Journal of Clinical Anesthesia (2014) xx, xxx–xxx
Correspondence
A case of internal jugular vein dissection that occurred during central venous catheter insertion To the Editor: A central vein catheter is essential for monitoring and drug administration in many instances. We report a case of internal jugular vein (IJV) dissection that occurred during central venous catheter insertion. A 78 year old man with two-vessel disease was scheduled to undergo coronary artery bypass surgery at our hospital. Transthoracic echocardiography on admission showed a normal ejection fraction (55%, Mod-Simpson’s method) with inferior wall motion abnormalities and mild tricuspid regurgitation. Advanced arteriosclerosis of both carotid arteries was observed during carotid artery ultrasound, but there was no significant stenosis. No abnormalities were found in the IJV. The patient had no abnormalities on lower limb ultrasound, chest abdominal computed tomography (CT), or head CT. The patient was brought to the operating theater and anesthesia was induced. Subsequently, a transesophageal ultrasound probe was introduced. The S-Nerve™ ultrasound system with FUJIFILM (SonoSite Inc., Bothell, WA, USA) was used to identify the bilateral IJV; however, no particular abnormalities were evident. The right IJV (RIJV) was punctured using the landmark method. Backflow of blood
into the needle was confirmed, and a guidewire was inserted. Resistance was encountered during insertion of the guidewire after approximately 13 cm, and ultrasound visualization along the long axis of the RIJV via a linear probe showed venous dissection 5 cm from the point of venipuncture (Fig. 1). After consultation with a cardiac surgeon, the guidewire was removed. A central venous catheter was inserted in the left IJV with ultrasound guidance. The surgery and postoperative management were uneventful. On postoperative day 3, ultrasound showed persistent venous dissection of the RIJV. On the advice of a cardiac surgeon, the patient was observed without treatment. Two weeks later, the patient was transferred to another hospital, and he experienced no additional major problems. This is the first report of vein dissection due to use of a guidewire during central venous puncture. Although the possibility of damage to a venous valve cannot be ruled out, it is generally noted that an IJV valve typically is not present on the head side of the vein corners [1,2]. Previously, the landmark technique, not ultrasound guidance, was used for central vein puncture. Therefore, it is likely that IJV dissection was difficult to detect. In addition, with IJV dissection, unlike aortic dissection, the possibility of cardiac tamponade and rupture as well as ischemia of the organs is low. As a result, venous dissection may be overlooked during the procedure.
Fig. 1 Ultrasound image of a right internal jugular vein dissection on the third day after guidewire extraction. (A) Short axis of the internal jugular vein (IJV). (B) Long axis of the IJV. IVC=inferior vena cava, CA=caroid artery. 0952-8180/Crown Copyright © 2014 Published by Elsevier Inc. All rights reserved.
2 The mechanism of onset may be considered in the same manner as that of aortic dissection, with peeling of the tunica media along with failure of the tunica intima. Fundamentally, because venous pressure is much lower than arterial pressure, there is very little expansion of the dissection, and follow-up is likely all that will be needed [3,4]. However, if continued expansion of the dissection is observed, surgery will be necessary. We report a medical case of IJV dissection due to use of a guidewire during central venous puncture. Currently, there have been no reports on the risk of venous dissection among the complications of central venous puncture in the IJV [5].
Hironobu Ueshima (Assistant Instructor of Anesthesiology) Tsutomu Mieda MD (Assistant Instructor of Anesthesiology) Yuki Ichikawa MD (Assistant Instructor of Anesthesiology) Jun Ariyama MD (Assistant Professor of Anesthesiology) Akira Kitamura MD (Professor of Anesthesiology)
Correspondence Department of Anesthesiology Saitama Medical University International Medical Center Hidaka City, Saitama 350–1298, Japan E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2014.01.006
References [1] Anderhuber F. Venous valves in the large branches of superior vena cava. Acta Anat 1984;119:184-92. [2] Midy D, Le Huec J, Dumont D, Chauveaux D, Cabanie H, Laude M. Anatomic and histologic study of the valves of the internal jugular veins. Bull Assoc Anat 1988;72(216):21-9. [3] Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897-903. [4] Mehta RH, Suzuki T, Hagan PG, et al. International Registry of Acute Aortic Dissection (IRAD) Investigators. Predicting death in patients with acute type A aortic dissection. Circulation 2002;105:200-6. [5] Rosen M, Latto P, Ng SW. Handbook of percutaneous central venous catheterization. 2nd ed. London: W.B. Saunders; 1992. p. 112.
Correspondence
A case of internal jugular vein dissection that occurred during central venous catheter insertion To the Editor: A central vein catheter is essential for monitoring and drug administration in many instances. We report a case of internal jugular vein (IJV) dissection that occurred during central venous catheter insertion. A 78 year old man with two-vessel disease was scheduled to undergo coronary artery bypass surgery at our hospital. Transthoracic echocardiography on admission showed a normal ejection fraction (55%, Mod-Simpson’s method) with inferior wall motion abnormalities and mild tricuspid regurgitation. Advanced arteriosclerosis of both carotid arteries was observed during carotid artery ultrasound, but there was no significant stenosis. No abnormalities were found in the IJV. The patient had no abnormalities on lower limb ultrasound, chest abdominal computed tomography (CT), or head CT. The patient was brought to the operating theater and anesthesia was induced. Subsequently, a transesophageal ultrasound probe was introduced. The S-Nerve™ ultrasound system with FUJIFILM (SonoSite Inc., Bothell, WA, USA) was used to identify the bilateral IJV; however, no particular abnormalities were evident. The right IJV (RIJV) was punctured using the landmark method. Backflow of blood
into the needle was confirmed, and a guidewire was inserted. Resistance was encountered during insertion of the guidewire after approximately 13 cm, and ultrasound visualization along the long axis of the RIJV via a linear probe showed venous dissection 5 cm from the point of venipuncture (Fig. 1). After consultation with a cardiac surgeon, the guidewire was removed. A central venous catheter was inserted in the left IJV with ultrasound guidance. The surgery and postoperative management were uneventful. On postoperative day 3, ultrasound showed persistent venous dissection of the RIJV. On the advice of a cardiac surgeon, the patient was observed without treatment. Two weeks later, the patient was transferred to another hospital, and he experienced no additional major problems. This is the first report of vein dissection due to use of a guidewire during central venous puncture. Although the possibility of damage to a venous valve cannot be ruled out, it is generally noted that an IJV valve typically is not present on the head side of the vein corners [1,2]. Previously, the landmark technique, not ultrasound guidance, was used for central vein puncture. Therefore, it is likely that IJV dissection was difficult to detect. In addition, with IJV dissection, unlike aortic dissection, the possibility of cardiac tamponade and rupture as well as ischemia of the organs is low. As a result, venous dissection may be overlooked during the procedure.
Fig. 1 Ultrasound image of a right internal jugular vein dissection on the third day after guidewire extraction. (A) Short axis of the internal jugular vein (IJV). (B) Long axis of the IJV. IVC=inferior vena cava, CA=caroid artery. 0952-8180/Crown Copyright © 2014 Published by Elsevier Inc. All rights reserved.
2 The mechanism of onset may be considered in the same manner as that of aortic dissection, with peeling of the tunica media along with failure of the tunica intima. Fundamentally, because venous pressure is much lower than arterial pressure, there is very little expansion of the dissection, and follow-up is likely all that will be needed [3,4]. However, if continued expansion of the dissection is observed, surgery will be necessary. We report a medical case of IJV dissection due to use of a guidewire during central venous puncture. Currently, there have been no reports on the risk of venous dissection among the complications of central venous puncture in the IJV [5].
Hironobu Ueshima (Assistant Instructor of Anesthesiology) Tsutomu Mieda MD (Assistant Instructor of Anesthesiology) Yuki Ichikawa MD (Assistant Instructor of Anesthesiology) Jun Ariyama MD (Assistant Professor of Anesthesiology) Akira Kitamura MD (Professor of Anesthesiology)
Correspondence Department of Anesthesiology Saitama Medical University International Medical Center Hidaka City, Saitama 350–1298, Japan E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2014.01.006
References [1] Anderhuber F. Venous valves in the large branches of superior vena cava. Acta Anat 1984;119:184-92. [2] Midy D, Le Huec J, Dumont D, Chauveaux D, Cabanie H, Laude M. Anatomic and histologic study of the valves of the internal jugular veins. Bull Assoc Anat 1988;72(216):21-9. [3] Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897-903. [4] Mehta RH, Suzuki T, Hagan PG, et al. International Registry of Acute Aortic Dissection (IRAD) Investigators. Predicting death in patients with acute type A aortic dissection. Circulation 2002;105:200-6. [5] Rosen M, Latto P, Ng SW. Handbook of percutaneous central venous catheterization. 2nd ed. London: W.B. Saunders; 1992. p. 112.
