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Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 113-114

Troubleshooting venous valve during internal jugular cannulation under ultrasound guidance

Associate Professor, Department of Anaesthesiology, Dr. Ram Manohar Lohia Hospital and Atal Bihari Vajpayee Institute of Medical Sciences, PGIMER, New Delhi, India

Date of Submission27-Jun-2020
Date of Decision07-Aug-2020
Date of Acceptance07-Sep-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Uma Hariharan
BH-41, East Shalimar Bagh, Delhi - 110 088
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sccj.sccj_28_20

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How to cite this article:
Hariharan U, Kanojia A, Kaur M. Troubleshooting venous valve during internal jugular cannulation under ultrasound guidance. Saudi Crit Care J 2020;4:113-4

How to cite this URL:
Hariharan U, Kanojia A, Kaur M. Troubleshooting venous valve during internal jugular cannulation under ultrasound guidance. Saudi Crit Care J [serial online] 2020 [cited 2022 Dec 8];4:113-4. Available from: https://www.sccj-sa.org/text.asp?2020/4/3/113/296837


A young adult, American Society of Anesthesiologists (ASA) Grade 1, female patient of South-East, Asian-Indian ethnicity, weighing 45 kg, was posted for right pterional craniotomy in view of a suprasellar space-occupying lesion. She had no other comorbidities. The patient had no history of peripheral vascular or cardiovascular disease or any incidence of cerebrovascular events. There was no history of previous central venous cannulation or surgeries. The patient was not on any medication. After a thorough preoperative evaluation (which was unremarkable), the patient was taken to the operation theater and standard general anesthesia was planned with invasive monitoring. After attaching all routine ASA monitors, the patient was induced, intubated, and put on controlled ventilation. After securing arterial line, the patient was positioned for right internal jugular vein (IJV) cannulation (central line). Under all aseptic precautions, the right IJV was located using ultrasonography (USG) guidance at the level of the cricoid cartilage lateral to the sternocleidomastoid muscle belly [Figure 1]. A 7 Fr, triple-lumen, central venous catheter was prepared for cannulating the vein (Seldinger technique). After confirming the correct entry point by ultrasound visualization using out-of-plane approach, a needle (with syringe prefilled with 2-mL heparinized saline) was advanced into the IJV, and a back flow of dark red blood in the syringe was visualized. Needle position was also confirmed by M-mode and Doppler ultrasound. The guidewire (soft, J-tip) was then introduced through the guidewire port of the introducer needle, but advancement was not possible beyond the 10-cm mark on the guidewire. Change in the needle direction and angulation also did not facilitate guidewire insertion. The placement of the needle in the vein was reconfirmed by free aspiration of venous blood and continuous visualization through ultrasound. Another attempt at threading the guidewire into the vein also failed, with resistance encountered at the 10-cm mark. The possibility of valve in the vein obstructing the guidewire passage was hypothesized. The venous valve was visualized on tilting the USG probe along the length of the IJV. Further, USG Doppler was done on the course of the vein to rule out any thrombus in the vein, but no thrombus or emboli were visualized [Figure 2]. With real-time ultrasound visualization of vascular lumen, the opposite end of the guidewire was threaded in smoothly, avoiding the venous valve. Then, the standard procedure of dilatation and central venous pressure (CVP) catheter insertion was followed as per the routine protocol. All the three ports of the catheter were patent with both antegrade and retrograde flows. Continuous CVP monitoring was also started after suturing and dressing. Proper precautions were taken to avoid damage to the vein, and literature description about venous valves is discussed below.
Figure 1: Ultrasound image showing internal jugular vein along with carotid artery and sternocleidomastoid muscle

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Figure 2: In-plane ultrasonographic view of the internal jugular vein showing the presence of valve (marked by an arrow)

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The insertion of guidewire in the presence of valve can cause injury or shearing of the valve tissue, which can be risky and can impede successful central venous catheterization.[1],[2] Fukazawa et al. in their study of internal jugular valves and central venous catheter placement [1] encountered similar problems of venous valves while cannulating the right IJV. In order to avoid damage to the valve, they then switched sides and placed a left-sided IJV catheter instead of a right-sided IJV. Tsai et al.[3] noticed a tenting of the cannula under the skin of the patient's neck after catheter placement in IJV. On ultrasound imaging, they discovered a valve in the IJV, while on the second attempt with ultrasound guidance, they were able to cannulate the IJV even in the presence of the valve. Monish and Maheshwari too faced similar issues.[2] Even after free back flow in the introducer needle while cannulating the right IJV, a resistance was encountered while advancing the J-tip guidewire. Further attempts on the right side were abandoned to avoid damage. A left IJV catheter was placed instead, successfully under ultrasound guidance. Tadokoro et al.[4] were unable to advance the guidewire >8 cm while cannulating the right IJV due to resistance. During ultrasound-guided insertion of the guidewire, a large membranous structure was detected protruding from the posterior wall of the IJV. The guidewire was caught by the membranous structure, and they could not advance the wire further. After several failed attempts, they placed the sheath introducer into the left IJV instead.

The complications of central venous cannulation can be immediate or delayed in nature. Immediate complications occur at the time of catheter insertion and include vascular, cardiac, pulmonary, and placement complications. Delayed complications include device dysfunction and infection.[5] Placement complications can arise during guidewire insertion (as in our case) or during catheter threading. In our case, the guidewire was introduced from the straight end (i.e., opposite end) rather than the J-shaped front end. Intraoperatively and postoperatively, there were no complications related to central venous cannulation.

  Conclusion Top

Our case was unique in that the guidewire cannulation was possible by inserting the reverse (straight) end of the guidewire under USG guidance, despite the presence of the IJV valve. This finding is not specific to any race or ethnic origin. This case report warrants further studies on venous valves, especially after the advent of point-of-care ultrasound. Future interventions must focus on safely circumventing valve encounter during central venous catheterization by routine visualization of the vascular structures and the entire venous course during cannulation.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Fukazawa K, Aguina L, Pretto EA Jr. Internal jugular valve and central catheter placement. Anesthesiology 2010;112:979.  Back to cited text no. 1
Monish SR, Maheshwari A. Difficult venous catheterization in internal jugular vein. Ann Card Anaesth 2015;18:106-7.  Back to cited text no. 2
Tsai MH, Allen TE, Limanek JS, Potenta SE, Martin JA, Bhave AD. Internal jugular vein valves: Clear and present danger. J Cardiothorac Vasc Anesth 2017;31:e21-2.  Back to cited text no. 3
Tadokoro T, Yoza K, Sugahara K. Guidewire advancement is interrupted by an internal jugular vein valve with a restricted opening: An ultrasound image. Can J Anaesth 2013;60:1163-4.  Back to cited text no. 4
Kornbau C, Lee KC, Hughes GD, Firstenberg MS. Central line complications. Int J Crit Illn Inj Sci 2015;5:170-8.  Back to cited text no. 5
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