The jugular vein is a well-recognized structure in both the lay and the medical community. Various phrases used by individuals relating to the jugular veins include such statements as “go for the jugular,” “cut to the quick,” “cut to the jugular,” and “did it get the jugular?” The jugular venous system is the major drainage system for the head and cerebral structures. Table 16-1 demonstrates several considerations regarding the jugular veins. From the time one enters medical school, the physician is made aware of the jugular system. This first comes during direct anatomic dissection in the animal and cadaver laboratories where the structures and characteristics of the internal jugular vein (IJV) and external jugular vein (EJV) are well visualized along with their relationships to their accompanying muscular, neural, vascular, and pharyngeal structures. In physical diagnosis, the anatomic jugular system and many clinical relationships are pointed out to students. The venous system is usually larger and thin walled compared with accompanying arteries and thus acts as capacitance structures. Disease considerations are related to these veins by the instructors and how to recognize such implications of collapsed or dilated veins when the patient is lying down or in the upright or standing position. Correlation of these findings with cardiac and pericardial processes and the methods of examination are also discussed. The jugular system forms a vital connection between the structures of the head and chest.
Veins are found in both the superficial and the deeper tissue levels divided by fascia and are connected transfascially by venous collaterals. Valves help direct the venous blood in the appropriate direction as it returns to the heart. The larger veins such as the jugular and the vena cava have fewer or no valves, but most other veins have one or more valves separated by a few centimeters. Histologic examination of the veins shows 1) the intima, which consists of the endothelium, the subendothelial connective tissue, and in the larger veins, an internal elastic membrane; 2) a media formed by smooth muscle cells usually arranged in bundles intermixed with fibrous networks that may be active and contractile, tributary veins with weaker and thinner walls, and collagen and elastic fibers in various amounts depending on the vein size and location, and 3) an adventitial layer around these vessels that carries the vasa vasorum (through the loose connective tissue), nerve fibers, and the lymphatic system. The veins may have a venous sheath surrounded by thin fibers. Superficial veins are located in the epifascial plane and held in place by a laminar system that protects them from stretching and tearing. As a bradytrophic system, the veins are also able to receive nutrition from their endoluminal side as oxygen-laden and nutritious blood passes through the vessel. Venous return is from the periphery toward the central system and from the smaller into the larger vessels. The cardiac venous pump, gravity (especially in the jugular vein), and muscular pumping action such as that seen in the lower extremities all contribute to the venous blood return to the heart.
The jugulovenous system is made up of multiple structures, including the IJV (a derivative of the anterior cardinal vein), EJV, anterior jugular vein (AJV), and jugular bulb. The IJV is a continuation of the cranial sigmoid sinus through which the cerebral venous blood flows along with cerebrospinal fluid. It extends downward from the sigmoid sinus to the retroclavicular subclavian vein to form the brachiocephalic vein on the right. On the left side, the thoracic duct joins the IJV near the IJV junction with the left subclavian vein to form the left brachiocephalic vein in front of the scalenus anterior muscle. The IJV originates in the jugular foramen of the skull medial to the styloid process where it enters the posterior cranial fossa and collects blood from the brain via the confluence of sinuses (the transverse, occipital, cavernous, marginal, and intercavernous sinuses of the brain) superficial parts of the face, the skull, and much of the neck. It begins at the posterior compartment of the jugular foramen where it joins the sigmoid sinus and is dilated into the superior jugular (upper) bulb lying in the jugular fossa of the petrous temporal bone posterior to the tympanic floor. The vein follows the carotid artery along with the vagus nerve within the carotid sheath and unites with the subclavian vein posterior to the sternal (medial) end of the clavicle where it is again dilated to form the inferior jugular (lower) bulb, above which there may be a pair of valves.
The IJV lies posterior and lateral to the internal carotid artery and the last four cranial nerves in the upper neck and along the common carotid artery lower down in the neck. The vein itself runs along the scalenus medius and scalenus anticus muscles anterior to the transverse spinal processes and near the cervical plexus and the phrenic nerve. Distally, the subclavian artery lies posterior to the vein. The vagus nerve runs posteriorly between the vein and the carotid arteries within the carotid sheath. It is covered by the sternocleidomastoid muscle (SCM) and the posterior belly of the digastric muscles superficially as well as the superior belly of the omohyoid muscle. The IJV receives branches from multiple other venous structures, including the inferior petrosal sinus; the vein of the cochlear canaliculus; the lingual, superior, and middle thyroid veins; the vena comitans; and occasionally the occipital vein. The common facial vein and its branches enter the IJV near the greater cornua of the hyoid bone and may extend along the anterior border of the SCM. The lingual vein that begins near the tip of the tongue and runs posteriorly may also enter the IJV near the greater cornua of the hyoid bone. The superior thyroid vein may drain either into the internal jugular or the facial vein. The pharyngeal veins and the middle thyroid vein also join the internal jugular. Distally, the subclavian and the IJV unite to form the brachiocephalic vein as the phrenic nerve now runs along these vessels at this level. The vertebral veins may drain into the IJV in front of the first portion of the subclavian artery. In the lower neck, the IJV separates from the common carotid artery. Anatomically, the IJV enters into and is believed to be the most important structure in the anterior triangle of the neck.1,2,3,4,5
The EJV drains the more superficial tissues of the head and neck and is the primary drainage for the scalp, face, and some of the deeper related tissue areas. It is formed by a junction of the retromandibular or posterior facial vein and the posterior auricular vein. The EJV descends posteriorly from the angle of the mandible to the mid-clavicle area in the superficial part of the posterior triangle running obliquely and superficial to the SCM. It then may cross the fascia and end in the deeper subclavian vein in front of the third part of the subclavian artery and lateral or anterior to the scalenus anticus muscle. The EJV is covered by the platysma and superficial cervical fascia as well as the skin. It may be small or large, depending on the size of the other collecting veins in the neck, and runs parallel to the great auricular nerve. The vein may have a sinus just above the clavicle and two valves. In addition to the above, the vein receives branches from the transverse cervical, suprascapular, and anterior jugular areas as well as occasionally from the IJV or the occipital vein.
The posterior EJV (PEJV), which starts in the occipital scalp, draining the skin and muscles of the posterior and superior areas of the head and neck, usually joins with the EJV. It crosses the roof of the upper part of the posterior triangle to join the main EJV and, when injured here, the PEJV may remain open, thus allowing air to enter the venous system. The PEJV may be small, receiving no communication from the posterior facial vein, or large, receiving all of the posterior facial vein or the cephalic vein drainage.
The AJV arises from veins of the lower lip and chin near the hyoid bone and deep to the SCM but superficial to the infrahyoid muscles. It may join the end of the EJV at the posterior belly of the SCM or may enter the subclavian vein and communicate with the IJV. Just above the sternum, the AJV enters the suprasternal space. Venous drainage from the common facial, laryngeal, and thyroid vein may contribute to its flow. There may also be two AJVs maneuvering into a large transverse jugular arch, which then receives inferior thyroid tributaries.2,3
As mentioned, a number of anatomic structures accompany or are associated with the jugular venous system. The carotid artery and its branches are most notable running in parallel directions for a large part of the IJV. The phrenic, vagus, and recurrent laryngeal nerves are nearby. A number of muscles, including the SCM, omohyoid, and digastric muscles, are apparent. Lower down, the thoracic lymphatic drainage enters the left thoracic duct and the right lymphatic duct. The lymphatic system is represented by the internal jugular group (IJG) (10–20 nodes) and is the chief collecting system for most head and neck areas. These drain from the base of the skull to the collecting system at the lower part of the neck. Nodes in this group include the parapharyngeal, superior, and inferior cervical nodes. Other regional nodes, such as the transverse cervical (especially the deepest jugular system), superficial cervical, and tracheal nodes, may then blend with the jugular system. Nodal and jugular patterns are of importance to surgical oncologists, especially during radical neck dissection and scalene node biopsy.
As early as 3 to 4 weeks of gestation, fetuses develop a conglomerate of vascular structures. The vitelline veins return poorly oxygenated blood from the yolk sac, and the umbilical veins carry placental oxygenated blood to the embryo. At 6 weeks gestation, the IJV and EJV are developing and uniting through continued coalescence and areas of regression of various venous channels. By the seventh week, the major veins that drain the upper trunk are developing from the anterior and posterior cardinal veins, formed from a unification and expansion of venous lakes or irregular capillary networks into the definitive veins. As the paired anterior and posterior cardinal veins carrying poorly oxygenated blood develop, they unite to form the common cardinal veins as the main venous drainage of the developing embryo body to drain into the sinus venosus (the venous end of the heart).6,7,8 The right anterior cardinal vein gives rise to the right IJV and EJV, which unite with the right subclavian vein to form the right innominate (brachiocephalic) vein. The left brachiocephalic vein (formed by the junction of the left internal jugular and left subclavian vein) then connects the left IJV (formed from the left anterior cardinal vein) to the right IJV vein between the seventh and tenth weeks of gestation to form the superior vena cava (SVC). The right anterior cardinal vein and thus the right IJV drains directly into the SVC, which empties into the right atrium. Because of the multiple early channels and the number of potential options available, there is a much higher incidence of anatomic variations in the venous system than there is in the arterial system, leading to various congenital anatomic abnormalities in adults. Thus, the jugular venous blood may drain into a double SVC or into a single left SVC draining into the coronary sinus.6 Normally, the continued expansion and growth of the upper body venous system and the uniting of the subcardinal veins of the lower body leads to the development of the venous drainage into the right heart via the SVC and inferior vena cava (IVC).
When examining a patient for jugular, head and neck, or intrathoracic abnormalities, a number of techniques may be used. Certainly, the history of the patient’s concerns may be very illuminating and guide one in the correct diagnostic direction. When the patient relates a history of trauma, especially penetrating knife or gunshot wounds, the concerns are readily apparent. However, when a slowly progressive process with venous congestion, dilated veins, and neck swelling is present, the patient’s examination will require a careful history and physical examination. Neck appearance, tenseness of the veins, and the presence of a mass all aid one in establishing the diagnosis. Primary cervical, cardiac, pericardial, and tumor causes are then pursued. Various diagnostic techniques are then used to establish the cause for concern (Table 16-2).
Physical examination of the jugulovenous system is more difficult because of the low pressure within the system, the softness of the vessels, and the collapsibility of the vessels. Therefore, it is difficult to evaluate the amount of flow or the decrease in flow through these veins on physical examination. However, there are certain indications of venous structures that are readily apparent to all. For example, on the hand or in the upper extremity, one may readily see the venous structures in the subcutaneous tissues. In some individuals, these veins are more apparent and more distended than in others. Difficulty with these vessels in the upper extremity (or in the lower extremity) is more readily seen when they are subcutaneous than in the deep venous system. Various indications of venous difficulties may include tenderness on palpation over the venous structure as well as the patient’s noticing discomfort and pain in the area of the vein. Inflammatory or thrombotic changes may be noted with EJV as well as IJV disease. As a result, cordlike structures may be readily palpated as firm, somewhat moveable structures in the neck that follow the course of the venous system when these occur. In addition, redness, inflammatory changes, and edema of the neck may be seen with venous occlusive processes. Cyanosis is uncommon but may be associated with bilateral IJV thrombosis or obstruction in the SVC syndrome. As the veins dilate or venous pressure increases in the head and neck, one may see a markedly distended EJV or IJV. A patient who develops these difficulties usually complains to the physician, and the physical examination will initiate additional evaluation for the cause.
Diagnosis of cardiovascular difficulties may be reflected in the IJV as described by Hurst in the book The Heart.9 Venous waveforms may be noted in the IJVs during examination of the jugulovenous pulse (JVP). A number of different waves may be visualized and recorded. The normal jugular venous waveform consists of three positive and two negative troughs that reflect the changes in the right atrial pressures. Comparing these waveforms with the cardiac cycles, the positive waveforms include the A, C, and V waves. The negative downward waves are the X and Y descents. The A wave is generated by the right atrial contraction and is the largest of the wave forms. The C wave is produced by bulging of the tricuspid valve into the right atrium when right ventricular isometric systole occurs and by the adjacent carotid artery. The V wave is a result of the increased blood volume in the vena cava and the right atrium during ventricular systole with a closed tricuspid valve. The negative X wave follows the C wave as a result of the atrial relaxation and downward displacement of the tricuspid valve with right ventricular systole. The Y wave represents a diastolic collapse as a result of the tricuspid valve’s opening and the rapid inflow of blood into the right ventricular cavity.
Abnormal venous pressure elevation may be noted in the jugular venous system when there is pulmonary hypertension, pulmonary valvular stenosis, and elevated right ventricular pressure or right ventricular failure such as seen with right ventricular infarction. Similarly, a finding of venous pressure elevation may be noted with right ventricular inflow obstruction such as tricuspid stenosis, right atrial myxoma, constrictive pericardial disease, or obstruction of the SVC. Thus, abnormalities of the waveforms may be seen in various cardiac conditions, including atrial fibrillation, first-degree atrioventricular (AV) block, complete AV block, constrictive pericarditis, tricuspid regurgitation, tricuspid stenosis, and atrioseptal defects. Abnormalities of these jugular waveforms occur when the atrial contraction is modified or absent in conditions such as tachycardia with a rate above 90 or in atrial fibrillation. When the tricuspid valve is stenotic and the atrium is contracting against this pressure, large jugular A waves may be noticed.
With the patient lying flat or above 30 degrees, one can estimate the venous pressure as being normal, abnormal, or elevated according to collapse of the veins in the upper extremity while raising or lowering the upper extremity beyond the sternal angle of Louie (at the level of the second interspace). However, the distension of the jugular venous system does not always indicate venous hypertension. A patient taking a slow deep breath may increase the amplitude of the presystolic A wave while decreasing the right atrial mean pressure. The negative X wave may be altered because of tricuspid regurgitation. Atrial fibrillation usually does not have an effect on this. Thus, a positive X wave in a JVP during ventricular systole suggests tricuspid regurgitation. The V wave is usually lower in amplitude than the A wave. The Y trough, or descent, representing collapse in the diastolic cycle, occurs with severe tricuspid regurgitation. A slow Y descent in reverse occurs with obstruction to the right ventricular filling such as tricuspid stenosis or a myxoma in the right atrium. When the venous pressure is elevated, such as with constrictive pericarditis or right heart failure, a sharp, wide dip is noted. The A wave is absent in patients with atrial fibrillation. Flutter waves may be observed with a rate of 250 to 300 BPM. Kussmaul’s sign, an increase in the peripheral venous distension and pressure, may be seen in the jugular system during inspiration in such conditions as cardiac tamponade with pulses paradoxus of the arterial system. An expiratory increase in venous pressure may be noted in patients with pulmonary disorders such as asthma, emphysema, or chronic obstructive pulmonary disease.
Venography represents the gold standard in radiologic diagnosis of venous changes in the jugular system. However, this is a more complex process than the noninvasive programs. When a patient has marked distension of the veins in the upper extremity or in the neck, a close examination of the cardiac as well as the mediastinal and lung structures should be performed. Distension without thrombosis may be confirmed by a number of venous injection techniques through the transfemoral venous catheter approach or with percutaneous cannulation of an upper extremity vein, injection of the iodinated dye, and proper sequence timing of the x-ray exposure. Retrograde filling of the IJV or EJV may be noted in patients with unilateral innominate vein or SVC obstruction. These procedures may be performed under local anesthesia and may be particularly helpful when attempting to place central venous lines in an individual in whom the catheter or guidewire will not thread. Venous injection in these situations may define the cause and the level of the obstruction. On occasion, these venous stenoses or obstructions may be treated with venous balloon angioplastic distension and stent placement (Figures 16-1 and 16-2). Use of dye in the nonallergic patients and single exposure in the operating room or serial x-rays may further delineate the situation and etiology.
FIGURE 16-2.
(A) Venogram of fibrosing mediastinitis showing structure with graduated marker. Stenosis of SVC at junction R and L brachiocephalic veins with previous stent at arrow. (B) Postdilation and stent showing open jugular and superior vena cava (on the right) with covered stent in brachiocephalic (on the left) and another going into the SVC (on the right).
(courtesy: Dr. Stanley Kim)
With the onset of ultrasound capabilities and the further development of these modalities, duplex real-time B-mode imaging has become standard in diagnostic studies of cardiac, venous, and arterial abnormalities. Sonographically, the IJVs are not routinely studied. However, when thrombosis, congestion, or aneurysmal changes are suspected, these studies are used for vessel evaluation. In addition, ultrasonic scanning may be used for cannulation and insertion of central lines. Cross sectional areas as well as velocity and flow volume may be calculated when necessary using these techniques. Normally, the IJV is compressible, and when it does not compress with the ultrasound study, this lends to the diagnosis of thrombosis. The vessel itself may be of multiple shapes, such as half moon, angular, or ovaloid, and at different levels may have different shapes depending on whether a muscle or artery is causing a compression change. With the duplex scanner, venous flow patterns with varying pulsations can be recognized in the lumen of the IJV. Differences in the right and left IJV structures and caliber may be noted, and in particular, right-sided IJV findings suggest it is larger than the left. However, the mean caliber may be equal in these individuals with cross-sectional diameters varying greatly from one individual to another. Changing the patient’s position will also have an effect on these studies, whether the patient is lying down or upright when the study is performed.
During thrombosis of the IJV, a wide vessel may be noted with low-intensity echoes that are stationary and no flow signals noted on Duplex scanning (Figure 16-3). Evaluation of recanalization and thrombolysis with various medications may be monitored with these techniques. As mentioned, venous dilatation may occur as a result of mediastinal tumors without much change in the Doppler signal or with the Valsalva maneuver. IJV aneurysmal dilatation or phlebectasia may be noted by a readily compressible mass that protrudes during a Valsalva study.10 The jugular valves and their effect may be noted using sound waves to image the inferior jugular bulb caudad to the clavicular head. This valve may be bicuspid or unicuspid when present. Incompetence of the valve may also be noted. Flow measurements in the jugular veins have been proposed for a quarter of a century using various techniques as well as velocity studies by means of a single-gated, pulsed-wave Doppler system or a duplex scanner and a mechanical probe.11 It has also been found that in the upright position, on some studies, the vertebral venous plexus instead of the IJV has been a predominant channel of cranial venous outflow. Longley et al12 have described the use of Doppler sonography in the upper extremity and in jugular veins to review the anatomy of the vessels and the various pressure effects. They have encouraged a noninvasive duplex and color Doppler sonography for evaluating patients for thrombosis of the jugular as well as brachiocephalic and subclavian veins. Dampened wave forms were noted and false-positive results were rarely noted.12 On occasion, the evaluation of the IJV may be difficult, especially where it dips medially behind the clavicle.
Computed tomography (CT) angiography has been of value in delineating the IJV and its possible thrombosis in chest and neck angiography during evaluation for tumors and other diseases. Serial x-ray cuts at various levels define the vein’s distension and whether clots are present, particularly when contrast dyes are used in association with the CT scan. Limiting factors may include iodine allergy, renal function, or the patient’s hesitancy to accept the CT equipment because of claustrophobia. However, when using this technique, one will obtain information about not only the venous but also the arterial system and associated the soft tissue structures (Figure 16-4).
Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) have more recently been used in the evaluation of patients and the vascular structures.13 These studies may be performed both with and without appropriate contrast materials with additional definition of the venous as well as the surrounding tissues.
Jugular access considerations are multiple and varied. Table 16-3 lists the multiple and numerous purposes for which the IJV and EJV have been used. As is readily noted, these purposes vary from pure venous access for fluid therapy to complicated and risky cardiac procedures. The most common usage of the IJV and EJV are access procedures for instillation of fluids and blood. Most such indications focus around major surgery, intensive care patients, and trauma. When high-volume replacement in short time periods are required, the jugular system is a reasonably accessible access route with fewer potential access complications than some of the other intravenous (IV) routes may present. Long-term use may be less optimal because of the location and inconvenience for the patient. This is partially ameliorated by the tunneling techniques in the chronic situation such as with hemodialysis catheter placement.
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Diagnostic access techniques have been frequently used for patients with critical needs. In the past, Swan-Ganz pulmonary artery pressure monitoring catheters and central venous monitoring lines were frequently inserted. More recently, however, the routine use of these diagnostic lines and their potential complications, including the accuracy of the pressure readings obtained, has been questioned and reevaluated. Certainly, venous blood for laboratory, oxygen samplings, cardiac, or neurosurgical needs is readily available via jugular lines. Cardiac output and circulation times have been so measured. Pulmonary artery catheters may be placed for pulmonary artery angiography when other routes are less favorable. More involved and more complicated procedures may also be performed through the jugular venous systems. The right IJV is usually preferred because of its more direct and straight route to the central cardiac and venous systems.
Both therapeutic and diagnostic procedures are possible through the jugular vein. Balloon dilatation of venous structures, IVC or SVC filter insertion, and hepatic portal system shunting procedures may be accomplished through the IJV. Therapeutic procedures such as transseptal mitral valvuloplasty, pacemaker insertion, juguloatrial bypass, and cardiopulmonary support or bypass procedures may all be performed through the availability of the IJV. Additional diagnostic techniques, including transvenous organ biopsy procedures of the endomyocardium, liver, and renal transplants, are possible. As one reviews the list of jugular system access modalities in Table 16-3, it becomes apparent that this system is a valuable asset to clinicians and patients. In fact, the system probably has more usages then any other venous system in the body with certain safety advantages.
The jugular system has been used for venous access in both adults and children. A few decades ago, with fewer techniques available, the EJV was frequently used in children, particularly in those with dehydration and in those in whom either the scalp veins or the peripheral veins were not readily accessible. By lowering the head and raising the feet in these children, venous access for blood draw or IV lines was much more readily obtained. However, with the newer venous access needles, plastic IV tubing, and “photo” or venous lighting definition of the venous system, anesthesiologists, IV teams, and nursing staff all are very adept at venous access in infants, negating the need for the jugular approach in most infant and childhood IV situations. However, soft central venous line maintenance has continued to be of value using the jugular venous system for long-term necessities and nutrition. Compared with stiff venous catheters, the soft, flexible lines reduce the chance for venous perforation and pleural or pericardial effusion with subsequent tamponade in our experience.
Jugular venous access in adults primarily has revolved around the use of indwelling catheters or lines for the purpose of emergent, surgical, and longer-term IV therapy. Percutaneous central venous access through the IJV is most readily accomplished with the patient in the supine position with the head down and the foot of the bed elevated to distend the proximal venous system. The head-down position reduces the chance for air emboli and dilates the vein for more ready access. One may then insert the needle between the two inferior heads of the SCM and direct a needle, guidewire, and overlying venous catheter into the IJV, angling slightly lateral and anterior with a downward angulation of 30 degrees. When venous access is accomplished, the guidewire and catheter are then passed and positioned, and the needle is removed. A higher IJV approach uses the midpoint of the SCMM to direct the needle toward the nipple at 30 to 45 degrees downward. It should be noted that on the left side, the thoracic duct and the cupola of the pleura are higher than on the right. Thus, the chance of a procedural pneumothorax is less on the right than on the left and less than that of a subclavian vein puncture. The IJV is frequently used by anesthesiologists in high surgical fluid or blood requirement situations and, in particular, is used when peripheral venous access is limited or very difficult. In an extreme case in which large volumes of fluid or blood were required in a very short period of time, we have cut down on the IJV and placed the IV tubing directly into the IJV and sutured it in place using a purse-string suture on the IJV and a skin holding suture.
Use of the jugular vein line may be somewhat awkward for mobile patients on a long-term basis unless the catheter is tunneled downward over or under the clavicle. On occasion, ultrasound guidance may be of assistance in cannulation of the vein in a large “bull-like” neck. The technique for insertion of central venous catheters requires understanding of the anatomy and the accompanying structures. Anesthesiologists and non-anesthesiologists may all benefit from and rapidly adapt these techniques. To further teach the procedure and minimize the potential complications, inexpensive models for the ultrasound-guided venous cannulation technique have been developed.14 These methods have included the use of a rubber tourniquet and Silastic tubing to simulate vessels in agar models. The purpose of these aids is to reduce the number of puncture attempts and inadvertent puncture of other structures while placing the central line. This is particularly important with regard to the IJV because the carotid artery lies parallel to the vein for some distance. The number of indications for central venous access continues to enlarge. But when placing the access line into the jugular system, a host of concerns are considered. Proper puncture and placement of the catheter within the jugular vein is primary.
The external jugular is usually visible for its access. In severely ill patients, such as compromised liver patients, external jugular venipuncture has been used to overcome many of the difficult problems with venous access.15 Patients with hepatitis C requiring antiviral treatment have benefited greatly from this approach with minimal additional concerns or complications. Posttransplant patients may also benefit from use of the EJV.16
Postcannulation infection and secondary sepsis concerns do develop as a result of central venous lines. Consequent to this concern, various catheters and exchange techniques have been developed to reduce the rate of infection and enhance the duration of the central line access.17 In kidney transplant recipients, silver ion catheter impregnation has been used to reduce catheter-associated bloodstream bacterial and fungal concerns while the central venous catheter remains in place.18 Tunneling of an infusion catheter and bilateral tunneled IJV catheters have been placed for various indications, including bone marrow transplantation.19 Patients who have leukemia, aplastic anemia, or lymphoma all have decreased resistance and thus increased susceptibility to catheter-related infections. Use of bilateral tunneled catheters has been found to be safe with a low incidence of complications except for a trend toward a higher infection rate. When a concern for catheter-related infection or bacterial colonization does occur, culture of the catheter tip on removal may be of assistance. Also, in patients with double- or triple-lumen catheters, a higher mechanical failure rate has been noted. Catheter-related infection may be reduced by handwashing, barrier precautions during insertion, use of topical chlorhexidine, and avoidance of unnecessary catheter and femoral lines.20
Pneumothorax has been seen subsequent to IJV cannulization. This complication is far less frequent than with the subclavian access approach. Catheter tip misplacement as well as carotid artery puncture and hematoma formation have been noted and should be monitored.21 The incidence of these complications is reduced in the hands of more experienced individuals and imaging controls. Insertion of central catheters during periods of high prothrombin times (International Normalized Ratio [INR] elevation) and coagulopathy periods require greater caution or delay in the performance of the procedure. In the latter patients, the EJV, if available, provides a safer access. In addition, catheter-related thrombosis of the jugular vein or central venous catheter may occur, particularly with long-term placement and maintenance. These thromboses may be either clinical or subclinical. Doppler ultrasound studies may assist in maintenance and diagnostic evaluation of the catheter and jugular vein.22 As many as 25% of patients with long-term central venous catheters may develop thrombotic processes. Fortunately, most are subclinical. Many of these are only diagnosed on repeat cannulization attempts some time after the initial catheter had been removed. It has been our experience, however, that the IJV may recannulize after removal of the central line in a high percentage of these patients.
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