Imaging for central venous cannulation: A necessity rather than luxury.

Central venous cannulation is quite common a procedure in the perioperative period, usually for fluid replacement in surgeries expected to involve major fluid shifts, and often also as a measurement guide to central venous pressure. Internal Jugular vein cannulation is often done owing to its obvious advantages of being superficial and ease of hematoma formation prevention in patients with coagulation disorders. Mostly cannulation is done as a blind procedure utilizing anatomic landmarks Certain complications have been reported with IJV cannulation such as inadvertent arterial puncture, pneumothorax, arrhythmias etc.12 We encountered a rarer complication.

A 69 year female was posted for ICSOL removal surgery. The right IJV was to be canulated with the purpose of CVP assessment through traditional landmark approach. After skin puncture and advancement of needle venous blood could be freely aspirated. Thereafter guidewire was inserted through the needle. Initially it passed freely but after crossing the 10 cm mark resistance was felt. Suspecting perivascular placement, the guidewire was immediately withdrawn and aspiration was again performed with the needle still in the same place, surprisingly there was still free flow of venous blood. The guidewire was again inserted and again resistance was encountered at about 10 cm mark. At this juncture there was need of some form of visualization to diagnose the anomaly. Keeping the needle and the guidewire in the same place, a C-arm aided image intensifier was utilized to visualize the path of guidewire. The image showed the guidewire to be looped over itself (Fig 1). The needle and guidewire were withdrawn. Later the IJV was cannulated with a more horizontal approach.

Figure 1

The most probable cause could be presence of a vein with an aberrant anatomy.3 The guidewire could have entered a tributary of IJV that had an abnormal course. Though malpositioning of catheters have been reported, usually perivascular placements, we encountered a situation in which although the catheter was intravascular, still it was malpositioned.4 The C arm aided image intensifier was highly useful in judging the complication. Catheter placements being blind procedures, complications are likely and any form of visualization would be beneficial. In most of the developed countries, cannulation under visualization is being made mandatory.5 Recently there have been reports of use of Ultrasound and fluoroscopy by radiologists for placement of 14 French large bore IJV catheters in hemorrhaging gravid patients.6 Ultrasound guided placements have a definite advantage as it provides real time imaging. USG guided placements, with a little practice are easier, quicker and safer. Hence the anaesthetists themselves must perform the procedure after some training. The “Stanford Evidence based practice center” has recommended USG CVC as one of the 11 point recommendations in “A critical analysis of patient safety practices”.7 US assistance for CVC should therefore be a routine rather than a luxury for anaesthetists to reduce complications as well for preservation of time.8