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Background and Aims Ultrasound guidance of central venous catheter (CVC) insertion improves the safety and efficacy of its placement, but still it may not ensure correct placement of catheter tip. In our study, we aimed to identify the correct placement of CVC tip and to detect mechanical complications, by visualizing it in real time with the help of sonography and comparing this to the chest X-ray findings. Patients and Methods This was a cross-sectional observational study conducted on 80 patients with American Society of Anesthesiologists grades 1 and 2, in the age group of 18 to 65 years, who required central venous catheterization in intensive care unit. The CVC tip placement was identified with ultrasound and then the finding was compared with postinsertion chest X-ray. Results In only 9 out of the 80 patients (11.3%) malposition was detected on ultrasound and was corrected immediately, whereas in remaining 71 patients (88.8%) no intervention was required. It was observed that all the patients had correct position of CVC tip on postprocedural chest X-ray. Accidental arterial cannulation occurred in two (2.5%) patients in whom right internal jugular vein was cannulated and in two (2.5%) patients who had arrhythmia. Conclusion Ultrasonography (USG) examination can be used as a diagnostic tool method for confirmation of CVC tip and identification of cannulation-related complications. Thus, we can say that USG might obviate the need for post-CVC insertion chest X-ray.

Tunneled central venous catheter (TCVC) placement is often an easy and uncomplicated procedure. As such, some clinicians pay little attention to the procedure, and different complications occurred. Catheter fragment loss in major vessels is a rare but serious complication of in situ catheter exchange with few reported cases in the literature. Once catheter fragments slip into a deep vein, endovascular retrieval should be attempted, due to its high success rate and minimal associated morbidity. A 37-year-old male patient underwent replacement of his temporary catheter with TCVC through a trans-right-internal-jugular-vein approach for maintenance of dialysis. As a major unintended outcome of the operation, a catheter fragment slipped into the right internal jugular vein, then migrated and lodged in the inferior vena cava. We retrieved it with a gooseneck snare without complications. We report the case hoping to emphasize on and raise awareness of the fact that catheter fragment loss is a completely evitable complication, provided the operator follows the correct safety measures and protocols. However, if catheter fragment loss occurred, the fragment should be retrieved as soon as possible. A gooseneck snare is an ideal option for retrieving catheter fragments that have migrated into deep veins.

Approximately 13,500 children each year are treated for non-powder gun injuries of which approximately one-quarter of these injuries are puncture wounds. Although rare, vascular migration of the bullet or pellet (otherwise known as the “wandering bullet”) may result in downstream organ damage secondary to vascular or venous occlusion, most commonly travelling anterograde and lodging within the lung venous system. Interestingly, we present a case of a 12-year-old female who was shot in the neck with a compressed-air gun loaded with ball-bearing pellets. Eventual retrograde vascular migration of the ball-bearing pellet from the right internal jugular vein to the hepatic vein caused hepatic venous occlusion and congestion. It is important for radiologists to remember the possibility of retrograde travel of bullets and pellets, and radiographs should be scrutinized for foreign bodies present in areas other than the region of injury. Bullet retrieval is determined by clinical evaluation and necessity, and if indicated, endovascular, percutaneous retrieval, or surgical exploration may be considered.

Background Central venous catheterization is a vital procedure for volume resuscitation, infusion of drugs, and for central venous pressure monitoring in the perioperative period and intensive care unit (ICU). It is associated with position-related complications like arrhythmia's, thrombosis, tamponade, etc. Several methods are used to calculate the catheter insertion depth so as to prevent these position-related complications. Objective To compare Peres' formula and radiological landmark formula for central venous catheter insertion depth through right internal jugular vein (IJV) by the anterior approach. Materials and methods A total of 102 patients posted for elective cardiac surgery were selected and divided into two equal groups-Peres' group (group P) and radiological landmark group (group R). Central venous catheterization of right IJV was done under ultrasound (USG) guidance. In group P, central venous catheter insertion depth was calculated as height (cm)/10. In group R, central venous catheter insertion depth was calculated by adding the distances from the puncture point to the right sternoclavicular joint and on chest X-ray the distance from the right sternoclavicular joint to carina. After insertion, the catheter tip position was confirmed using transesophageal echocardiography (TEE) in both the groups. Results About 49% of the catheters in group P and 74.5% in group R were positioned optimally as confirmed by TEE, which was statistically significant. No complications were observed in both the groups. Conclusion Radiological landmark formula is superior to Peres' formula for measuring optimal depth of insertion of right internal jugular venous catheter. How to cite this article Manudeep AR, Manjula BP, Dinesh Kumar US. Comparison of Peres' Formula and Radiological Landmark Formula for Optimal Depth of Insertion of Right Internal Jugular Venous Catheters. Indian J Crit Care Med 2020; 24(7):527-530.

Background Poor positioning of a central venous catheter (CVC) can cause severe complications. The objective is to create a formula that predicts the optimal insertion depth of a real time ultrasound-guided CVC in the right internal jugular vein (RIJV) in newborns. Methods Between 2015 and 2017, 91 newborns that required a CVC were included in a prospective observational study. Variables such as gestational age, gender, weight, height, and neck length were studied. On the chest x-ray, the distance between the insertion site on the skin and the catheter tip was measured. Results Of the patients included, 50 (54.9%) were males and 40 (44.4%) females; 64 (70.3%) were preterm. Mean gestational age was 33.44 (25 to 41) weeks, weight 2020 (580 to 3980) g, and height 43.04 (26 to 53) cm. Variables were correlated with catheter length and an algorithm was modeled for the introduction method, in which the highest corrected determination coefficient was obtained for weight (R2 = 0.723). Conclusion This study demonstrated that the weight of the newborn was the most significant individual predictor of optimal insertion depth of a CVC in the RIJV. The formula Y = 2.6 + 0.7 (weight in kg) that we suggest is practical and reproducible. Level of evidence Level IV.

For critically ill patients, central venous catheterization may not always be placed in a correct tip position, even when guided by ultrasound. A case of inadvertent catheterization into azygos vein is described.

Purpose: This study examined the safety and efficacy of placing both a central venous dialysis catheter and a central venous catheter for infusion in the right internal jugular vein compared to only a central venous dialysis catheter. Methods: We conducted a retrospective chart review for all adult patients who underwent the placement of the right internal jugular dialysis catheter by a single surgeon. Patients were grouped based on whether they received a tunneled dual lumen dialysis catheter alone or in combination with a central venous infusion catheter in the right internal jugular vein. Catheter-related thrombosis, line infections, line malfunctions, pneumothorax, and need for line replacement were evaluated. Results: There were 97 patients in the dialysis catheter and central venous infusion line group and 63 patients in the dialysis catheter only group. The two groups were not different with regard to age (62.1 ± 16.3 years vs 57.9 ± 17.6 years) and gender (47.4% male vs 55.6% male). No significant differences were found in the incidence of thrombosis (1.0 % vs 0.0%, p > 0.999), line infection (2.1% vs 0.0%, p = 0.519), or line malfunctions (2.1% vs 0.0%, p = 0.516) in patients who did or did not have a central venous infusion catheter placed concomitantly with the dialysis catheter, respectively. No patients in either group had a pneumothorax. Conclusions: Although not currently utilized with frequency, these preliminary data indicate that placing both a dual lumen dialysis catheter and central venous infusion catheter in the right internal jugular simultaneously could be a viable option.

Here we report an extremely rare presentation of internal jugular vein catheterization, presenting as massive hemoptysis which was noted during right internal jugular vein cuffed hemodialysis catheter insertion of a 39-year-old man known-case of End-Stage Renal Disease. Chest roentgenogram and computerized tomography scan showed pleural effusion and misplacement of the tip of hemodialysis catheter in the posterior mediastinum causing possible damage to the right main bronchus. After chest tube insertion and removing the misplaced hemodialysis catheter, a proper cuffed catheter was inserted and the patient was discharged with an uneventful post-op course.

Objective The primary aim of this study was to assess the effects of a combination of the passive leg raising (PLR) and Trendelenburg positions on the cross-sectional area (CSA) of the right internal jugular vein (RIJV) using ultrasound measurement in awake patients. Methods This prospective observational cross-over study measured the CSA of RIJV in patients in supine (Supine-I), Trendelenburg, Trendelenburg with passive leg raising (T + PLR position), and repeated supine position (Supine-II). The CSA and vertical and horizontal diameters of the RIJVs were compared before and after each position. Results A total of 120 adult patients were enrolled in the study. The mean CSA of the RIJV significantly increased from 91.2 ± 31.7 mm2 to 110.4 ± 38.2 mm2 in the Trendelenburg position compared to the supine position (P < 0.05). However, there were no statistically significant differences in CSA were observed between the Trendelenburg and Trendelenburg + PLR positions. Conclusion Although the PLR + Trendelenburg position increased the jugular vein diameter relative to the supine position, its clinical usefulness is limited as this increase was still lower than that achieved with the Trendelenburg position alone.

Background Due to excess catheter length, pediatric patients undergoing cardiac surgery frequently have the tip of the central venous catheter trimmed while on bypass to obtain optimal catheter positioning. Aims We sought to determine if there is a correlation between the patient's height or weight and the length of catheter removed. Our secondary aim compared the instances of central line-associated bloodstream infections and venous thromboembolisms between the trimmed and untrimmed catheters. Methods This retrospective study included patients having undergone cardiac surgery over a 3-year period who had an 8 cm central venous catheter placed in the right internal jugular vein. Hospital lists of central line-associated bloodstream infections and venous thromboembolisms that occurred were cross referenced with our study patients. Results There were 147 cases where the 8 cm central venous catheter was trimmed, which represents 35% of the cases. Of the catheters that were cut, on average 2.17 cm was removed. There is negligible correlation between the length of catheter removed and patient height (r = -.19, p = .021). There is negligible correlation between the length of catheter removed and patient weight (r = -.17, p = .039). There were no instances of central line-associated bloodstream infections or venous thromboembolisms attributed to the trimmed catheters. Of the 273 untrimmed catheters, there were no instances of an infection and one instance of a venous thromboembolism. Conclusion Right internal jugular 8 cm central venous catheters are trimmed during pediatric cardiac surgery, and there is minimal correlation between the length removed and the patient height or weight. Due to the difficulty in estimating the proper length of a central venous catheter in smaller pediatric patients, placing an 8 cm long catheter in these patients and then trimming the distal tip while on bypass may be the most accurate way to properly position a catheter.

Purpose To describe the first known case of an extracorporeal membrane oxygenation (ECMO)-related complication in an adult. Methods Case report. Results A 34-year-old man awaiting a lung transplant for interstitial lung disease was connected to an ECMO circuit as a bridge to lung transplant, with a drainage catheter attached to his right internal jugular vein. Shortly after he was cannulated, he developed blurred vision in his right eye and was found to have a progressively worsening bullous exudative retinal detachment. After receiving a lung transplant and getting decannulated from ECMO, his bullous detachment rapidly improved. The patient's clinical course as well as his ophthalmic testing showed findings inconsistent with alternative diagnoses such as central serous chorioretinopathy. His findings were best explained as a complication of ECMO cannulation. Conclusion Extracorporeal membrane oxygenation may be associated with bullous exudative retinal detachment in rare cases where there is a possible anatomical or physiological predisposition.

PURPOSE The appropriate depth of right internal jugular venous (RIJV) catheterization is still under debated. In this study, transesophageal echocardiography (TEE) is used to develop a prediction formula for fixed RIJV catheter depth. METHODS Eighty patients with indications for intraoperative TEE and central line placement were enrolled. After intubation, a RIJV catheter was inserted via the middle approach using the Seldinger technique. When the J-tip of the guide wire appeared at the junction of the superior vena cava and the right atrium under TEE guidance, the guide wire was pulled back by approximately 2-3 cm, until its tip was out of the pericardial fold. This depth was regarded as the insertion depth of the central venous catheter. Body landmark distance was measured, and the prediction formula was generated. RESULTS The mean central line depth after TEE-guided placement was 15.1 ± 1.7 cm. The prediction formula developed is as follows: Insertion depth = (Height ÷ 20) + (D ÷ 2), where D equals the distance from the insertion point to the sternal angle via the right sternoclavicular joint (r = 0.595, r2 = 0.354, P

Background: The commonly preferred right internal jugular vein was investigated in terms of its dimensions, the relationship between its dimensions and anthropometric measures, and the outcomes of its cannulation in infants. Data regarding its position with respect to the carotid artery indicated anatomical variation. Aim: The aim of this study was to share our observations pertaining to the anatomy and position of the right internal jugular vein with respect to carotid artery using ultrasound and our experience with ultrasound-guided right internal jugular vein access in neonates and small infants. Materials and methods: A total of 25 neonates and small infants (Results: The position was lateral to the carotid artery in 84% of all infants and similar in both groups. The first-attempt success rates of cannulation were similar (70% vs 73.3%) in both groups, with an overall success rate of 88%. Conclusion: Right internal jugular vein revealed a varying position with respect to carotid artery with a higher rate of lateral position. The presence of such anatomical variation requires ultrasonographic evaluation prior to interventions and real-time guidance during interventions involving right internal jugular vein.

Background:Central venous cannulation is an invasive procedure commonly used by many physicians. The aim of this study was to evaluate the effects of the right lateral tilt position on the cross-sectional area and size of the right internal jugular vein, and the relationship between the right internal jugular vein and the carotid artery.Method:Forty healthy volunteers aged over 18 years were included in this prospective, observational study. The right internal jugular vein cross-sectional area and the anatomic relationship with the carotid artery were assessed using ultrasound imaging. This measurement was repeated for four positions (baseline position, 10° right tilt position, 10° Trendelenburg position, and 10° right tilt + 10° Trendelenburg position). The head was rotated 30° to the contralateral side in all patients.Results:The mean (standard deviation) right internal jugular vein cross-sectional area, transverse diameter, and anteroposterior diameter were significantly increased with the Trendelenburg position and 10° right tilt + 10° Trendelenburg position (p 0.05).Conclusion:We found that the right lateral tilt position had no effect on the internal jugular vein cross-sectional area and that the Trendelenburg position was still the most valid position for safely increasing the right internal jugular vein cross-sectional area.

Background and Aims: Central venous catheterization is a frequently performed procedure in anesthesia and critical care, and is indispensable in the practice of emergency medicine. Correct positioning of the central venous catheter (CVC) tip is often regarded as a secondary goal and there are various complications that can occur due to abnormal position of the catheter tip. Different methods have been advocated to guide accurate prediction of optimal CVC depth insertion before or during the procedure at the bedside. Material and Methods: A prospective randomized double blinded study was conducted in 180 patients aged between 18 to 65 years requiring central venous catheterization. The optimal depth of insertion of right internal jugular vein (IJV) catheter using three different techniques, Peres' formula method, Landmark technique and Intra atrial Electrocardiography (ECG) guided technique was performed and the three techniques were compared with respect to optimal positioning using carina as a landmark in post procedural chest radiograph. Correct position of the catheter tip was considered upto 1 cm above or below the carina in post procedure X ray. Results: The average final depth of insertion was 15.30 ± 0.62 cms in the Formula group, 12.74 ± 0.77 cms in landmark group and 12.64 ± 0.70 cms in ECG group. The vertical distance from carina was 0.91 ± 0.94 cms in formula group, 0.54 ± 0.67 cms in landmark group and 0.53 ± 0.43 cms in ECG group. The CVC tip was properly positioned within 1 cm above and below the carina in 58.33% patients in the formula group, 93.33% patients in landmark group and 96.67% patients in ECG group. Conclusion: We conclude that both landmark guidance and ECG guidance are comparable with regard to accurate central venous catheter tip positioning when CVCs are placed through right internal jugular vein whereas formula based technique is least accurate and results in over insertion of CVCs.

Knotting of a pulmonary artery catheter (PAC) is a rare, but well-known complication of pulmonary artery (PA) catheterization. We report a case of a double-knotted PAC with a large loop in a patient with hepatocellular carcinoma (HCC) undergoing liver transplantation, which has been rarely reported in the literature. A PAC was advanced under pressure wave form guidance. PAC insertion was repeatedly attempted and the PAC was inserted 80 cm deep even though PAC should be normally inserted 45 to 55 cm deep. However, since no wave change was observed, we began deflating and pulling the balloon. At the 30-cm mark, the PAC could no longer be pulled. Fluoroscopy confirmed knotting of the PAC after surgery (The loop-formed PAC was shown in right internal jugular vein); thus, it was removed. For safe PA catheterization, deep insertion or repeated attempts should be avoided when the catheter cannot be easily inserted into the pulmonary artery. If possible, the insertion of PACs can be performed more safely by monitoring the movement of the catheter under fluoroscopy or transesophageal echocardiography.

Objective The main objectives of the present study were to analyze the right internal jugular vein tunneled dialysis catheter (TDC) tip displacements, functional changes, pathway deformities, and angulations associated with different arm positions. Methods We prospectively studied 21 patients who had undergone TDC implantation for hemodialysis via the right internal jugular vein at a single center from February to September 2020. After implantation, a baseline resting fluoroscopy image was taken, and three movement-mimicking images of the ipsilateral arm were obtained for comparison, with the arm in maximum abduction, maximum flexion, and maximum adduction. Device function was analyzed for each movement-mimicking position and correlated with catheter tip displacement, catheter deformity, and catheter pathway angulation. Results TDC pathway deformity occurred in 16 patients (69.5%). Deformities were more frequent in the movement-mimicking positions than in to the control resting baseline images (P = .004). The different arm positions did not lead to significant tip displacement (either horizontal or vertical; P > .05), nor did they result in significant pathway angulation between the subcutaneous and intravenous regions (P = .114). However, in the maximum abduction position, a positive relationship was present between the catheter pathway angle and impairment of catheter function (P = .028). Conclusions Catheter deformity was more frequent and more severe with maximum adduction and flexion of the arm. Although no significant changes were observed in the tip of the catheter with the movements, a positive relationship was found between the catheter pathway angle and impairment of catheter function with the arm in the maximum abduction position.

Background: Lipomas are the most common form of benign soft tissue neoplasms and most frequently occur in the subcutaneous tissue. Rarely does a lipoma primarily arise from the arteries or veins. The most common location for an intravascular lipoma is the inferior vena cava, and rarely lipomas originate in the superior vena cava (SVC). Large lipomas of the SVC may be associated with central venous occlusive symptoms. There are only 7 cases of SVC lipomas reported in the literature. Here, we present only the second case of a large symptomatic lipoma located in the SVC, right internal jugular vein, and innominate veins. Methods We present a case of a 5-cm lipoma located in the SVC, discovered incidentally and surgically resected via median sternotomy. Results The patient underwent a successful open surgical resection of a symptomatic lipoma located in his SVC. Conclusions Lipomas of the SVC are exceptionally rare, with only 7 cases described in the literature. This case demonstrates that lipomas can be safely excised from the SVC leading to resolution of central venous occlusive symptoms. A comprehensive literature review reveals that surgical resection is generally without complication, leads to resolution of symptoms, and does not require long-term follow-up.

Background and Aims Acute extracorporeal dialysis is a short treatment, performed by a central venous catheter of large size, ensuring high flow. These devices have limitations: high caliber, excessive length, impossibility of tunneling and exit-site location in the supraclavicular region, with a subsequent high risk of dislocation and contamination. The authors report a new approach to dialytic central venous catheters selection in children. Method From January 2013 to December 2017, 16 children weighing less than 15 kg needed acute extracorporeal dialysis. Patients received an ultrasound guided percutaneous implantation of a two-way PICC power injectable catheter, in the right internal jugular vein or in the anonymous right vein. The device size always respected the ratio of 1/3; the catheters were cut to be adapted to child height, and subclavear tunnelizations and stabilizations were ensured. The hemodialysis was performed with the Prismaflex Gambro system. The effectiveness of treatment was evaluated by recirculation test and by measuring the KT/Vat the third hour, expressing the dialysis adequacy. Results Two-way power injectable central venous catheter,sized from 5 to 7 Fr and long from 8 to 15 cm were used. The recorded blood flow ranged from 4.7ml/min/kg to 7ml/min/kg; a KT/V variable from 0.5 to 1 was detected; the recycling rate was between 32% and 40%. No catheter related complications were observed. Conclusion In children weighing less than 15 kg, PICC power injectable have lower blood flow and higher recirculation rate compared to traditional dialysis catheters. However, the dialytic adequacy was suitable for an acute hemodialysis treatment. In addition, these catheters are available in a wide range of calibers and result more adaptable to the venous system of younger children.

Background and Aims Across the globe, vascular assess placement for haemodialysis is performed by Anaesthesiologist, Nephrologist, Radiologist, and surgeons depending on the experts availability of that locality. Patient care should not suffer because of lack of round the clock surgical and radiological expertise. We would like to share our ten year experience of vascular assess placement and their outcomes which were performed in the Department of Nephrology. Method A total 11429 vascular assess procedures have been carried out during 2009 to 2019. There were 781 AVF, cuffed 476 and non-cuffed 10172 (Internal Juglar 5375, Subclavian 2042 and femoral 2755) catheter insertions were performed. For construction of AVF, Pre-procedure ultrasound Doppler was performed to see both the anatomy of vein and artery. Radiocephalic and brachiocephalic AVF construction were done by side to side arteriovenous anastomosis using 6-0 Prolene double ended needle under strict asepsis. Insertion complications (bleeding and air-embolism), procedure time, patency, blood flow, and post-procedure complications (hematoma) were recorded. Follow up was done on 10th and 30th day of post surgical period. Of 476 Permcath, 58 were placed without valve guided peel away sheath catheters and rest with valve guided peel away sheath catheters in right internal jugular vein. Results Of 781 AVF, 557 (71.3%) were males and mean age 42.7±15.1 years. Of them, diabetes 330 (42.25%) and non-diabetes 451 (57.74%) were, Basic disease were DM 134 (16.15%), HTN 115 (14.72%), CGN 121 (15.49%), CTIN 124 (15.87%), Unknown 173 (22.15%) and others 114 (14.59%) were respectively. Common sites of AVF site were were left radiocephalic 319 (40.84%), left brachiocephalic 321 (41.1%) and both side brachiobasilic 141 (18%). Pre procedure ultrasound doppler findings were arterial diameter 2.79±0.96, venous diameter 2.75±0.86, arterial pulse wave velocity 57.93±19.49, diameter. The average duration of the procedure was 70 min without any intra operative complication. Five patients developed post-operative bleeding required re-exploration. The average duration between the construction of the fistula and the day of successful cannulation was 37 days. After six weeks venous diameter were 5.06±1.58 having blood blow of 766.17±536.36 ml/min. Successful cannulation could be done in 418 (53.52%) patients and another 363 (46.47%) patients did not have satisfactory thrill even after the stipulated time of maturation were declared failed AV fistulas. Other common complications observed were stenosis 351 (44.94%), edema 140 (17.92%), ischemia 124 (15.87%), thrombosis 124 (15.87%), infections 109 (13.95%) and aneursyms 112 (14.34%) respectively The technical success rate of catheter placement were 98% without any major insertion or post-procedure complications. Average procedural time was 20 minutes. Mal position of Permcath was seen in 38 (7.9%) patients, catheter thrombosis 45 (9.4 %) patients. Conclusion It is quite safe for nephrologists to perform surgical procedures required for vascular access for dialysis. The valve-guided tunnelled catheter insertion and side to side anastomosis AVF construction may be adopted as a routine practice by the Nephrologists.

PURPOSE To evaluate dislodgement of tunneled dialysis catheters (TDCs) in de novo (DN) placement with ultrasound versus over-the-wire exchange (OTWE). MATERIALS AND METHODS Data were collected retrospectively on all TDC placements at this institution from 2001 to 2019 and were excluded if no removal date was recorded or if dwell time was more than 365 days. Information on TDC brand, placement, insertion/removal, and removal reason were collected. Multiple logistic regression evaluated factors associated with TDC dislodgement. DN placement and OTWE were compared for rate of dislodgement (generalized estimating equations method) and TDC dwell time (survival analysis). RESULTS In total, 5328 TDCs were included with 66% (3522) placed DN and 32% (1727) via OTWE. Mean dwell time was 65 ± 72 days, and dislodgement occurred in 4% (224). TDC dislodgement rates in the DN and OTWE groups were 0.48 and 0.93 per 1000 catheter days, respectively. Brand (Ash Split vs. VectorFlow), placement technique (OTWE vs. DN), laterality (left vs. right), and site (left vs. right internal jugular vein) were significant predictors of dislodgement. OTWE placement exhibited 1.7 times the odds of dislodgement (95% confidence interval, 1.2-2.6; P = .004) compared to DN and had significantly higher probability of dislodgement across time (hazard ratio = 2.0; P < .001) compared to DN. Dislodgement rates for OTWE vs. DN were 8% vs. 3% (3 months), 13% vs. 6% (6 months), and 38% vs. 17% (1 year). CONCLUSIONS TDC spontaneous dislodgement rates were significantly and consistently higher after OTWE compared to DN placement. These data support more careful attention to catheter fixation after OTWE placement.

Mitsutoshi Shindo,1 Hiroaki Takemae,2 Takafumi Kubo,2 Masatsugu Soeno,2 Tetsuo Ando,2 Yoshiyuki Morishita1 1Division of Nephrology, First Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan; 2Department of Dialysis and Transplant Surgery, Hidaka Hospital, Gunma, Japan Purpose: This study was performed to investigate the primary patency rate and catheter-related problems associated with use of the femoral vein as a route for tunneled hemodialysis catheterization compared with those of the right internal jugular vein as the first-choice route in patients undergoing maintenance hemodialysis. Patients and methods: Twenty-two patients underwent placement of indwelling tunneled hemodialysis catheters in the right internal jugular vein as the first option for maintenance hemodialysis, and 20 patients underwent placement in the right femoral vein as the second option. The primary patency rate of the catheters and catheter-related problems at 1, 3, 6, and 12 months after placement were investigated. Results: The 1-, 3-, 6-, and 12-month primary patency rates of the tunneled hemodialysis catheters in the right internal jugular vein were 95.5%, 95.5%, 81.3%, and 58.3%. The primary patency rates of the catheters in the right femoral vein were 95.0%, 89.5%, 86.7%, and 66.7%. There were no statistically significant differences in the primary patency rates at 1, 3, 6, and 12 months or in catheter-related problems between the right internal jugular vein and right femoral vein. Conclusion: The primary patency rate and catheter-related problems of indwelling tunneled hemodialysis catheters placed in the right femoral vein were not different from those in the right internal jugular vein in patients undergoing maintenance hemodialysis. These results suggest that the right femoral vein might be a useful option for placement of indwelling tunneled hemodialysis catheters in patients undergoing maintenance hemodialysis. Keywords: tunneled hemodialysis catheter, right femoral vein, primary patency rate, catheter-related problems

Primary cough headaches (PCHs) are mainly observed in people aged >40 years, but cough-induced headaches are potentially symptomatic in children. We report a case of a child diagnosed with PCH without an intracranial disease. A 7-year-old boy presented with cough due to pertussis and powerful cough-induced headaches. No brain abnormalities were detected, but the right side of his neck was observed to swell. Echo examination confirmed right internal jugular vein dilatation during a Valsalva manoeuvre, and the patient was diagnosed with PCH with internal jugular phlebectasia. PCHs are normally reported in adults, but they can also occur in children. PCHs and internal jugular vein abnormalities may be related. Thus, tests assessing internal jugular vein morphology and function should be considered for PCH cases.

Persistent left superior vena cava is a rare vascular anatomical variant. Although ultrasonography has facilitated the process of central venous catheterization, it cannot be used to locate the tip of a catheter. Postprocedure chest X-ray is desirable for locating the course and tip of the catheter. In our case, initial ultrasonography demonstrated the absence of the right internal jugular vein. This prompted insertion of a central venous catheter on the left side of the neck in the presence of normal vascular anatomy. A subsequent chest X-ray revealed an abnormal course of the catheter consistent with presence of persistent left superior vena cava.

Study objective Several authors have reported rare, but severe, complications associated with the length of the intravascular guidewire during central venous catheter placement, as the wire tip can cause cardiac arrhythmia or perforation or become trapped within the vessel. Although one report investigated the optimal guidewire length using fluoroscopy, few reports have precisely measured guidewire position using transesophageal echocardiography (TEE). Here, we investigated the appropriate intravascular length of a guidewire for right internal jugular vein approach using TEE during cardiac surgery. Design A prospective observational study. Setting Operating room. Patients Fifty-two patients undergoing elective cardiac surgery. Measurements The intravascular guidewire distance from the insertion site to the superior vena cava–right atrium (SVC-RA) junction was measured by TEE. Demographic factors (height, weight, age, etc) were recorded. Results The mean distance from the access site to the SVC-RA junction was 17.8 ± 1.3 cm (maximum/minimum =20.0/15.0 cm). There was a greater correlation with height than with weight or age. Conclusion We confirmed the wire tips at all cases by ultrasonography. The distance using TEE was similar to that by fluoroscopy, but TEE was more precise. Guidewire length was weakly correlated to height. About 15 cm as minimum length should be considered the limit for guidewire length in an adult, in consideration of height, to ensure patient safety during central catheter placement for right internal jugular vein approach.

A pulmonary artery catheter is an important tool for the monitoring of hemodynamics in patients. Unfortunately, misplacement of a catheter tip may occur in the vasculature local to the intended placement. Misplacement of the catheter can be further complicated by entrapment at the unintended destination. We present a case of a misplaced and entrapped pulmonary artery catheter in a patient with worsening pulmonary disease. After multiple unsuccessful attempts to float the catheter, it was partially retracted and found to be stuck. Imaging showed the tip terminating in the right internal jugular vein at the level of the jugular foramen. It was initially suspected that the catheter had become looped, knotted, or otherwise entangled within the vasculature of the skull and surgical removal would be necessary. Before surgical removal was performed, it was instead determined that the catheter had become kinked and entrapped at the end of the introducer sheath, and noninvasive removal was accomplished by first removing the introducer sheath.

Background Many formulas based on the patient's height, weight and/or age exist to determine central venous catheter (CVC) depth in children. However, this information is unavailable in some emergency conditions. Therefore, direct methods should be developed to guide catheter position in children. Methods Eighty patients aged 1-10 y were enrolled from July 2015 to August 2016 and seventy-five were completed; fifty were male, and twenty-five were female. The exclusion criteria were inability to identify the sternal angle or failure to use the right internal jugular vein approach. The catheter was inserted using the right internal jugular vein approach, the distance from the skin puncture point to the midpoint of the sternal angle plane was measured, and the catheter tip was positioned to this distance minus 1 cm. Chest radiography were performed for those children after catheter insertion. The relative position between the catheter tip and carina was confirmed and the longitudinal distance from the catheter tip to the carina was calculated on radiographic images, and related complications were recorded. Results All catheter tips were above the carina, and the average distance from the catheter tip to the carina was 9.8 mm. No patients experienced serious complications. Conclusion The sternal angle is a useful and reliable anatomic landmark for guiding CVC position in children. Using this landmark, the catheter can be quickly and conveniently placed at a safety position in right internal jugular vein, especially in some emergency conditions.

Central venous catheters are used for various purposes in the operating room. Generally, the use of ultrasound to insert a central venous catheter is rapid and minimally complicated. An advanced venous access (AVA) catheter is used to gain access to the pulmonary artery and facilitate fluid resuscitation through the internal jugular vein. The present report describes a case in which ultrasound was used in a 43-year-old man to avoid complications during insertion of an AVA catheter with a relatively large diameter. The sheath of the catheter was so thin that a dilator was essential to prevent it from folding upon insertion. Despite the use of ultrasound guidance, the AVA catheter sheath became folded within the patient’s internal jugular vein. Mechanical complications of central venous catheter insertion are well known, but folding of a large-bore catheter in the internal jugular vein has rarely been reported.

Resumo A veia jugular interna direita é considerada a melhor via para um acesso vascular, devido a baixas taxas de complicação e ao fornecimento de fluxo satisfatório durante a hemodiálise dado seu trajeto mais retilíneo para o átrio direito. O presente estudo relata a identificação, prévia à punção, de uma variação anatômica da posição da veia jugular interna em relação à artéria carótida comum. Destaca-se o benefício dessa identificação prévia, enfatizando-se a importância de se realizar a ultrassonografia vascular com Doppler em detrimento de utilizar somente reparos anatômicos externos para a punção da veia jugular interna.

Central venous catheter placement is a common procedure performed on critically ill patients. Routine postprocedure chest radiographs are considered standard practice. We hypothesize that the rate of clinically relevant complications detected on chest radiographs following ultrasound-guided right internal jugular vein catheterization is exceedingly low.Retrospective chart review.Adult ICUs, emergency departments, and general practice units at an academic tertiary care hospital system.All 1,322 ultrasound-guided right internal jugular vein central venous catheter attempts at an academic tertiary care hospital system over a 1-year period.None.Data from standardized procedure notes and postprocedure chest radiographs were extracted and individually reviewed to verify the presence of pneumothorax or misplacement, and any intervention performed for either complication. The overall success rate of ultrasound-guided right internal jugular vein central venous catheter placement was 96.9% with an average of 1.3 attempts. There was only one pneumothorax (0.1% [95% CI, 0-0.4%]), and the rate of catheter misplacement requiring repositioning or replacement was 1.0% (95% CI, 0.6-1.7%). There were no arterial placements found on chest radiographs. Multivariate regression analysis showed no correlation between high-risk patient characteristics and composite complication rate.In a large teaching hospital system, the overall rate of clinically relevant complications detected on chest radiographs following ultrasound-guided right internal jugular vein catheterization is exceedingly low. Routine chest radiograph after this common procedure is an unnecessary use of resources and may delay resuscitation of critically ill patients.

Background: Although some investigations have shown higher rates of successful first attempt and fewer attempts by using ultrasound-guided Internal Jugular Vein (IJV) catheterization, arterial puncture is still common.. Objectives: The present study aimed to investigate US-guided catheterization of the right IJV via medial-oblique technique and also compare this technique to short-axis technique in open-heart surgery patients.. Patients and Methods: In this randomized clinical trial, 80 patients referred to cardiac operating room of Namazi hospital, Shiraz, Iran from March to July 2014 were selected using census method. Block randomization with website was also done. Then, the patients were divided into two groups of 40, Short Axis Group (SAG) and Medial-Oblique Group (M-OG). For short-axis technique, patient’s head was positioned at zero degree angulation with his trunk. For medial-oblique technique, on the other hand, patient’s head was tilted to left to 45 degrees between the head and trunk. Sex, age, Body Mass Index (BMI), access time, guidewire time, cannulation time, total attempts for catheterization, first, second, and third attempt success, arterial puncture, hematoma, bleeding, and catheter malposition were recorded. The overlap between the carotid artery and IJV in zero- and 45-degree angulation was estimated through ultrasound print. After all, Kolmogorov-Smirnov test was used to assess normal distribution of the data. Then, the data were analyzed through Student’s t-test, Mann-Whitney U test, and chi-square test. P < 0.05 was considered as statistically significant.. Results: The results showed no significant differences between the two groups regarding the duration of different catheterization steps (P = 0.376). In all the cases in both groups, accessing the vein was successful with three attempts or less. There were no clinical complications of catheterization in the two groups. The mean of overlap was 23.60 ± 33.47 in zero-degree angulation between the head and trunk and 32.72 ± 36.38 in 45-degree angulation and this difference was statistically significant (P = 0.001).. Conclusions: The results of the present study showed that both US-guided techniques under investigation had the same duration in different catheterization steps, total success rate, and primary mechanical complications, and could be used in clinics..

Rationale: Because central venous catheters (CVCs) are placed at the great vessels, mechanical complications can be fatal. Using the landmark method alone can make CVC difficult to access, depending on the skill of the operator and various patient conditions, such as anatomical variations of the vessels, young age, hypovolemic state, obesity, and short neck. Therefore, ultrasound (US)-guided techniques, including visualization of the vein and needle in the lumen of the vessel, are recommended. Nevertheless, our experience demonstrated that CVC malposition or vascular penetration cannot be prevented completely, even with real-time US guidance. Patient concerns: The first patient was a 19-year-old woman (weight = 58 kg, height = 155 cm) who underwent CVC cannulation in the right internal jugular vein (IJV) under general anesthesia using real-time US. The second patient, a 50-year-old woman (weight = 51.6 kg, height = 155.7 cm), underwent CVC insertion in the right IJV using real-time US. Diagnoses: During guidewire insertion in the first case, the posterior wall of IJV was penetrated, and a break in the core body of the guidewire was detected. In the case of second patient, CVC was embedded in the posterior wall of IJV and misplaced in the interpleural space in the right thorax. In both cases, an out-of-plane US approach was used. Interventions: In the first case, the broken guidewire was completely removed with real-time US guidance. In the second case, all fluid injected through CVC was aspirated, and then CVC was removed. Outcomes: In both cases, surgeries were completed successfully and all the patients were discharged without any complications. Lessons: Even if the needle tip is located in the lumen of IJV and blood aspiration is confirmed on real-time US, vascular penetration or CVC malposition during the procedure cannot be completely prevented because of the limitation of the US imaging field. These results suggest that care must be exercised even during US-guided CVC placement and that alternative US-guided techniques or supplementary monitoring should be considered to confirm proper CVC position.

Background Several formulae or methods are reported to predict the ideal central venous catheter insertion depth. However, they are complicated and often unsuitable in cases requiring rapid management. Aims This study aimed to determine a simple and practical method to predict the ideal central venous catheter insertion depth after the real-time ultrasound-guided right internal jugular vein, or left or right supraclavicular approach in pediatric patients. Method Pediatric patients with congenital heart diseases who underwent cardiovascular surgery between July 2015 and February 2018 in the German Pediatric Heart Center Sankt Augustin were enrolled. Body height, body weight, patient age (months), and central venous catheter insertion depth were retrieved from the anesthesia records. Ideal central venous catheter insertion depth was calculated by measuring the distance between the level of the carina tracheae and the central venous catheter tip on the first postoperative chest radiograph. The relationships of body height, body weight, and patient age (months) to ideal central venous catheter insertion depth for the right internal jugular, left supraclavicular, and right supraclavicular approaches were investigated. Results Body height was the best parameter, providing the best coefficients of determination as well as the simplest relationship. Based on analysis for ideal central venous catheter insertion depth for every 10-cm increase in body height, there was an ideal central venous catheter insertion depth for each body height, independent of the anesthesiologist's experience with the approach used. Whereas ideal central venous catheter insertion depths for the right internal jugular vein approach and the left supraclavicular approach showed no significant difference, ideal central venous catheter insertion depth for the right supraclavicular approach was significantly shorter than that of the other two approaches. Conclusion This study successfully determined a visually simple and practical bar graph to predict the ideal central venous catheter depth inserted using only the real-time ultrasound-guided insertion technique for the right internal jugular vein, left supraclavicular, and right supraclavicular approaches.

Central venous catheter (CVC) placement is a commonly done procedure but is associated with a few complications, and guidewire-related complications are one of them. In our case after induction of general anaesthesia, we planned to insert a CVC in the right internal jugular vein under ultrasound guidance. After the insertion of the introducer needle, when we tried to insert the guidewire, it got stuck and was neither moving forward nor in a backward direction. Too much force was not applied to remove the guidewire as it might have caused shearing of the guidewire and further complicated the picture. This problem was solved by simultaneous withdrawal of guidewire along with the needle, and on examination we found soft tissue debris lodged within the lumen which was preventing the guidewire movement in both directions. So, it is suggested that guidewire should be removed along with needle as a single unit if it is required.

We report a case of septic thrombophlebitis of the right internal jugular vein linked with right-sided acute parotitis caused by methicillin-resistant Staphylococcus aureus (MRSA) in a patient who had recently undergone a pylorus-preserving pancreaticoduodenectomy. Our case is unique because acute parotitis is a less-recognized cause of Lemierre’s syndrome, never previously linked with MRSA infection in this context. We review the literature on diagnosis and management of Lemierre’s syndrome caused by acute parotitis. Prompt diagnosis and aggressive antibiotics ensured a favourable outcome.

Awareness of persistent left superior vena cava (PLSVC), a rare congenital variant is helpful to a clinician to avoid the unnecessary complications. We report a case of PLSVC in a patient with chronic kidney disease which was identified following a difficult catheterization into the right internal jugular vein (IJV). The catheterization was attempted through the left IJV and the position of which could not be confirmed with check radiograph and two-dimensional echo. PLSVC was suspected in the computed tomography angiography and was confirmed following digital subtraction angiography.

Central venous catheters (CVCs) are placed in operating rooms worldwide via different approaches. Like any other medical procedure, CVC placement can cause a variety of complications. We report the case of an unexpected malposition of a catheter in the right internal jugular vein, where it looped back on itself during placement and went upward into the right internal jugular vein. CVC line placement should always be viewed as a procedure that could become complicated, even in the hands of the most experienced operators.

The objective of this paper was to develop a generally applicable formula to estimate correct catheter length after surgical cutdown in right internal jugular vein (RIJV) in neonates. The carina has been utilized as an anatomic landmark indicating superior vena cava-right atrium junction (SVC-RA) for the optimal placement of the central venous catheter (CVC) tip position. However, this landmark may not be accurate in neonates. Recent researches noted that the sixth vertebral body (T6) could better serve as a new landmark of SVC-RA in neonates and smaller children. We prospectively performed RIJV cutdown. For a controlled and reproducible surgical procedure, the venous entry site was consistently taken as the point where the omohyoid muscle crosses the RIJV. On intraoperative infantogram, the vertical distance between the venous entry site and T6 was measured and the catheter was inserted to this length. A linear regression model was investigated using the following variables to elicit the best prediction model for catheter length: gestational age, postconceptional age, birth weight, and weight at operation. Weight at operation best correlated with the measured CVC length (R2 = 0.916, P = 0.00), and the following linear equation was derived: estimated CVC length (mm) = 9 × [weight at operation (Kg)] + 30. There was no statistically significant difference between measured and estimated CVC length. With this formula, the optimal catheter length could easily be estimated when considering RIJV cutdown.

The aim of this study was to determine the degree of head rotation that creates the maximal anatomic separation between the right internal jugular vein and the carotid artery.Single-center prospective, observational cohort study.University medical center.Fifty patients aged21 years and undergoing cardiac surgery.An ultrasound machine equipped with a digital caliper was used to determine the relational anatomy of the internal jugular vein and the carotid artery, with patients in the Trendelenburg position at head angles of -15°, 0°,+15°,+30°,+45°,+60°,+75°, and+90°.When examining the percentage of the internal jugular vein vertical diameter that is not overlapped by the carotid artery (vertically unencumbered), there was a difference between the head angle groups (p0.01). Unencumbered vertical distance was different between+75° versus 0°, and+75° versus+15°. At+75°, 60.3%±5.3% of the internal jugular vein was unencumbered vertically, whereas at 0°, it was 37.2%±3.9%, and at+15° it was 40.3%±3.8%. Only 72% of the patients were able to position their head at+75°, and 54% of the subjects were able to position their head at+90°.The authors found the internal jugular vein becomes more vertically separated from the carotid artery at more extreme angles of contralateral head rotation.

ResumenDescribimos un caso de una paciente de sexo femenino de 55 años de edad a quien se le diagnosticó síndrome de Wolff-Parkinson-White, y al ser llevada al procedimiento de ablación se le encuentra agenesia de la vena cava inferior, con continuidad hacia las cavidades cardiacas derechas a través de la vena ácigos. La realización posterior del procedimiento a través de dicha vena se consideró exitosa, pero ante la recurrencia de las alteraciones electrocardiográficas y nuevos episodios de taquicardia se le realizó nuevo estudio electrofisiológico y ablación por vía yugular interna derecha con éxito. Presentamos además una revisión de la literatura sobre este tópico.AbstractWe describe a case of a female patient aged 55 who was diagnosed of Wolff-Parkinson-White syndrome. When taken to the ablation procedure, agenesis of the inferior vena cava with continuity into the right cardiac cavities through the azygos vein is found. The subsequent completion of the procedure through the said vein was considered successful; however, due to the recurrence of new episodes of tachycardia and of electrocardiographic alterations, a new electrophysiological study and successful ablation was performed via right internal jugular vein. We also present a review of the literature on this topic.

Knowledge of the optimal lengths for central venous catheterization prior to the procedure may lessen the need for repositioning and prevent vascular complications. To establish the optimal lengths for non-tunneled central venous catheter insertion through the right and left internal jugular veins. We included 92 children who received US-guided central venous catheterization via right or left internal jugular veins in intensive care units. The calculated distance between the skin and carina was considered the optimal length for right and left internal jugular venous catheterization. Univariate and multivariate linear regression analyses was used to identify predictors. Age, height and weight showed significant correlations with optimal insertion lengths for right and left internal jugular vein approaches on univariate analysis, while height was the only significant independent predictor of optimal insertion length. The optimal insertion lengths (cm) suggested by our data are, for the right internal jugular vein 0.034 × height (cm) + 3.173, and for the left 0.072 × height (cm) + 2.113.

Background: Perioperatively, the preferred site for central venous access by anesthesia providers is the right internal jugular vein (RIJV). Maneuvers such as Trendelenburg position and positive end-expiratory pressure are commonly performed to increase the size of the RIJV and increase the success rate of cannulation. Methods: We evaluated the size of RIJV at various anatomic levels in the neck to assess the most advantageous level for cannulation with patients in a flat, supine position without use of Trendelenburg. In this study 18 healthy subjects were placed in a flat, supine position for measurements of the cross-sectional area (CSA) of the RIJV using vascular ultrasound. Three measurements were obtained at each of the 5 anatomic levels of the neck. The first baseline measurement was taken at the level of cricoid cartilage (0 cm), followed by measurements at 4 other levels: cephalad to the cricoid cartilage at +1 and +2 cm, and caudad to the cricoid cartilage at −1 and −2 cm. The measurements of the CSA in centimeters2 were electronically calculated after manual anatomic outlining of the vein. Factors that may influence the RIJV size, including age, gender, and body surface area, were included in the data analysis. Results: The average CSA of the RIJV at the 5 levels measured (from +2 to −2 cm) were 0.91, 0.97, 1.06, 1.10, and 1.14 cm2, respectively. The CSA of the RIJV was significantly larger at every 1-cm interval from the most cephalad level at +2 cm to the −2 cm most caudad level, except for the 0 to the −1 cm interval. Statistically significant difference in the CSA (P < .001 or 20%), was noted from the −2 to the +2 cm levels. No differences were found based on age, gender, or body surface area. Conclusions: The anatomic level of the neck in relation to the cricoid cartilage at which jugular puncture is performed should be considered together with other maneuvers that may increase RIJV size. Success of RIJV cannulation may be increased by accessing the vein at a point with the largest CSA—1 to 2 cm caudad of the cricoid cartilage—especially in cases when the patient does not tolerate Trendelenburg position or ultrasound guidance is not available.

A 1.7 kg infant with obstructed supracardiac total anomalous pulmonary venous drainage (TAPVD) presented with severe pulmonary hypertension secondary to vertical vein obstruction. The child, in addition, had a large omphalocele that was being managed conservatively. The combination of low weight, unoperated omphalocele, and severe pulmonary hypertension made corrective cardiac surgery very high-risk. Therefore, transcatheter stenting of the stenotic vertical vein, as a bridge to corrective surgery was carried out. The procedure was carried out through the right internal jugular vein (RIJ). The stenotic segment of the vertical vein was stented using a coronary stent. After procedure, the child was discharged well to the referred hospital for weight gain and spontaneous epithelialization of the omphalocele. Stenting of the vertical vein through the internal jugular vein can be considered in very small neonates as a bridge to repair obstructed supracardiac total anomalous venous drainage.

Recently, a percutaneous right ventricular assist device (RVAD) called the TandemLife Protek Duo (TPD; TandemLife, Pittsburgh, PA) has been introduced. The Protek Duo (TPD) is a temporary RVAD placed via the right internal jugular vein, capable of providing up to 4.5 L of flow. We report a two-center experience using the TPD in 17 patients with right ventricular (RV) failure, 12 of whom were post-left ventricular assist device (LVAD) implantation.

BACKGROUND: Central venous cannulation is a necessary invasive procedure for fluid management, haemodynamic monitoring and vasoactive drug therapy. The right internal jugular vein (RIJV) is the preferred site. Enlargement of the jugular vein area facilitates catheterization and reduces complication rates. Common methods to enlarge the RIJV cross-sectional area are the Trendelenburg position and the Valsalva maneuver. OBJECTIVE: Compare the Trendelenburg position with upper-extremity venous return blockage using the tourniquet technique. DESIGN: Prospective clinical study. SETTING: University hospital. SUBJECTS AND METHODS: Healthy adult volunteers (American Society of Anesthesiologists class I) aged 18-45 years were included in the study. The first measurement was made when the volunteers were in the supine position. The RIJV diameter and cross-sectional area were measured from the apex of the triangle formed by the clavicle and the two ends of the sternocleidomastoid muscle, which is used for the conventional approach. The second measurement was performed in a 20 degrees Trendelenburg position. After the drainage of the veins using an Esbach bandage both arms were cuffed. The third measurement was made when tourniquets were inflated. MAIN OUTCOME MEASURE(S): Hemodynamic measurements and RIJV dimensions. RESULTS: In 65 volunteers the diameter and cross-sectional area of the RIJV were significantly widened in both Trendelenburg and tourniquet measurements compared with the supine position (P, NA

Venous reperfusion and double-lumen cannulae for extracorporeal membrane oxygenation (ECMO) are usually inserted via the right internal jugular vein. The supraclavicular approach to the right or left subclavian vein could serve as a possible alternative. The aim of this analysis was to compare feasibility, complications, and performance of supraclavicular and jugular cannulation. We retrospectively analyzed charts and registry data of patients undergoing venovenous ECMO. Twenty-four patients underwent jugular cannulation, and 11 patients underwent supraclavicular cannulation. Ten patients underwent femoro-jugular, and five patients underwent femoro-supraclavicular ECMO. Double-lumen cannulae were inserted via the jugular approach in 14 patients and via the supraclavicular approach in 6 patients. No cannulation-associated complications but for a single minor bleeding from the insertion site of a supraclavicular double-lumen cannula were recorded. Performance of the extracorporeal circuit was comparable between jugular and supraclavicular groups but for a more pronounced oxygenation effect in the supraclavicular double-lumen group caused by higher blood flows via larger (24 F) cannulae. The supraclavicular approach seems safe and equivalent to jugular cannulation and could serve as a valid alternative.

This chapter addresses the case presentation of a 55-year-old woman, who was diagnosed with IgG lambda multiple myeloma and was referred to Interventional Nephrology for evaluation of arm swelling on the ipsilateral side of a recently created arteriovenous fistula (AVF). She had been receiving hemodialysis for the past 3 months via right internal jugular vein tunneled catheter. Two prior left upper extremity attempts at AVF placement had failed. A right upper extremity brachial artery to cephalic vein perforator AVF was created several weeks prior to presentation.