Difficult venous catheterization in internal jugular vein.

The Editor,

A 55-year-old male patient with severe aortic valve regurgitation was scheduled for aortic valve replacement. After smooth anesthesia induction and intubation, we attempted to place a central venous pressure catheter via the right internal jugular vein (IJV), initially without ultrasound. IJV was easily punctured with 18 G needle using anatomic landmarks. Free back flow was observed, but the resistance was encountered while advancing j-tip guide wire. We then performed vascular ultrasound examination using Philips HD11 XE ultrasound system, and found to have a large venous valve in right IJV [Figures 1 and 2]. Further attempts on the right side were abandoned to avoid damage. Left IJV catheter was placed instead successfully under ultrasound guidance.

Figure 1

Left panel – short axis view showing unicuspid valve. Right panel – long axis view showing valve and flow direction in internal jugular vein

Figure 2

Color flow Doppler image of internal jugular vein (IJV: Internal jugular vein, ICA: Internal carotid artery)

Valve in IJV is seen in 90% of the individuals.[1] IJV valve is mostly located in the distal portion of the IJV, just proximal to the jugular bulb in the retroclavicular space.[2] This site makes the ultrasound assessment of the valve difficult with large ultrasound probes. The valve leaflet is commonly bicuspid (77–98%), but tricuspid W(0–7%) or unicuspid (1.4–16%) valves have also been observed.[3] Competent IJV valve is important in maintaining the transcranial blood pressure gradient during chest compression in cardiopulmonary resuscitation.[4] Central venous catheterization of the IJV can cause persistent incompetence of the IJV valve and thrombus formation on damaged valve.[15] In the present case, we found the large unicuspid valve in IJV that itself an uncommon observation. Such a large valve could potentially have caused difficult passage of the guide wire of venous catheter. Any forceful attempt to overcome resistance could have damaged the valve. Ultrasound examination helped us to visualize IJV and find out the cause for difficult central venous catheterization.