Leadless pacemaker implantation via the internal jugular vein.

BACKGROUND: Leadless pacemaker therapy was introduced to overcome lead- and pocket-related complications in conventional transvenous pacemaker therapy. Implantation via the femoral vein, however, may not always be feasible. The aim of this study was to evaluate leadless pacemaker implantation using a jugular vein approach and compare it to the standard implantation approach through the femoral vein. METHODS: The records of the first consecutive 100 patients undergoing MicraTM leadless pacemaker implantation via the right internal jugular vein from two centers were included in this study. Periprocedural safety and efficacy of the jugular approach were compared to the first 100 patients having undergone a femoral implantation approach at the University Hospital Zurich. RESULTS: 100 patients underwent successful implantation of a leadless pacemaker via the internal jugular vein (mean age, 81.18 ± 8.29, 60% males). Mean procedure time was 35.63 ± 10.29 min with a mean fluoroscopy time of 4.66 ± 5.16 min. The device was positioned at the inferior septum in 25 patients, at the high septum in 24 and mid-septum in 51 patients. The mean pacing threshold was 0.56 ± 0.35 V at 0.24 ms pulse width with a sensed amplitude of 10.0 ± 4.4 mV. At follow-up, electrical parameters remained stable in all patients. Compared with femoral implantation, patients undergoing jugular transvenous pacemaker implantation were of similar age and had similar comorbidities. Mean procedure- (48.9 ± 21.0 min) and fluoroscopy times (7.7 ± 7.8 minutes, both p <0.01) were shorter compared to the femoral approach. Electrical parameters were similar between the two approaches. There were only two complications during jugular veinous implantations (1 pericardial effusion and 1 dislocation), compared to 16 complications using the femoral approach (1 pericardial effusion, 2 femoral artery injuries and 13 major groin hematomas). CONCLUSION: The jugular approach may represent a safe and efficient alternative to the femoral implantation method for implantation of the Micra leadless pacemaker.

Ultrasound based estimate of central venous pressure: Are we any closer?

Central venous pressure (CVP) serves as a direct approximation of right atrial pressure and is influenced by factors like total blood volume, venous compliance, cardiac output, and orthostasis. Normal CVP falls within 8-12 mmHg but varies with volume status and venous compliance. Monitoring and managing disturbances in CVP are vital in patients with circulatory shock or fluid disturbances. Elevated CVP can lead to fluid accumulation in the interstitial space, impairing venous return and reducing cardiac preload. While pulmonary artery catheterization and central venous catheter obtained measurements are considered to be more accurate, they carry risk of complications and their usage has not shown clinical improvement. Ultrasound-based assessment of the internal jugular vein (IJV) offers real-time, non-invasive measurement of static and dynamic parameters for estimating CVP. IJV parameters, including diameter and ratio, has demonstrated good correlation with CVP. Despite significant advancements in non-invasive CVP measurement, a reliable tool is yet to be found. Present methods can offer reasonable guidance in assessing CVP, provided their limitations are acknowledged.

Comparison of Two Intravenous Propofol Doses after Jugular Administration for Short Non-Surgical Procedures in Red-Eared Sliders (Trachemys scripta elegans).

This study compares the effects of two different doses of propofol administered intravenously (IV), in the jugular vein, to red-eared sliders (Trachemys scripta elegans). In this crossover study, 5 or 10 mg/kg propofol was administered to six Trachemys scripta elegans after cannulation of the jugular vein. Each turtle received each dose, G1 (5 mg/kg IV) and G2 (10 mg/kg IV), after a 7-day washout period. The parameters evaluated were heart rate, palpebral reflex, cloacal reflex, muscle relaxation, ease of handling, sensitivity to anterior and posterior pinch stimuli, and possibility of intubation. Additionally, respiratory rate was measured when possible, and the times from propofol administration to full recovery and from intubation to extubation were recorded. None of the turtles in G1 could be intubated, and this dose provided little relaxation and ease of handling, with a duration of effect until full recovery of 12.16 ± 8.32 (SD) min for this group. In G2, five out of the six turtles could be intubated, and the duration of effect was 32.33 ± 5.85 (SD) min. Heart rates were influenced by manipulation for catheter placement. There were statistically significant differences (p value ≤ 0.05) between the two groups in muscle relaxation degree, handling, cloacal reflex, and possibility of intubation. The 5 mg/kg propofol dose was not sufficient to induce anesthesia, even when administered in the jugular vein, in red-eared sliders. A dose of 10 mg/kg IV or higher should be used.

Effect of puncture position on catheter patency rate during tunnelled dialysis catheter insertion from the right internal jugular vein.

Background: No recommendations have been made regarding the puncture position during tunnelled dialysis catheter (TDC) insertion from right internal jugular vein (RIJV). We investigated the effect of puncture positioning along with other characteristics and clinical factors associated with TDCs to determine their correlation with catheter patency rate. Methods: We retrospectively reviewed TDC insertion procedures performed between January 2018 and December 2020 at a single institution. Patients were monitored for at least 1 year or until TDC removal or replacement. The distance on the post-operative chest radiography were measured to determine the height of puncture position. End points were freedom from catheter dysfunction. Results: Total 949 catheters met the eligibility criteria. Catheter dysfunction occurred in 233 patients and catheter infection in 127 patients. By multivariate analysis, female sex [hazard ratio (HR) =1.497, 95% confidence interval (CI): 1.119-2.002; P=0.007] and split-tip catheter (HR =1.453, 95% CI: 1.087-1.944; P=0.012) were associated with an increased rate of catheter dysfunction. Every 10-year increment in age (HR =1.243, 95% CI: 1.123-1.376; P<0.001) and every 1-cm increase in the height of the catheter insertion site (HR =1.270, 95% CI: 1.096-1.473; P=0.001) were also associated with an increased rate of catheter dysfunction. After classifying the height of puncture position into 3 groups, significant worse patency was observed in the catheter with puncture height more than 4 cm (P=0.025). No immediate complications were observed. Conclusions: TDC insertion at a high puncture site correlates with an increased risk of catheter dysfunction. Puncturing the RIJV close to the clavicle is safe and enhances catheter patency.

The human craniospinal venous system and its influence on postural intracranial pressure: a review.

OBJECTIVE: The cerebral and spinal venous systems have similar functions but unique anatomical and physiological properties. CSF occupies space in the cranial and spinal vaults, is continuously produced, and has many roles, including maintaining a favorable environment for CNS structures. The influence of the cerebrospinal venous system on CSF dynamics has been theorized since the 1940s. Newer studies suggest venous outflow pattern alterations in response to changes in body position. However, the relationship of postural cerebrospinal venous outflow shifts with and their influence on CSF homeostasis is not well understood. METHODS: The authors searched the published literature related to the anatomy and function of vertebral venous plexus (VVP), CSF, and positional cerebral venous flow characteristics. A comprehensive collection of literature was compiled and reviewed, and the relationship between cerebrospinal and venous system changes and alterations in body positions, with an emphasis on the craniocervical system, is discussed. RESULTS: The VVP is a network of valveless veins extending from the sacrum to the cranium that are interconnected with the cranial dural sinuses. The internal VVP occupies space within the extradural spinal canal and functions to return spinal venous blood to the heart, but it has additional properties, including the capability of bidirectional venous flow, an intraspinal dilatory capacity, and a role in cerebral venous outflow. When one rises to the upright position, CSF shifts toward the spinal canal and force vectors change, leading to reduced intracranial CSF pressure; simultaneously, cerebral venous outflow shifts from the jugular vein to the VVP outflow pathway. The venous outflow shift mechanism and its purpose are poorly understood. The authors review the known physiology of the system, identify gaps in knowledge to direct future research, and propose an interpretation of these data, concluding that position-dependent CSF and cerebrospinal venous shifts are part of a complementary positional craniospinal pressure regulation system that must be kept in balance for optimal CNS function. CONCLUSIONS: Current knowledge of the cerebrospinal venous anatomy, dynamic flow characteristics in response to gravity, and the venous system's influence on CSF suggests that the VVP plays a role in influencing CSF pressure, and the authors hypothesize that it plays a role in supporting intracranial pressure in the upright body posture. Further research is needed to better characterize the functional relationship of the VVP to CSF dynamics as well as identify potentially related disease states.

Point of Care Ultrasound (POCUS) in the Management of Heart Failure: A Narrative Review.

Assessing for volume overload is a key component of both short and long-term management of heart failure patients. Physical examination findings are neither sensitive nor specific for detecting congestion, and subclinical congestion may not be evident at the time of examination. Point of care ultrasound (POCUS) is an efficient and non-invasive way to assess heart failure patients for volume overload. The aim of our narrative review is to summarize how each of the following ultrasound modalities can be used to assess for congestion in the heart failure population: 2D and Doppler echocardiography, lung ultrasound, inferior vena cava ultrasound, internal jugular vein ultrasound, and venous excess grading. While each of these modalities has their limitations, their use in the acute and outpatient space offers the potential to reduce heart failure readmissions and mortality.

An Ectopic External Jugular Vein Draining into the Axillary Vein: a Rare Anatomical Variation with Clinical Implications.

OBJECTIVE: The external jugular vein drains a considerable part of the head and neck and constitutes a vessel implicated in various procedures in the cervical region. The aim of this study is to present an uncommon anatomical variation of the external jugular vein, and discuss the clinical implications of its presence. CASE REPORT: We present a rare case of an ectopic external jugular vein terminating into the axillary vein, that we came across during routine dissection of a male cadaver of Greek origin. CONCLUSION: The venous system of the external jugular vein is used during procedures for the treatment of various conditions such as cardiac arrhythmias, hydrocephalus and defects of the head and neck. Hence, encountering the unpredictable course of a variant draining into the axillary vein may complicate these interventions, leading to multiple manipulations and undesirable results. Surgeons should be aware of the alternate anatomy of the venous system of the cervical region, and mindful of the possibility of encountering them.

A Rare Case of Internal Jugular Venous Malformation Treated by Surgical Excision.

This paper reports a case of an internal jugular venous malformation (IJVM) and route of treatment in a patient with limited symptoms. After history and imaging studies, a determination of surgical excision was made to rule out possible malignancy and future problems such as thrombosis. The mass was resected, and part of the IJVM was ligated. The mass had no identifiable malignancy, and the patient recovered fully with no complications. The paper highlights the importance of identifying venous malformations and highlights the reasoning behind the course of action.

Septic Emboli to the Brain Secondary to a Patent Foramen Ovale: A Rare Complication of Internal Jugular Vein Catheter.

The prolonged use of hemodialysis catheters is associated with several complications with infection being the most common. The increased susceptibility to infections in patients on hemodialysis can be attributed to decreased immunity, though age, other comorbidities, and properties of the catheter act as modifiers. Hematogenous spread of the infection can lead to sepsis and seeding into other organs. In this article, we report an unusual case of septic emboli to the brain in a 30-year-old male on prolonged use of a right internal jugular vein (IJV) catheter for hemodialysis. An interesting finding in the case was the presence of a patent foramen ovale (PFO), a persisting embryonic structure that allows right-to-left shunting. It is suspected that this PFO led to the passage of septic emboli from the right IJV site to the brain. Before our case, septic emboli to the brain have been reported to occur from valvular vegetation in case of infective endocarditis. The mainstay of managing patients with septic emboli is the use of antibiotics; additional interventions may be needed on a case-to-case basis.

Evaluation of the Efficacy of a Novel Dermatotomy Device for Central Venous Cannulation.

OBJECTIVE: To test the effectiveness of a novel wire-guided scalpel (Guideblade) to create a precise dermatotomy incision for central venous catheter (CVC) insertion. DESIGN: Prospective, nonrandomized interventional study. SETTING: Stanford University, single-center teaching hospital. PARTICIPANTS: Cardiac and vascular surgical patients (n = 100) with planned CVC insertion for operation. INTERVENTIONS: A wire-guided scalpel was used during CVC insertion. RESULTS: A total of 188 CVCs were performed successfully with a wire-guided scalpel without the need for additional equipment in 100 patients, and 94% of CVCs were accomplished with only a single dermatotomy attempt. "No bleeding" or "minimal bleeding" at the insertion site was observed in 90% of patients 30 minutes after insertion and 80.7% at the conclusion of surgery. CONCLUSION: The wire-guided scalpel was effective in performing dermatotomy for CVC with a 100% success rate and a very high first-attempt rate. The wire-guided scalpel may decrease bleeding at the CVC insertion site.

Surgical intervention of Lemierre's syndrome: a case report and review of the literature.

BACKGROUND: Lemierre's syndrome is a fatal and rare disease that is typically characterized by oropharyngeal infection and internal jugular vein thrombosis. Timely institution of appropriate antibiotics is the standard treatment. CASE PRESENTATION: The authors report a case of Lemierre's syndrome. A 67-year-old male patient of Han ethnicity in China suffered from a large inflammatory neck mass involving left internal jugular vein thrombosis diagnosed as Lemierre's syndrome and finally cured by surgical treatment. In addition, a literature review was carried out through PubMed using the terms "Lemierre's syndrome/disease and review, meta-analysis or retrospective study" and "Lemierre's syndrome/disease and internal jugular vein". This search yielded six articles that recorded surgical methods such as drainage, craniotomy, tooth extraction, and ligation of the occluded vein to give clinicians more ideas about the treatment of the Lemierre's syndrome. CONCLUSION: This is the first review to summarize the conditions under which surgical treatment are conducted. Additionally, this is the first report of such a large inflammatory neck mass that was completely cured by surgical resection and internal jugular vein ligation. The authors also offer several conclusions regarding surgical intervention in Lemierre's syndrome for the first time.

External Jugular Vein Slow-Flow Venous Malformation Presenting as a Swelling Over the Neck: A Report of a Rare Case.

Vascular malformations originating from the wall of the external jugular vein are exceedingly uncommon. We present a unique case of a venous malformation arising from the external jugular vein, successfully treated through surgical excision with no subsequent recurrence. This case highlights the importance of early diagnosis and timely intervention in managing such rare clinical entities without any resulting morbidity.

Causes of Pulsatile Tinnitus and Treatment Options.

Pulsatile tinnitus (PT) requires detailed workup to evaluate for an underlying structural cause. With advances in neuroimaging, structural venous abnormalities that can cause PT have becoming increasingly recognized. A number of anomalies, including dural arteriovenous fistulas, idiopathic intracranial hypertension, transverse sinus stenosis, sigmoid sinus wall abnormalities, jugular venous anomalies, and hypertrophied emissary veins, have been implicated in flow disruption and turbulence in the vicinity of auditory structures, resulting in PT. Endovascular treatment options, including stenting, coiling, and embolization with liquid agents, have demonstrated high efficacy and safety. These treatments can lead to symptomatic relief in carefully selected cases.

Characterization of internal jugular vein region-specific distension and flow patterns during progressive volume shifting.

Blood volume shifts during postural adjustment lead to irregular distension of the internal jugular vein (IJV). In microgravity, distension may contribute to flow stasis and thromboembolism, though the regional implications and associated risk remain unexplored. We characterized regional differences in IJV volume distension and flow complexity during progressive head-down tilt (HDT) (0°, -6°, -15°, -30°) using conventional ultrasound and vector flow imaging. We also evaluated low-pressure thigh cuffs (40 mmHg) as a fluid shifting countermeasure during -6° HDT. Total IJV volume expanded 139 ± 95% from supine position (4.6 ± 2.7 mL) to -30° HDT (10.3 ± 5.0 mL). Blood flow profiles had greater vector uniformity at the cranial IJV region (P < 0.01) and became more dispersed with increasing tilt (P < 0.01). Qualitatively, flow was more uniform throughout the IJV during its early flow cycle phase and more disorganized during late flow phase. This disorganized flow was accentuated closer to the vessel wall, near the caudal region, and during greater HDT. Low-pressure thigh cuffs during -6° HDT decreased IJV volume at the cranial region (-12 ± 15%; P < 0.01) but not the caudal region (P = 0.20), although flow uniformity was unchanged (both regions, P > 0.25). We describe a distensible IJV accommodating large volume shifts along its length. Prominent flow dispersion was primarily found at the caudal region, suggesting multidirectional blood flow. Thigh cuffs appear effective for decreasing IJV volume but effects on flow complexity are minor. Flow complexity along the vessel length is likely related to IJV distension during chronic volume shifting and may be a precipitating factor for flow stasis and future thromboembolism risk.NEW & NOTEWORTHY The internal jugular vein (IJV) facilitates cerebral outflow and is sensitive to volume shifts. Concerns about IJV expansion and fluid flow behavior in astronauts have surfaced following thromboembolism reports. Our study explored regional volume distension and blood flow complexity in the IJV during progressive volume shifting. We observed stepwise volume distension and increasing flow dispersion with head-down tilting across all regions. Flow dispersion may pose a risk of future thromboembolism during prolonged volume shifts.

Flowreversal in the left internal jugular vein due to a prominent brachiocephalic trunk: A case report.

Reversal of blood flow has only been reported in the left internal jugular vein following interventions such as central venous catheter, dialysis shunt placement, or external compression from a tumor. We describe a rare case of chronic headache and hearing loss due to flow reversal in the left internal jugular vein and compensatory massive dilation of the right internal jugular vein. Flow reversal was caused by a prominent brachiocephalic trunk with subseqent compression of the vena brachiocephalica sinistra. Vascular anomalies and associated venous bypass circulation may be considered as a rare cause of non-specific malaise. Restoration of the physiological direction of blood flow should be discussed on an interdisciplinary basis given the unpredictable haemodynamic consequences.

Jugular Venous Response for Risk Stratification in Heart Failure.

BACKGROUND:  The response of jugular venous pressure (JVP) to increased preload with inspiration has been recognized as a method of stratifying risk in the management of heart failure (HF). Whether the JVP response to inspiration may be more effective than other simple approaches in this setting remains unclear. METHODS:  This study enrolled 79 patients with stable HF. JVP was assessed from the right internal jugular vein in the sitting position and was considered high if visible above the right clavicle at rest. JVP responses to inspiration, the five-repetition sit-to-stand test (5-STS), and squatting were also evaluated. The primary outcome was a composite of all-cause death and hospitalization for worsening HF. RESULTS:  JVP assessment after 5-STS and during squatting was not conducted in two and 14 HF patients, respectively, due to physical limitations. During a mean follow-up of 837 days, the primary outcome was associated with a high JVP at rest (hazard ratio, 2.47; 95% confidence interval [CI], 1.09 to 5.60; P <0.05), with inspiration (hazard ratio, 2.53; 95% CI, 1.17 to 5.46; P <0.05), after 5-STS (hazard ratio, 2.61; 95% CI, 1.23 to 5.97; P <0.05), and during squatting (hazard ratio, 2.40; 95% CI, 1.03 to 6.06; P <0.05). Among patients without a high JVP at rest, the specificity of the primary outcome at one year was greater for the JVP response to inspiration (89%) and squatting (92%) than for the response to 5-STS (80%). CONCLUSIONS:  JVP response to increased preload with inspiration may be a simple and practical method for risk assessment in patients with stable HF.

Jugular Foramen Paragangliomas.

Paragangliomas are the most common tumors at jugular foramen and pose a great surgical challenge. Careful clinical history and physical examination must be performed to adequately evaluate neurological deficits and its chronologic evolution, also to delineate an overview of the patient performance status. Complete imaging evaluation including MRI and CT scans should be performed, and angiography is a must to depict tumor blood supply and sigmoid sinus/internal jugular vein patency. Screening for multifocal paragangliomas is advisable, with a whole-body imaging. Laboratory investigation of endocrine function of the tumor is necessary, and adrenergic tumors may be associated with synchronous lesions. Preoperative prepare with alpha-blockage is advisable in norepinephrine/epinephrine-secreting tumors; however, it is not advisable in exclusively dopamine-secreting neoplasms. Best surgical candidates are young otherwise healthy patients with smaller lesions; however, treatment should be individualized each case. Variations of infratemporal fossa approach are employed depending on extensions of the mass. Regarding facial nerve management, we avoid to expose or reroute it if there is preoperative function preservation and prefer to work around facial canal in way of a fallopian bridge technique. If there is preoperative facial nerve compromise, the mastoid segment of the nerve is exposed, and it may be grafted if invaded or just decompressed. A key point is to preserve the anteromedial wall of internal jugular vein if there is preoperative preservation of lower cranial nerves. Careful multilayer closure is essential to avoid at most cerebrospinal fluid leakage. Residual tumors may be reoperated if growing and presenting mass effect or be candidate for adjuvant stereotactic radiosurgery.

Carotid Artery Aneurysm-Induced Mediastinal Hematoma Leading to Airway Compression-A Rare Complication of Internal Jugular Vein Puncture.

Carotid artery puncture is a common complication of internal jugular vein (IJV) catheterization. However, there are few reports about an aneurysm from the carotid artery that can develop into an occult mediastinal hematoma, leading to airway compression. In this case study, we present the case of a 71-year-old male who experienced an aneurysm and delayed mediastinal hematoma, ultimately resulting in airway compression after right jugular line insertion. Our findings highlight the importance of not only addressing local hematoma formation at the puncture site promptly, but also recognizing the potential for aneurysm extension into the mediastinum and the formation of an occult hematoma, which can lead to airway compression. Additionally, we provide a summary of landmark technique precautions that can help reduce the occurrence of such severe complications.

Impact of insertion into the left internal jugular vein in chemoport-associated infections: a retrospective single-center study of 1690 cases.

We analyzed chemoport insertion procedures to evaluate infectious morbidity and factors causing infection. This single-center retrospective study included 1690 cases of chemoport implantation between January 2017 and December 2020. Overall, chemoports were inserted in 1582 patients. The average duration of chemoport use was 481 days (range 1-1794, median 309). Infections occurred in 80 cases (4.7%), with 0.098 per 1000 catheter-days. Among the 80 cases in which chemoports were removed because of suspected infection, bacteria were identified in 48 (60%). Significantly more cases of left internal jugular vein punctures were noted in the infected group (15 [18.8%] vs. 147 [9.1%]; p = 0.004). Pulmonary embolism was significantly different between the infection groups (3 [3.8%] vs. 19 (1.2%), p = 0.048). The hazard ratio was 2.259 (95% confidence interval [CI] 1.288-3.962) for the left internal jugular vein, 3.393 (95% CI 1.069-10.765) for pulmonary embolism, and 0.488 (95% CI 0.244-0.977) for chronic obstructive pulmonary disease. Using the right internal jugular vein rather than the left internal jugular vein when performing chemoport insertion might reduce subsequent infections.