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The Micra™ transcatheter pacing system (TPS) (Medtronic, Minneapolis, MN, USA) is the only leadless pacemaker currently approved by the United States Food and Drug Administration. A limitation to the use of this device in the pediatric population is the large size of the delivery sheath. We present a 28-kg, nine-year-old male with symptomatic asystolic pauses who underwent successful placement of a Micra™ TPS via right internal jugular vein surgical cutdown as a first-line option. Current reports in the literature using the right internal jugular vein due to small patient size are limited to those involving patients with concurrent medical conditions that render the use of traditional systems unfavorable or contraindicated. Given the potential benefits of a leadless pacemaker system, its use in the pediatric population will likely continue to increase with time. This case describes technical strategies and procedural caveats that could aid in continued successful implantations of the Micra™ TPS in smaller patients as first-line therapy. In this report, room setup, the use of preprocedure vascular duplex studies, sheath manipulation, and a multidisciplinary approach are reviewed.

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.

Early detection and treatment are critical for preventing catheter allotopia in the totally implantable access ports and whenever possible, the right internal jugular vein should be selected as the first puncture point.

BACKGROUND Central Venous Cannulation is a very important technique needed intra operatively and in critical care setting. Most commonly accessed is the right internal jugular vein due to lesser incidence of complications and easy accessibility. Ultrasound guidance improves the successful insertion rate than blind technique. Increasing the cross-sectional area (CSA) of IJV improves the success rate and decreases complications. Several manoeuvres such as Trendelenburg’s position, Valsalva’s manoeuvre, hepatic compression and positive end-expiratory pressure have been used to increase the diameter of the IJV. Application of PEEP of 10–12 cm H2O in supine position has been found to increase the CSA of right IJV in various studies. The aim of the study is to determine the optimal PEEP which increases size of IJV without complications. METHODS This is an observational study conducted in the Government Medical College, Thrissur. The groups were chosen from instances where three different levels of PEEP were used. A total of 90 ASA PS 1 & 2 patients who received general anaesthesia for elective surgeries where assigned to three groups - P0, P5 and P10 with different values of PEEP- 0, 5, and 10 cm of H2O respectively. Patients with obesity, raised intracranial pressure, previous neck surgery were excluded from the study. After application of PEEP for 2 minutes, the diameter of Right Internal Jugular was sonologically measured. The increase in cross sectional area of IJV in each group was analysed. Application of PEEP affects heart rate and mean arterial pressure in patients. So, the heart rate and mean arterial pressure readings were taken at the time of measurement of IJV. These were also analysed statistically. RESULTS The three groups P0, P5 and P10 were comparable in demographic parameters like age and weight. Cross-sectional area of three groups was compared. The mean CSA in P0 was 1.3345, P5 was 1.399 and P10 was 1.443 cm2. (p .001). There was a statistically significant increase in cross-sectional area of IJV when PEEP was applied. Increase in CSA was significantly higher with higher PEEP (p .001). CONCLUSIONS The application of PEEP of 5 to 10 cm of H2O is a safe method to increase the area of IJV for successful cannulation. This value of PEEP did not cause clinically significant haemodynamic effects. KEYWORDS PEEP, Cross-Sectional Area of IJV, Sonoanatomy, IJV Cannulation

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.

Background Real-time ultrasound (US) in central venous catheterization is superior to pre-procedure US. However, ensuring real-time US into routine practice is impeded by its perceived expense and difficulty. This expertise requires hand–eye coordination and learning curve. Moreover, availability of multiple US machines and probes for multiple operation theatres may not be possible even at the tertiary level care set-up. Currently, pre-procedure US and landmark methods are most widely used. We investigated both the techniques with application of skin markings in the pre-procedure group to ascertain efficacy and safety with a view to incorporate pre-procedure US in our practice. Methods In this randomized study, we investigated 66 patients. Thirty-three patients in the pre-procedure ultrasound group and 33 patients in the landmark group were included for right internal jugular vein (RIJV) cannulation. We recorded the first needle pass success rate, cannulation time and complications. Results Pre-procedure US was associated with more successful attempts, shorter cannulation times and less complications. Under pre-procedure US, 75.76% of first attempts were successful with a cannulation time of 50 (25–180) seconds. Under landmark technique, 27.27% of first attempts were successful with a cannulation time of 85 (20–200) seconds. First puncture success rates were higher in pre-procedure US than landmark technique, 66.67% vs 27.27%, respectively. Conclusion Pre-procedure US for RIJV catheterization is safer, quicker and superior to landmark technique.

Central venous catheterization has an essential role in the management of patients who are critically ill, and patients who have special operative interventions. In general, the bigger the vein cross sectional area and diameter the easier the catheterization will be. There are different maneuvers to increase internal jugular vein caliber. These include; passive legs elevation, hepatic or abdominal compression, Trendelenburg position, Valsalva maneuver, and positive end-expiratory pressure. The objective of the study is to evaluate the effect of passive legs elevation and hepatic compression on the diameter and the cross-sectional area of the right internal jugular vein. This prospective study included 80 adult patients ASA class I and II. Patients who had any contraindication to the passive legs elevation or hepatic compression, or those with disruption of the local neck anatomy; were excluded from the study. Patients were evaluated for their right internal jugular vein cross-sectional area and diameter by the use of linear high frequency two-dimensional ultrasound. Each patient has three stages of measurement; supine, Passive legs elevation at (30o-45o) for one minute, and hepatic compression. Of the 80 patients, 70% were males, the age range was (19–55 years) with a mean of (37.75±12.16) years, and the majority were overweight. The maximum diameter was achieved during hepatic compression with a stepwise statistically significant increase of about (0.44±0.27 cm) from the baseline in supine position, when compared to only (0.26±0.21 cm) during passive legs elevation. The cross-sectional area is significantly and maximally increased from the baseline of (0.93 ± 0.59 cm2), during hepatic compression. The increase in the diameter and the cross sectional area was more significant in males irrespective to age and weight. In conclusion, Hepatic compression is significantly superior to the passive legs elevation in achieving more right internal jugular vein diameter and cross-sectional area.

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.

Introduction Inferior vena cava (IVC) filter retrieval is generally a straightforward procedure but can be challenging with unique complications. A technique used for endovascular rescue of a patient where sheath perforation by the IVC filter occurred during IVC filter retrieval is described. Report A 75 year old man underwent retrieval of an IVC filter that had been in place for 10 months. Using the IVC filter retrieval set from a standard right internal jugular vein approach and the loop–snare technique, the hook and collet were captured, and the filter was collapsed into the retrieval sheath. Approximately halfway through removal of the filter through the sheath, mild resistance was encountered and the tip of the IVC filter was found to have perforated the side of the retrieval sheath. The sheath appeared to have bent slightly in this region, probably weakening the sheath wall and creating angulation, which allowed sheath perforation to occur. From a right common femoral vein approach, an Amplatz wire was used to cannulate the distal end of the perforated sheath. A balloon was then used to pull the perforated sheath with the IVC filter into a larger sheath. After removing the Tuohy-Borst and Luer adapters on the perforated sheath, it was able to be internalised and removed via the femoral vein sheath. Discussion The endovascular rescue technique described herein may prove useful to other practitioners encountering similar situations, and the complication shows areas of caution when using the loop–snare retrieval technique., Highlights • Inferior vena cava (IVC) filters cannot always be removed using standard techniques. • Advanced retrieval techniques for IVC filters can have complications. • Endovascular rescue methods can be used in a variety of scenarios.

BACKGROUND In recent years, with the popularity of laryngeal mask airway (LMA) for the management of clinical anesthesia, the influence of the LMA on the position and blood flow of the internal jugular vein (IJV) has attracted an increasing amount of attention. AIM To investigate the effect of placement of different types of LMA (Supreme LMA, Guardian LMA, I-gel LMA) on the position and blood flow of the right IJV. METHODS This was a prospective randomized controlled trial. A total of 102 patients aged 18-75 years who were scheduled to undergo laparoscopic abdominal surgery with general anesthesia were randomly assigned to three groups: Supreme LMA (group 1), Guardian LMA (group 2), and I-gel LMA (group 3) groups. The main indicator was the overlap index (OI) of IJV and the common carotid artery (CCA) at the high, middle, and low points before and after the placement of the LMA. The second indicators were the proportion of ultrasound-simulated needle crossing the IJV and CCA, and the cross-sectional area and blood flow velocity of the IJV before and after placement of the LMA at the middle point. RESULTS Data from 100 patients were included in the statistical analysis. The OI increased significantly after placement of the LMA in the three groups at the three points (P < 0.01), except group 2 at the low point. In group 2 and group 3, the OI was lower than that in group 1 after LMA insertion at the high point (P < 0.0167). At the middle point, after LMA insertion, the proportion of simulated needle crossing the IJV significantly decreased in all three groups (P < 0.05), and the proportion in group 2 was higher than that in group 3 (P < 0.0167). The proportion of simulated needle crossing the CCA or both the IJV and CCA significantly increased in group 1 and group 2 (P < 0.05), which increased with no statistical significance in group 3. After LMA insertion, the cross-sectional area of ​​the IJV significantly increased, while the blood flow velocity significantly decreased (P < 0.01). There was no significant difference among the three groups. CONCLUSION The placement of Supreme, Guardian, and I-gel LMA can increase the OI, reduce the success rate of IJV puncture, increase the incidence of arterial puncture, and cause congestion of IJV. Type of LMA did not influence the difficulty of IJV puncture. Therefore when LMA is used, ultrasound is recommended to guide the IJV puncture.

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.

Background Central venous catheterization is a standard clinical practice for infusion of fluids, blood products, or vasoactive drugs to the central circulation and to monitor central venous pressure during perioperative periods. However, this procedure can lead to significant complications, including cardiac arrhythmia, vascular injury, hydrothorax, hemothorax, hydromediastinum, and cardiac tamponade. Such complications can occur when the catheter tip is inserted within the heart chamber or when it abuts the vascular wall at a steep angle. Objectives The primary aim of the current study is to examine the accuracy of the C-distance or surface landmarks in determining the length of CVC that is required to place the catheter tip at the mid-SCV as confirmed by transesophageal echocardiography (TEE). A secondary aim is to derive an equation or formula to calculate the depth of the CVC that is required in order to have the catheter tip placed at the mid-SVC. Patients and Methods After obtaining the approval from research ethical committee of Ain Shams University and obtaining informed consent from patients the study was conducted in The Academic Institute for Cardiothoracic and Vascular Surgery, Ain Shams University hospitals. 30 adult patients scheduled for elective cardiac surgeries were enrolled in the study after being selected by random simple method. Results We used the TEE to visualize the CVC tip 3 cm above SVC-RA junction and use this actual depth to compare between the accuracy of the expected depth by C-length method and expected measured depth by surface landmarks method; we found out that the two methods were nearly the same to the actual depth guided by TEE. The mean ± SD surface landmarks distance was 142 ± 12 mm (range, 120 - 162 mm) and the mean ± SD by C-length was 128 ± 18 mm (range, 95 - 174 mm). The mean ± SD TEE-guided CVC length needed to place CVC tip at mid-SVC was140 ± 13 mm (range, 110 - 162 mm). Also in none of the patients was the CVC tip placed below the carinal level on postoperative plain AP chest x-ray. The CVC tip was placed at a mean ± SD height of 12 ± 2 mm (range, 5 to 16 mm) above the carinal line, which concludes that the mid SVC region lies above the carina level by 0.5-1.5 cm and it’s a reliable landmark for postoperative confirmation of optimum placement of CVC tip. Conclusion TEE can be used to effectively determine the proper fixed catheter insertion depth for a patient through the right internal jugular vein. This study showed that both C-length and surface landmarks methods are accurate to determine the depth of the central venous catheter in the mid SVC region (3-3.5 cm) above SVC-RA junction above pericardial reflection. Another conclusion is that the mid SVC region is above carinal level in all cases by 5 mm -15 mm. From this study we formulated two regression equations depending on the expected surface landmarks and C-length with an accuracy of ± 11.662 mm and ± 10.643 mm respectively.

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.

This is a report of a 45-year-old female with thoracic central venous obstruction (TCVO) and alpha-1 antitrypsin deficiency requiring an implanted port for infusions. The azygos vein was used for catheter access in the setting of an occluded right internal jugular vein, bilateral innominate, and superior vena cava . A literature review examines the etiology of TCVO and superior vena cava syndrome (SVC), as well as the potential benefits and complications for using the azygos vein in patients with TCVO requiring port or catheter venous access.

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.

An Arnold-Chiari malformation is a congenital central nervous system defect. Raised intracranial pressure is commonly observed, and posterior decompression neurosurgery is the treatment of choice. We describe a patient with iatrogenic occlusion of bilateral jugular veins, subclavian vein, and superior vena cava resulting from repeated central venous cannulations. Because of venous hypertension, the patient suffered from neurologic symptoms: headaches, vision disturbances, and marked head edema. Two stents were used to recanalize the right internal jugular vein and superior vena cava. Symptoms subsided, and the patient returned to work. During 24-month follow-up, stents were patent. The patient remains symptom free and continues working. Keywords: Vena cava obstruction, Endovascular treatment, Stenting

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.

Summary: Background: The ipsilateral nipple has been used as a directional guide for needle advance during internal jugular vein (IJV) catheterization. We attempted to validate the utility of the ipsilateral nipple during IJV catheterization. Methods: One hundred and two patients scheduled for elective surgery were enrolled. In the 15° Trendelenberg position with 30° head rotation, the apex of the triangle formed by the sternocleidomastoid muscle and the clavicle was identified. The angle formed by the line connecting the apex and the ipsilateral nipple and the actual course of the IJV was measured. The distance between the apex of the anatomical triangle and the IJV center identified were measured via ultrasound. Results: The angle formed by the line connecting the apex and the ipsilateral nipple and the IJV was 16 ± 7.6° and was greater in females than males (14.8 ± 1.1 vs 17.4 ± 1.0°, P = 0.043). Regression analysis showed that height, weight, gender, and age did not affect the angle as an independent factor. The apex of the anatomical triangle was 0.5 cm medial to the IJV center and was shorter in females compared to males (0.33 ± 0.12 vs 0.6 ± 0.09 cm, P = 0.039). Conclusion: Our study shows that when the needle is inserted at the apex of the anatomical triangle directed towards the ipsilateral nipple, it crosses the IJV at 16°. Since the common carotid artery is usually medial to the IJV, directing the needle towards the ipsilateral nipple seems to be a safe way to avoid the common carotid artery and successfully puncture the IJV. Keywords: Internal jugular vein catheterization, Ipsilateral nipple, Common carotid artery

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.

This study reports on a rare variation of the right internal jugular vein (IJV) identified during routine anatomic dissection of a male cadaver. The right IJV had a tributary located parallel and medially to the IJV itself. This branch of the IJV emerged between the transverse processes of the 3rd and 4th cervical vertebrae and drained into the junction between the right internal jugular and brachiocephalic veins. The present study described a rare branch of the right IJV, which is important knowledge for surgeons, in order to prevent accidental injury and bleeding during surgical procedures.

To analyze relevant metrics involved in Denali Vena Cava Filter placement via different venous access sites.Patients with Denali filters inserted between March 2017 and February 2018 were retrospectively analyzed. Pre-procedural and pre-retrieval computed tomography (CT) were reviewed. We compared inferior vena cava (IVC) diameter, filter tilt angle, filter tip IVC wall abutment, fluoroscopy time, and retrieval outcomes by venous access site. Filter tip abutment/limb penetration and procedure-related complications were investigated.Seventy-eight patients had successfully-placed Denali filters. Seventy-one of 78 (91%) patients had both pre-procedural and pre-retrieval CT. The majority (35 [49%]) were placed via the right femoral vein (left femoral vein: 22 [31%]; right internal jugular vein: 14 [20%]). The jugular approach involved a longer fluoroscopy time (mean 117 ± 37 s [s]) than the right and left femoral approaches (mean 64 ± 21 s, mean 67 ± 15 s, respectively [p 0.05]). Filter tilt and filter tip abutment were not significantly different between the 3 access routes. Filter tip abutment and limb penetration were observed in 8/71 (11%) and 2/71 (3%) patients, respectively. Filter retrieval was attempted in 68 of 78 (87%) cases, and all filters were successfully retrieved. One filter arm fractured during advanced retrieval; no other procedure related complications were recorded.Both femoral venous approaches can be safely used for placement of the Denali filter. Femoral venous access involved a shorter fluoroscopy time without any differences in filter tilt and filter tip abutment compared to transjugular access.

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.