Ultrasound-guided internal jugular vein cannulation: Can an artery be missed?

Internal jugular vein (IJV) cannulation using ultrasound guidance has become a common practice as it provides improved safety profile.[1] Here we report a case of arterial cannulation occurring despite delineation of the carotid artery (CA) using ultrasound guidance.

A 10-year-old female patient was posted for correction of kyphoscoliosis. In the operating room, the patient was prepared for the placement of central venous catheter into the right IJV. A 7.5 MHz linear probe of an ultrasound machine (Sonosite Inc. Bothell USA), was placed in short axis view. Both right IJV and CA were visualized, with CA being medial to IJV [Figure 1]. Under real-time ultrasound, IJV was punctured and a 6.0 Fr central venous catheter (Multicath 2, Vygon, France) was inserted. On transducing catheter, the monitor showed an arterial waveform and pressure values. To confirm, the probe was placed longitudinally, and it was discovered that catheter was not present in the IJV. Placing the probe in oblique axis, revealed two pulsating vessels (arteries), on each side of IJV [Figure 2a] and the catheter visualized entering into the artery lateral to the IJV [Figure 2b]. The effort to obtain a single view of all three vessels in longitudinal axis was not successful. In the short axis, 2 ml 0.9% normal saline was injected into the catheter and fluid was seen entering in the CA [Figure 3]. Thus, the catheter was removed, and pressure was applied for an adequate period. No evidence of hematoma was seen on ultrasound. During the second attempt, the ultrasound probe was placed obliquely, midway between the long and short axis (medial oblique axis) and IJV was cannulated successfully. It was further confirmed by short and long axis views.

Figure 1

Short axis view on ultrasound showing the right carotid artery medially (arrow A) and the right internal jugular vein laterally (arrow B)

Figure 2

(a) Oblique axis view showing two arteries (white arrows) one each on medial and lateral aspect of internal jugular vein. (b) Central venous catheter seen entering into the artery lateral to internal jugular vein. Black arrows showing the path of central venous catheter

Figure 3

(a) Short axis view showing the carotid artery (medial) and internal jugular vein (lateral) and path of catheter (white arrow). Catheter entered the artery on lateral aspect passing through the internal jugular vein (not visible in short axis view). (b) Saline injected through the catheter seen entering the carotid artery (black arrow)

Despite the use of ultrasound, arterial puncture has been described in up to 4% of IJV cannulation.[2] In our case, the saline injected was seen entering into the CA, which suggested that the catheterized artery to be in continuation of CA. Literature shows that CA can have various anatomical variations.[3]

Two main ultrasound approaches (long- and short-axis) are used for IJV cannulation. These two techniques have inherent advantages and risks, and neither technique best prevents CA puncture reliably.[4] A continuous scan in long axis can depict intravascular guidewire and catheter placement. However, a medial oblique approach allows for optimal imaging of the IJV and CA side by side and to follow the needle throughout from skin insertion to vessel penetration.[5] The oblique rotation helped us identifying the aberrant cannulated artery. We hypothesize that the cannulated artery was either a loop of ICA with its distal part lying lateral to IJV and not visualized on short axis view or an aberrant branch of ICA.

For IJV cannulation, ultrasound requires technical expertise involving different approach techniques. Careful maneuvering of the probe and not depending on any single approach can help in detecting any anatomical variation of CA, thereby decreasing the risk of arterial puncture.

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Conflicts of interest

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