation
of superior vena cava by a central venous catheter. Br J Anaesth
88:298–300.
Van Haeften TW, van Pampus EC, Boot H, Strack van Schijndel RJ,
Thijs LG. 1988. Cardiac tamponade from misplaced central
venous line in pericardiophrenic vein. Arch Intern Med 148:
1649–1650.
Webb JG, Simmonds SD, Chan-Yan C. 1986. Central venous catheter
malposition presenting as chest pain. Chest 89:309–312.
Weeden D, Abel M. 1982. Malposition of a central venous catheter.
Br J Anaesth 54:109.
Wisheart JD, Hassan MA, Jackson JW. 1972. A complication of per-
cutaneous cannulation of the internal jugular vein. Thorax 27:
496–499.
Yeum CH, Kim SW, Nah MY, Ma SK, Ko JH, Kim NH, Choi KC. 2001.
Percutaneous catheterization of the internal jugular vein for
hemodialysis. Korean J Intern Med 16:242–246.
22 Boon et al.