Timothy

C. McCowan,

MD

#{149} Ernest

J. Ferris,

MD

#{149} Danna

K. Carver,

Use of External Jugular Vein as a Route for Percutaneous Vena Caval Filter Placement’ Vena caval filter placement via the right external jugular vein was attempted in 13 cases. Eleven percutaneous vena caval filters of four types were successfully placed in the inferior vena cava. Two of the attempts were unsuccessful. The indications for the external jugular vein approach were obstructive lower-extremity deep venous thrombosis in eight cases and hip or pelvic fractures in three cases; the approach was simply the radiologist’s preference in the remaining two cases. There were five minor complications in four patients. None of the complications necessitated operative intervention or changed the clinical course of the patient. The external jugular vein is an excellent alternative route for caval filter placement. The external jugular vein approach does not necessitate surgical cutdown in the operating room for venous access, avoids deep vascular punctures in the neck and groin, and is safe in patients receiving systemic anticoagulation therapy. Index

terms:

Embolism,

Veins,

jugular,

907.1299

pulmonary, #{149} Venae cavae, interventional

982.1299 #{149} Venae dune, 982.1299

cavae,

Radiology

176:527-530

1990;

T

RANSVENOUS

cava

of

(IVC)

the

with

vena cavab filters is an established technique in patients with deep yenous thrombosis on pulmonary embolisrn

in whom

systemic

anticoagu-

lation therapy has failed traindicated (1,2). Caval may

also

be

indicated

(3).

In the

past,

filters

(the

were

reported

Kim-

variety of vena caval filters cificalby designed for percutaneous are now available (7-11). The size

sheaths

spe-

markedly

or in dinof the in-

of these

reduced

filters

compared

is

the

vein

of access.

ed to take advantage size of the introducers filters

to place

temnal

jugular

IVC

with

was

We

via

I

From

the

of Arkansas

556,

4301

72205. bly.

Medical

W Markham

St.

the

RSNA

From Received

RSNA,

of Radiology,

for

ed February cepted April T.C.M. C

Department

1989

January

21; revision 16. Address 1990

Sciences, Uittle

Rock,

scientific

3, 1990;

received reprint

revision

UnivemMail

ex-

assemrequest-

April 4; acrequests to

Patients The external jugular vein approach was attempted in 13 patients with deep yenous thrombosis, of whom eight were female. The average age at the time of filter insertion

was

57 years.

In

10 cases

in eight

cases

be-

that

deep of hip

approach

was

swelling apparatus external

cho-

on the use precludjugular

the route

nadioboin the

me-

The

external

below

and

dible ular (13).

jugular behind

the

vein

is formed

angle

of the

just man-

by the union of the posterior auricand netnomandibuban veins (Fig 1) It lies under the platysma muscle in

the neck and obliquely crosses the ficial surface of the stemnocleidomastoid muscle. Approximately 2 cm above of the

clavicle,

it passes

include

the

suprascapulan cervical vein. nal

jugular

its

insertion

anterior

is the vein

subclavian jugular

jugular

vein, and Of anatomic

the

fact

the

through

the cervical fascia to enter the vein. Tributaries of the external vein

super-

vein,

the

transverse importance

that

forms

an

into

the

subclavian

side

of the

the

acute

for

exter-

angle

at

vein.

right

draped

neck

in a sterile

is prepared

fashion.

The

external jugular vein is identified and by palpation. (In one obese with a large neck, the external vein and

was identified the puncture No

jugular

with ultrasound was performed attempts

right

visually patient jugular with

at performing

placement

were

[US], US left

made

in

this study because the tortuosity of this route was thought to present possible difficulties. Local anesthesia is achieved by means of lidocaine injection.

METHODS

Slot

AR

convein

Anatomy

external

sity

was jugular

vein approach was simply gist’s choice as preferred maining two cases.

The

vein.

AND

anti-

lower-extremity In three cases

fracture

guidance.)

PATIENTS

chosen

sen because soft-tissue of an external traction ed femoral access. The

and

decid-

the

therapy external

of obstructive thrombosis.

pelvic

because

had failed to prevent or recurrent deep in three cases, be-

Technique

of the smaller of these new filters

MD

indicated

cause anticoagulation traindicated. The

catheterization

that of the Kimmay-Greenfield filter. These filters can be placed via either a fernomal vein or jugular vein approach. With the jugular vein route, the internal jugular vein has routineby been

was

therapy embolism thrombosis;

middle

(4-6).

A

insertion icab trials

placement

or

ray-Greenfield being the accepted “standard”) were placed by means of surgical cutdown of the internal jugubar vein. Although the KimrayGreenfield filter was modified for percutaneous insertion, the large size of the introducer sheath (29.5 F) necessary to allow passage of the 24-F filter capsule was not readily accepted by some radiologists, and significant mates of insertion site complications

ter

coagulation pulmonary venous

cause venous

as a prophybac-

most

L. Harshfield,

approach

or is coninterruption

tic measure in patients with compromised cardiovascular or pulmonary reserve in whom a pulmonary embobism would likely prove damaging

troducer

60.72. filters, proce-

vena

#{149} David

Inferior

interruption

inferior

RN

the

fil-

A small

superficial

skin

incision

Abbreviation:

IVC

inferior

vena

is

cava.

527

b.

a. Figure

1.

Anatomy

of the

anterior jugular vein. 4 = right brachiocephalic (Modified from reference 3

external

jugular

vein.

(a) Relationship

(b) Insertion of the right external vein, 5 superior vena cava, 6 12.)

=

of the

right external jugular vein (1) into the right subclavian bnachiocephalic vein, 7 left internal

jugular left

vein

(1) to the stemnocleidomastoid muscle (2). vein (3). 2 = right internal jugular vein, jugular vein, 8 = left subclavian vein.

Figure

2. Catheterization of the right exjugular vein. (a) Contrast material inthrough a vessel dilator in the right jugular vein demonstrates the insertion of the external jugular vein into the subclavian vein (arrow). (b) Passage of an Amplatz Super Stiff guide wire straightens the angle of insertion of the right external jugular vein into the subclavian vein (anrows).

temnal jection external

made

with

skin

tract

a no. 1 1 scalpel is dilated

blade,

with

and

a hemostat.

the A

standard 19-gauge needle is used to punctune the external jugular vein. Altemnatively, a 19-gauge butterfly needle can be used; the tubing is cut off near the needle hub once venous access has been obtamed. A 0.025-inch (0.064-cm) J-tipped on straight guide wine is then advanced

under needle then

fluoroscopic control through the into the external jugular vein and into

the

Alternatively,

needle

superior

vena

a thin-walled

can be used

0.035-inch

cava

(Fig

for insertion

(0.089-cm)

guide

cm)

vena

guide

0.035-inch

wire

cava.

The

is then

(0.089-cm)

vein

0.025-inch

exchanged Amplatz

528

of insertion #{149} Radiology

of the

external

yes-

the

(0.064-

for a Super

wine (Medi-tech/Boston Scientific, town, Mass). The wine straightens gle

b.

a.

of a

wine.

The needle is then removed, and a sel dilator is placed oven the wine into superior

2).

19-gauge

Stiff

Waterthe an-

jugular

with

the subcbavian

tates further catheter insertion site is dilated dilators

of the

appropriate

ten to be inserted. sheath

is then

vein

size

The desired guided

and facibi-

manipulation. with sequential

into

the

for

the

fil-

filter IVC,

and

vena cavognam is obtained to assess the IVC for size, possible anomalies, and the presence

of thnombus.

The

filter

vanced through the sheath and dischanged into the IVC according to the manufacturer’s instructions. A postinsen-

The

is ad-

a

tion vena cavognam is obtained to document filter position. The filter introducer sheath is then removed, and hemostasis the insertion site manual compression and slight elevation

at

is achieved by means of on the insertion site of the patient’s head.

August

1990

ban vein during passage of the filter sheath. The filter (Bird’s Nest) was successfully placed. The skin incision was then widened by approximately 1 cm,

and

a single

suture

ligation

of

the puncture site was used to gain hemostasis. No further problems were encountered in this case.

DISCUSSION Most percutaneous vena caval fibare inserted via the fernoral vein. Occasionally, due to thrornbus involving the common femoral and iliac veins bilaterally, or the right fernoral or iliac vein when the left femoma! vein approach would be difficult or contraindicated, an alternative route must be employed. This route has usually been the internal jugular vein, frequently by surgical cutdown. A percutaneous internal jugular vein approach is becoming an accepted altemnative; however, it carries small but significant risks since it entails a deep puncture of the neck. Complications associated with attempted internab jugular vein puncture include amteriab puncture with associated hemorrhage, pneurnothomax, and venous thrombosis (14-17). In large samples (14,15), arterial puncture occurred in 1.9%-4.2% of cases, and pneumothomax occurred in 0.5% of cases. Varying rates of dysrhythmia and venous thrombosis have also been reported (14,16). Thrombosis of the internal jugular vein can lead to significant tens

a.

b.

Figure 3. Placement of a Vena-Tech filter ment vena cavogram via the right external common iliac vein (arrows). (b) Postpbacement ten (arrows) in position with no thrombus

via the right external jugular vein shows vena cavognam evident in the filter.

jugular vein. (a) Preplacea large thrombus in the right demonstrates a Vena-Tech fib-

morbidity

in some

The external used extensively gists, All

patients

24 hours

are assessed for

clinically

within

complications.

whom anticoagulation therapy was contraindicated. The attempt at filter placement was abandoned.

RESULTS Complications Filter

Placement

Eleven of 13 (85%) attempts at right external jugular vein filter placement were successful (Fig 3, Table). In one patient, the external jugular vein was small and could not be cannulated. The internal jugular vein was punctured instead, and an IVC filter was placed by means of a similar technique without problem. In another patient, the external jugular vein was successfully cannulated, but the intmahepatic IVC was occluded due to massive enlargement of the liver because of tumor metastases. This finding had not been recognized during bower-extremity duplex US imaging, which showed extensive deep yenous thrombosis in this patient, in Volume

176

#{149} Number

2

Five complications occurred in four patients. A 3-cm-diameter neck hematoma was evident 24 hours after filter placement (Vena-Tech) in one patient who had been receiving systemic anticoagulation therapy with hepamin. This patient also had a palpable cord in the distribution of the external jugular vein consistent with thrombosis. The patient was asyrnptomatic. Two other cases of thrombosis of the

external

jugular

vein

after

filter placement (Vena-Tech, Nitinol) were noted; one was detected clinicabby, and one was proved at duplex US imaging. Both cases were asymptomatic. During one of the early cases in this series, a small tear was madvertently made in the external jugu-

patients

(17).

jugular vein has by anesthesiobo-

surgeons,

and

internists

been for

central venous access (18,19). The success rate of cannulation has been high, and significant complications have been name (14,19). We decided to take advantage of the smaller size of the new percutaneous vena caval fibtens by using the external jugular vein as an alternative route for vena caval filter insertion in patients in whom transvenous vena cavab interruption

was

is indicated.

successful

in which

it was

This

approach

in 11 of 13 (85%) attempted,

cases

which

compares favorably with reported success rates of 74% and 97% for central venous catheterization via this route (14,19). Working near the patient’s face and head is somewhat awkward, but with proper positioning and draping, it can be done effectively. The externab jugular vein is usually easily identified visually or by means of palpation. Duplex US imaging can be helpful in localizing and puncturing Radiology

#{149} 529

the external jugular vein, especially in obese individuals. The risk of accidental puncture of the deeper vasculam structures of the neck, such as the carotid artery and the internal jugubar vein, is negligible if the external jugular vein is accessed in its course over the lower border of the sternocleidomastoid muscle (13,14). The key to successful filter placement by this route is the passage of a heavy-duty guide wine, such as the Ampbatz Super Stiff guide wire, into the IVC to straighten the insertion angle of the external jugular vein to the subclavian vein in order to allow further

dilator

and

filter-sheath

ma-

nipulations without kinking or undue trauma to vascular structures. Patients with ipsilateral subcbavian vein, bmachiocephalic vein, or supenior vena cava thrombosis are not candidates for this technique. If the patient has previously had an indwelling catheter, documentation of patency

of these

veins

may

be need-

ed prior to attempted filter placement. Depending on the flow dynamics of the IVC, retrograde injection for a postplacement vena cavogram may result in suboptirnal opacification if the introducer sheath is kept a safe distance from the newly placed filter. Although we had five complications, none required operative intervention on altered the patient’s course

or treatment.

The

external

#{149} Radiology

hematorna

was

probably

sec-

ondary to inadequate compression in a patient who had been receiving systemic anticoagulation therapy. The superficial location of the external jugular vein makes hernostasis control easier than with deeper punctures of the femomal vein or the internal jugular vein. The smaller size of the introducer sheaths of the newer percutaneously inserted vena caval filters makes the external jugular vein an acceptable alternative route for vena caval filter placement. External jugular vein puncture will probably be more acceptable to radiologists who are unfamiliam with or infrequently use internab jugular vein access. The external jugular vein may be the insertion site of choice in patients receiving systemic anticoagulation therapy, since this approach avoids deep vascular punctures and the risk of subsequent hemorrhage. Since no cutdown is necessary, the filter can in the angiography-intenventional

radiology laboratory, reduce hospital costs.

be

7.

8.

tion

3.

4.

5.

712. Rohrer

1981;

10.

UJ, Michna experience

caval

with

filter.

MJ,

BA. the

Surgery

Scheidlem

Twelve-year

11

vein

Roehm

MC,

12.

HB,

A, Clanz

5, Cordon

thrombosis.

AJR

1987;

DH,

Sclafani

DW,

R, et al.

filter:

trial.

et al.

Cun-

early

Ann

results

Vasc

Jr. Johnsmude

.

vena gy

C.

cava

The

filter:

1988;

Sung

1988;

M,

Simon

nitinol

initial

clinical

progress

Clemente

CA,

inferior

vena

experience.

CD.

Kim

D, et al.

cava

filter:

Radiology

1989;

Anatomy:

a regional

3rd

atlas

ed. Baltimore: 1987; sect VII,

of

the

RT.

The

superficial

neck.

In:

Woodbumne

UnFigs

of human York:

strucRT,

anatomy.

Oxford

5th

University

cannulation:

Press,

recognition

and

jugular

59:353-355. Shah KB,

Tadikonda

Etm AA.

A review

siology

use

DE, jugular

of the

Anesthesiology UKR,

exter-

1983; Uaughlin

5, El-

of pulmonary

in 6,245

1984;

1973;

of arterial

preferential

route.

ed.

ed.

144-149. Jobes DR. Schwartz AJ, Creenhow Stephenson UW, Ellison N. Safer

nal

artery

patients.

Anesthe-

61:271-275.

Pais SO, Mirvis neous insertion

SE, Orchis DF. Percutaof the Kimmay-Creenfield

filter:

technical

considerations

lems.

Radiology

Rose

ME. ment filter.

BS,

1987;

Simon

DC,

Radiology

Dailey

RH. and

1987;

External its

use

for

and

prob-

Van

Aman

156:377-381. Hess

ML,

Percutaneous transfemoral of the Kimmay-Creenfield

lation

19.

Radiolo-

586.

Woodbunne

New

18.

report.

Athanasoulis

Essentials

16.

MH,

inferior

103.

tunes

14.

Barth

nest

168:745-749.

Simon

585,

13.

IS,

bind’s

of the human body. ban & Schwarzenberg,

104:706-

Wheeler

Komth

“UCM”

JOF

172:99-

17.

Creenfield

1988;

SJA. Percutaneous insertion ray-Creenfield filter: incidence 6.

the

Ciantunco

116:1451-1456.

Cutler BS. Extended indications for placement of an inferior vena cava filter. Vasc Sung 1989; 10:44-50. Tadavarthy SM, Casteneda-Zuniga W, Cardella JF, et al. Kimray-Creenfield vena cava filter: percutaneous introduction. Radiology 1984; 151:525-526. Kantor

with

catheterization

Creenfield

Hunter

3:242-247.

15.

2.

vena

M,

of a multicenter

should

U

MD,

the Amplatz retrievable Radiology 1989; 172:105-

F, Dietzel

puncture

which

Darcy

with filter.

then vena caval filter: results of long-term follow-up. AJR 1988; 151:1031-1034. Ricco JB, Crochet D, Sebilotte P. et al. Percutaneous transvenous caval interrup-

vein

Creenfield UJ, Peyton R, Crute 5, Barnes R. Creenfield vena caval filter expemience: late results in 156 patients. Arch

clinical

DH,

Fobbe

9.

inserted

1.

Sung

Epstein

Experience vena cava 110.

References

jug-

ular vein is usually smaller than the common femonal vein on the internal jugular vein and may be more prone to thrombosis after catheterization. Because the external jugular vein is superficial, however, the potential morbidity from acute thrombosis is bess than that of deep venous thrombosis of the internal jugular vein or femoral vein. The single case of a

530

small

placevena cava

165:373-376.

jugular CVP

vein

cannu-

monitoring.

Ememg Med 1988; 6:133-135. Berthelsen P. Hansen B, Howardy-Hansen P. Moller J. Central venous access via the external jugular vein in cardiovascular surgery.

Acta

Anesthesiol

Scand

1986;

30:470-472.

of the Kimof femomal 149:1065-1066.

Pais SO, Tobin KD, Austin CB, Quemal U. Percutaneous insertion of the Creenfield inferior vena cava filter: experience with ninety-six patients. J Vasc Sung 1988; 8:460-464.

August

1990

Use of external jugular vein as a route for percutaneous inferior vena caval filter placement.

Vena caval filter placement via the right external jugular vein was attempted in 13 cases. Eleven percutaneous vena caval filters of four types were s...
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