Idiopathic unilateral hypoplasia of internal jugular vein and coagulopathy: Unusual case for central venous catheterization.

Central venous catheterization (CVC) is routinely done procedure in ICU or during surgery for various indications. Right Internal jugular vein (IJV) is preferred vessel among different routes for CVC. Anatomic variations of neck vessels are not uncommon and may increase the complication rate especially in patients with altered coagulation profile. Anatomic landmark technique is commonly used for CVC but not without possibility of complications. Ultrasound (US) guided IJV Cannulation provides high success rate, less access time and lesser complications. Superiority of US over anatomic landmark technique has been established, but use of US in clinical practice is still limited. We report a case of idiopathic unilateral hypoplastic IJV in a patient with altered coagulation profile who required CVC, we also tried to find out the barriers for limited use of US.

INTRODUCTION

Central venous catheterization (CVC) is a routinely done procedure in Intensive Care Unit or during surgery for invasive hemodynamic monitoring, diagnostic, and therapeutic purposes. Internal jugular vein (IJV) is preferred for CVC due to easy accessibility and lesser complications. Anatomic variations of neck vessels are not rare.[123] These variations may increase the complication during CVC, especially in patients with altered coagulation profile. Anatomic landmark technique is commonly used for CVC but not without the possibility of complications. Ultrasound (US)-guided techniques found to be safer and less time consuming than anatomic landmark technique.[45] We report a case of idiopathic unilateral hypoplastic IJV in a patient with altered coagulation profile, in whom CVC was performed successfully using the US-guided technique.

CASE REPORT

A 42-year-old male, diagnosed as cirrhosis of the liver was scheduled for cadaveric orthotopic liver transplant. He had no past history of trauma, surgery or IJV cannulation. His liver function tests and coagulation profile were markedly altered with activated partial thromboplastin time 72 s (control 30 s), international normalized ratio 2.5, and platelet count 44 × 109/L. After induction of anesthesia, for invasive hemodynamic monitoring CVC was planned through right IJV. Patient was placed in 15° Trendelenburg position and the head was rotated 45° to left. During real-time US, right IJV was found to be hypoplastic [Figure 1]. Then CVC was done through left IJV, which was of normal diameter [Figure 2], without any complications.

Figure 1

Hypoplastic right internal jugular vein

Figure 2

Left internal jugular vein with normal diameter

DISCUSSION

Central venous catheterization can be done through various routes, but right IJV is a preferred vessel to obtain central venous access, due to its superficial anatomical position, straight course, and low risk of pneumothorax. Anatomic variations of neck vessels are not rare and may increase the complication rate. Prasad et al. reported that the most common position of IJV in relation to the common carotid artery (CCA) was anterolateral; 81.66% on the right side and 78.33% on the left side. Dangerous position of IJV (anterior, medial, and posterior) was found in 13.33% on the right side and 15% on the left side. Mean transverse diameter of IJV was 13.2 mm on the right side and 10.4 mm on the left side of the neck. Small sized IJV (≤7 mm) was found in 1.6% on the right side and 4.16% on the left side.[1]

Lim et al. also reported that in 80.5% of cases, right IJV was larger than left IJV and with reference to the CCA 85.2% of the IJV were found in the lateral position, 12.5% anteriorly, 1.1% medially, and 1.1% posteriorly. Hypoplastic IJV was found in 3.9%.[2] In a study of 200 cases, Denys and Uretsky found abnormal anatomy in 8.5% cases with small IJV in 3%, no right IJV in 2.5%, and IJV medial to the carotid in 2% of cases.[3]

Complications during CVC are well known and can be serious. These anatomical variations may increase the complication rate. Eisen et al. reported overall complication rate of IJV cannulation was 33%, including failure to place catheter 22%, and arterial puncture 5%.[6] Ray et al. reported the incidence of carotid artery puncture in 7.5% and in a study by Tammam et al. arterial puncture and hematoma occurred in as high as 16.7% and 23.3% of cases, respectively.[45] Arterial puncture in patients who has altered coagulation profile could be a potentially very serious complication.

Anatomical landmark guided technique for IJV cannulation has been described and is used commonly, but the success rate is variable according operators experience, it is more time-consuming and the complication rate is high. In a study by Ray et al., they compared anatomical landmark technique with US-guided technique for IJV cannulation, and found that among various complications carotid artery puncture was more common (7.5%) in anatomical landmark technique. They conclude that US-guided technique increases the success rate and decrease the complication and time of catheterization in comparison to anatomical landmark technique.[4] Tammam et al. also reported that US-guided IJV catheterization is safer than landmark technique and has less complication rate.[5] National Institute of Clinical Excellence (NICE) guidelines recommend that, US should be consider in most clinical circumstances where CVC is indicated.[7]

In our patient, who had relatively rare malformation of neck vessels with markedly altered coagulation profile, we could avoid life-threatening complications only because of US-guided technique, that showed hypoplastic right IJV and then CVC was done through normal caliber left IJV without any complication.

Once the superiority of US over anatomic landmark technique has been established and recommendation of NICE guidelines, the US-guided technique should have been used regularly, but the situation is different. In a recent survey by Buchanan et al., 44% of respondents said they never use US-guidance for CVC placement and of respondents who had US training in vascular access, only 50% used US-guidance in practice.[8] The barriers to such translation are important to understand. Low availability and lack of training are few to mention. These barriers should be overcome to improve patient outcome.

CONCLUSION

Anatomic variations of neck vessels are not rare. To avoid life-threatening complications, we emphasize on the regular use of US-guided technique for CVC especially, when difficulties are anticipated for various reasons.