Anaesthesiology Intensive Therapy, 2009,XLI,3; 158-160

Internal jugular vein cannulation

Maciej Żukowski, Romuald Bohatyrewicz


Department of Anaesthesiology and Intensive Therapy, Pomeranian Medical University in Szczecin

The report on “Perforation of the internal jugular vein during cannulation for haemodialysis” (Anaesthesiology Intensive Therapy, 2009, number 2) prompted us to address the case presented [1]. The report meets all the criteria of an excellent instructional material for specialists in those issues. In everyday professional life, we are often faced with the medical procedure-related complications requiring difficult, frequently controversial decisions, the health or even life of a patient may directly depend on. We present readily life-saving, sometimes heroic procedures, less willingly the causes of complications or measures, which should be taken to avoid them in the future. Therefore, to increase the instructional value of the publication it would be favourable to describe in detail the circumstances that resulted in the complications reported.

The Authors write that “In chronically dialysed patients, arteriovenous fistulas are created. In acute renal failure, however, the treatment of choice is cannulation of big veins”. Cannulation may be performed with rigid, comparatively short catheters, the so-called “acute ones”, which do not require subcutaneous tunnelization, as well as permanent dialysis catheters, which need tunnelization [2]. Arteriovenous fistulas and permanent tunnelled accesses are of a similar value [3]. A permanent tunnelled catheter (the one the patient was inserted) should not be mistaken with a short, temporary non-tunnelled catheter. In their report, the authors mention the insertion of permanent catheter and later in the text talk about temporary one. It seems that to understand the essence of the case reported, a short description of modern catheters should be provided, including temporary and permanent ones, differences between them and possible complications related to their use [4]. 

The Reader, the specialist who often performs cannulation, should be provided with more comprehensive information than that that “catheters of wider diameters are used, often firmer than those applied during central vascular line procedures. The risk of complications accompanying such procedures is markedly higher”. Complications, in fact, result from the use of thicker and rigid dilators and introducers rather than the characteristics of catheters themselves. If the data concerning the catheter inserted in the case described were more consistent, it would be easier to interpret the complications. The radiological picture shows that the permanent tunnelled forked silicon double-lumen catheter was introduced. Such catheters are soft and more flexible in the vessel, thus vascular damage caused by the catheter is out of question – particularly, damage to the contralateral subclavicular vein.

Based on the description of the procedure carried out in the tertiary care hospital, the Authors state that “the patient had three arteriovenous fistulas created ..., which occluded due to vascular thrombosis. Further attempts to carry out the procedures on the arm and forearm failed. In this situation, the decision was made to insert the catheter through the left internal jugular vein”. This description contains ambiguities. In discussion, the Authors state that the vessel of choice is the right internal jugular vein, yet they chose the access through the left internal jugular vein. We should be informed why the access through the right internal jugular vein was not attempted first; the choice of actually suboptimal access is not clear for the Reader.

In most cases, cannulation of the right internal jugular vein is abandoned based on the past knowledge about local thrombosis, ultrasound scans performed before the procedure or due to earlier or present failures of providing the access. If in the tertiary care hospital the decision was taken to perform cannulation of the suboptimal left side, the reasons should be explained. “extremely laconic description” found in the records could have been supplemented with the data obtained by phone, even later. Moreover, if right side attempts were made, some fresh marks should be visible on the neck skin.

Another issue the Authors did not address was the cause of blood presence in the left pleural cavity. The catheter ran through the left internal jugular vein markedly above the left pleural cupula and possible bleeding from that site should not result in pleural haematoma on the left side.  

The above doubts should be elucidated, more so, that an additional problem occurred during the procedure, i.e. haemorrhage caused by pre-procedure undetected damage to the right subclavicular vein, which surprised the operator. Possible causes of this damage should be addressed in Discussion. The haemorrhage could not have been caused, which the title suggests, by the thin soft tip of the forked silicon catheter. It must have been induced by rigid dilators introduced too deep or vascular damage during right vein catheterization, which might have been attempted yet was not described.

Finally, we would like to congratulate the Authors on this report about the unusual case, which should start the discussion on the subject contributing to increased safety of very common procedures, i.e catheterizations of central veins, which are performed for various reasons and not only to provide dialysis accesses. The detailed guidelines for procedures of dialysis catheter insertions in this specific group of patients seem worth considering [5].

..............................................................................................................................................................

REFERENCES

1.   Wadelek J, Drobinski D, Szewczyk P, Abbas F, Franczyk M, Niewinska M, Majstrak F, Galazka Z, Kanski A: Uszkodzenie zyly wewnetrznej kaniula dializacyjna. Anaestesiol Intensive Ther 2009, 41: 110-113.

2.   Cetinkaya R, Odabas A.R, Unlu Y, Selcuk Y, Ates A, Ceviz M.: Using cuffed and tunnelled central venous catheters as permanent vascular access for hemodialysis: astudy. Ren Fail 2003; 25: 431-438.

3.   Kawecka A, Milkowski A: Dostep naczyniowy; w: Leczenie nerkozastepcze (Red.: Rutkowski B); Wydawnictwo Czelej Sp. ZLublin 2007: 95-103.

4.   Yetkin U, Ozelci A, Ozpak B, Yurekli I, Gurbuz A: The use of fluoroscopy for permanent hemodialysis catheter placement. J Thorac Cardiovasc Surg 2009; 13: 2.

5.   National Kidney Foundation – The Kidney Disease Outcomes Quality Initiative – KDOQI. Clinical practice guidelines for vascular access, update 2006.

..............................................................................................................................................................

The Authors reply

Jacek Wadełek1, Dominik Drobiński1, Piotr Szewczyk1, Fouad Abbas, Marzena Franczyk1, Monika Niewińska1, Franciszek Majstrak2, Zbigniew Gałązka3, Andrzej Kański1

1II Department of Anaesthesiology and intensive Therapy, Warsaw Medical Uniwersity
2Department of Cardiac Surgery, Warsaw Medical Uniwersity
3Department of Vascular Surgery, Warsaw Medical Uniwersity

Thank you for your interest in our report. Catheterization of big veins using the dialysis devices [1] is the life-saving procedure in patients with chronic renal failure. Unfortunately, the procedure is not easy to perform and in many cases is accompanied by complications. Twenty years ago, Lin and colleagues [2] demonstrated that in a high percentage of patients with chronic renal failure, the diameter of jugular veins was lower than 5 mm (13% on the right and 10.6% on the left side). Their findings were recently confirmed by  Asouhidou and co-workers in their cadaver examinations [3]. They showed clear variability of the course and diameter of internal jugular veins, which in some cases were so narrow that catheterization was not feasible. Dramatic cases of total vein occlusions, which make their catheterization impossible, are indications for recanalization procedures [4].

We would like to address the question about the reasons for not attempting the right internal jugular vein access first. The physicians attending the chronically dialysed patients for several months usually know which veins are not patent and give no chances for catheterization. We suppose that this case was similar. Previous failed attempts to catheterize central veins on the right side prompted the use of the left, ”more difficult” internal jugular vein. Our suppositions are confirmed by the description of thoracic CT scan: “The right brachiocephalic vein narrow with a slit lumen”.  

As far as the second question about the cause of blood in the left pleural cavity is concerned. “The catheter ran through the left internal jugular vein markedly above the left cupula and possible haemorrhage from this site should not have resulted in pleural haematoma on the left side”. The damage (perforation of both walls) to the internal jugular vein caused haemomediastinum. For obvious reasons, it was not responsible for the presence of blood in pleural cavities. According to our patient, catheterization was long, traumatic and extremely painful. Attempts to identify the veins were repeated and the guide and dilator were used several times. It may be assumed that during the manipulations the pleura was injured, which might explain the presence of blood in the pleural cavities. The tissues might have been injured by the needle, guide or extremely rigid and thick dilator yet definitely not by the soft silicon cannula.  

..............................................................................................................................................................

REFERENCES

1.   Oliver M: The optimal management of hemodialysis catheters. Nephrology Rounds 2003.  

2.   Lin BS, Kong CW, Tarng DC, Huang TP, Tang GJ: Anatomical variation of the internal jugular vein and its impact on temporary haemodialysis vascular access: an ultrasonographic survey in uraemic patients. Nephrol Dial Transplant 1998; 13: 134-138.

3.   Asouhidou I, Natsis K, Asteriy T, Sountoulides P, Vlasis K, Tsikaras P: Anatomical variation of left internal jugular vein: clinical significance for an anaesthesiologist. Eur J Anaesthesiol 2008; 25: 314-318.

4.  Haller C,  De´glise S, Saucy F, Mathieu C, Haesler E, Doenz F, Corpataux JM, Qanadli SD: Placement of hemodialysis catheters through stenotic or occluded central thoracic veins. Cardiovasc Intervent Radiol 2009; 32: 695-702.
Anestezjologia Intensywna Terapia 2009; 41: 159-160