Volume 26, Issue 2 , Pages e17-e18, April 2012
Misplacement of a Guidewire into the Vertebral Vein Through the Internal Jugular Vein
Article Outline
To the Editor:
We recently encountered a case in which a guidewire was misplaced into the vertebral vein through the internal jugular vein (IJV) despite visualization of the IJV by real-time transverse ultrasound images. This is the first report on the misplacement of a guidewire into the vertebral vein through the IJV.
A 61-year-old woman was scheduled for elective mitral valve replacement and tricuspid annuloplasty for mitral regurgitation and tricuspid regurgitation, respectively. In the operating room, anesthesia was induced with fentanyl and midazolam. Vecuronium was administered to facilitate tracheal intubation.
Real-time ultrasound was used for the placement of a central venous catheter (CVC) and a pulmonary artery catheter (PAC) in the right IJV. The patient was placed in the Trendelenburg position. The ultrasound probe was placed perpendicular to the vessels between the two heads of the sternocleidomastoid muscle approximately 2 cm cranial to the clavicle. The right IJV and carotid artery were visualized in the transverse plane, with the vein recognized by its large size, easy compressibility, and nonpulsatile blood flow within the vessel on a color Doppler image. After the placement of a guidewire for the CVC, the placement of a guidewire for the PAC was tried using an intro-Flex percutaneous sheath introducer kit (Edwards Lifesciences, Co, Irvine, CA). Transverse images of the IJV were obtained by real-time ultrasound guidance, and the tip of an 18-gauge intravenous catheter needle attached to a syringe was advanced into the IJV approximately 1 cm cranial to the site of the guidewire implanted for central venous catheterization. After confirming that dark nonpulsatile blood had been aspirated, the needle was withdrawn. The guidewire for the PAC placement was advanced smoothly through the intravenous catheter, and then the intravenous catheter was withdrawn. Although transverse images of the IJV showed that the guidewire for the PAC placement was located within the right IJV lumen, the longitudinal ultrasound images showed that the guidewire had passed through the right IJV and that its tip was placed in a small vein posterior to the right IJV (Fig 1A). The intravenous catheter then was passed through the guidewire again, and the guidewire was withdrawn. When the syringe was attached to the intravenous catheter, a dark nonpulsatile blood return was noted, indicating that the guidewire had migrated into a vein posterior to the IJV, probably the vertebral vein. The intravenous catheter was withdrawn gradually with the application of a slight negative pressure on the syringe, and the dark blood return disappeared. When the catheter was pulled out at 7 mm, the dark nonpulsatile blood appeared again. The guidewire was introduced smoothly through the intravenous catheter. A longitudinal ultrasound view showed that the guidewire was placed correctly within the right IJV (Fig 1B). Then, the CVC and PAC were threaded over the guidewires. Surgery was performed uneventfully without PAC-related complications, such as hematomas and bleeding.
Fig 1.
(A) Longitudinal ultrasound view shows that a guidewire (arrows) for the pulmonary artery catheter had passed through the right internal jugular vein (IJV) and likely was placed in the vertebral vein (arrowhead). (B) The guidewire for the pulmonary artery catheter (arrows) was inserted through an intravenous catheter, and a longitudinal ultrasound view shows that the guidewire was placed within the right internal jugular vein. A guidewire for the central venous catheter (arrowheads) is observed at the caudal side. AW, anterior wall of the right internal jugular vein; PW, posterior wall of the right internal jugular vein; VV, vertebral vein.
It has been reported that there are several complications associated with the puncture of the common carotid and vertebral arteries during CVC and PAC placement through the IJV.1 In this letter, we report for the first time a case in which a guidewire migrated into the vertebral vein through the IJV despite visualization of the IJV by real-time transverse ultrasound images. There are some small veins around the IJV, including the vertebral, anterior vertebral, deep cervical, superior thyroid, and internal thoracic veins. In the present case, the vein in which the guidewire was misplaced through the IJV appeared to have been the vertebral vein because the vein was located several millimeters posterior to the right IJV at the level of the sixth to seventh cervical vertebrae,2 which corresponds to the site where the intravenous catheter was inserted for the PAC placement. Because the cross-sectional area of the vertebral vein is 10.6 to 11.9 mm2 (Valdueza et al3) and the cross-sectional area of the PAC introducer sheath is 7.1 mm2 (data provided by the manufacturer), it is possible for the sheath to be placed in the vein. However, when the balloon of the PAC is inflated, its cross-sectional area reaches 132.7 mm2, possibly resulting in a rupture of the vertebral vein. Therefore, the insertion of the PAC might have caused a serious complication. An accidental puncture of the artery during central venous cannulation is recognized easily by the pulsatile blood flow with high pressure into a syringe. However, it would be difficult to detect an accidental puncture of the veins by the characterization of blood return or pressure monitoring. In the present case, a longitudinal view showed that the guidewire had penetrated the posterior vessel wall of the IJV and migrated into the vein posterior to the IJV, probably the vertebral vein. The most common approach for a real-time ultrasound guidance for cannulation of the IJV is the transverse visualization of the vessels,4 because a transverse view can show the anatomic relation between the carotid artery and the IJV. However, because it is difficult to visualize the tip of the needle on a transverse image, the posterior wall of the IJV might be punctured by the needle, possibly resulting in an accidental insertion of a catheter into other veins. The present case emphasizes that caution must be exercised to prevent the misplacement of a catheter into the deep cervical veins, including the vertebral vein, and that longitudinal ultrasound guidance can prevent such a complication.
References
- . Central venous catheter use (Part 1: Mechanical complications) . Intensive Care Med . 2002;28:1–17
- Termination of the vertebral veins: Evaluation by multidetector row computed tomography . Clin Anat . 2010;23:662–672
- Postural dependency of the cerebral venous outflow . Lancet . 2000;355:200–201
- Videos in clinical medicine (Ultrasound-guided internal jugular vein cannulation) . N Engl J Med . 2010;362:e57
PII: S1053-0770(11)00794-4
doi:10.1053/j.jvca.2011.11.004
© 2012 Elsevier Inc. All rights reserved.
Volume 26, Issue 2 , Pages e17-e18, April 2012
