An unusual case of iatrogenic central venous injury.

Central venous catheter (CVC) provides ready vascular access and is widely used for the performance of hemodialysis. The use of CVC is associated with many complications and one life-threatening complication is central venous injury. We describe an unusual case of central venous injury in a 69-year-old lady with a poorly functioning left internal jugular vein catheter, which was in situ at the time of attempting insertion of a replacement right internal jugular catheter. The management included initial stabilization, urgent hemodialysis, imaging, and an endovascular approach to mitigate the iatrogenic venous injury. The case highlights many learning points. The operator needs to be vigilant for anatomical abnormalities like stenosis in patients who have had previous CVC. In those with central venous perforation, the CVC should be left in situ till a definitive management plan is formulated. An endovascular approach, when feasible, is a minimally invasive effective management strategy.

Clinical application of ultrasound-guided totally implantable venous access ports implantation via the posterior approach of the internal jugular vein.

BACKGROUND: To determine the feasibility and safety of ultrasound-guided totally implantable venous access port (TIVAP) implantation via the posterior approach of the internal jugular vein (IJV). METHODS: From September 2021 to August 2022, 88 oncology patients underwent ultrasound-guided implantation of TIVAPs via the posterior approach of the IJV for the administration of chemotherapy. The catheter tip was adjusted to be positioned at the cavoatrial junction under fluoroscopic guidance. Clinical data including surgical success, success rate for the first attempt, intraoperative, and postoperative complications were all collected and analyzed. RESULTS: All patients underwent successful surgery (100%), whereby 58 were via the right IJV and 30 via the left IJV, and the success rate for the first attempt was 96.59% (85/88). The operation time was 20 to 43 minutes, with an average of 26.59 ± 6.18 minutes with no intraoperative complications. The follow-up duration ranged from 1 to 12 months (mean = 5.28 ± 3.07) and the follow-up rate was 100%. The rate of postoperative complications was 4.55% (4/88), including port-site infection in two cases, fibrin sheath formation in one case, and port flip in one case. No other complications were observed during follow-up. CONCLUSION: Ultrasound-guided TIVAP implantation via the posterior approach of the IJV is feasible, safe, and effective, with a low rate of intraoperative and postoperative complications. Not only was the curvature of the catheter device smooth, but patients were satisfied with the comfort and cosmetic appearance. Additionally, we could reduce the possible complications of pinching and kinking of the catheter by using this approach. Therefore, further large-sample, prospective, and randomized controlled trials are warranted.

Drainage Pattern of Craniofacial Veins With Emphasis on its Influence on Facial Reconstruction Procedures.

As the facial transplantation procedures are becoming more popular and frequent in recent years, for repairing facial trauma, variations in the veins of head and neck needs to be reported time and again. This study was undertaken to examine the course and drainage pattern of the facial vein and external jugular vein on this context and emphasize its surgical implications. The authors studied the head and neck region of 50 embalmed cadavers of both sexes to document normal and variant anatomy of facial, retromandibular, and external jugular veins. In 30% of the head and neck regions, different draining pattern of the above-mentioned veins were observed. One of the rare variation discovered was the splitting of the retromandibular vein to embrace the external carotid artery within the parotid gland. The data about variations in the termination of facial vein, retromandibular vein, and external jugular vein, as observed in the present study might be useful in avoiding accidental injury to these vessels during any surgical intervention in the face as well as neck. Level of Evidence: IV.

The Long-Term Patency of the Internal Jugular Vein and the Common Facial Vein as Entrance Sites for Venous Access in Ventriculoatrial Shunts: A Comparative Analysis from a Single-Center Study.

OBJECTIVE: The ventriculoatrial (VA) shunt is a surgical intervention used to manage hydrocephalus, although it is less often utilized compared to the ventriculoperitoneal (VP) shunt or endoscopic third ventriculostomy. Placement of the distal catheter typically involves the utilization of either the common facial vein (CFV) or the internal jugular vein (IJV), 2 frequently employed options for venous access. This study aims to determine whether there is a statistically significant difference between the long-term patency (2 years) of the distal end of the VA shunt of these 2 options. METHODS: A retrospective cohort analysis was conducted of patients who received VA shunt surgeries with the employment of the CFV or IJV as access veins at Rajavithi Hospital in Thailand between January 2015 and December 2020. The analysis focused on long-term patency and potential complications. RESULTS: The study comprised a total of 42 participants. Twenty-six (61.9%) individuals underwent ventriculoatrial (VA) shunt surgery via the CFV, while the other 16 (38.1%) underwent the same procedure using the IJV. Neither of the 2 groups required shunt revision due to distal catheter malfunction. Most cases exhibited no significant complications apart from a single instance of shunt system infection. CONCLUSIONS: In VA shunt surgery, both the CFV and IJV can be used as venous access sites for the right atrium because there is no discernible difference between their complications or long-term patency. Anatomical considerations, patient-specific characteristics, and the surgeon's preference should all be considered when choosing the venous access location for the placement of a VA shunt.

Safety and reliability of the internal jugular vein for venous anastomoses in head and neck oncological reconstruction: A retrospective study.

This study aimed to assess the efficacy of utilizing the internal jugular vein (IJV) as the primary recipient site for venous anastomoses in head and neck oncological reconstruction. Patients who underwent a free flap reconstruction of the head and neck were retrospectively included. Venous anastomoses were preferentially performed less than 1 cm from the IJV, either end-to-side (EtS) on the IJV, or end-to-end (EtE) on the origin of the thyrolingofacial venous (TLF) trunk. When the pedicle length was insufficient to reach the IJV, anastomoses were performed EtE to a size-matched cervical vein. Of the 246 venous anastomoses, 216 (87.8%) were performed less than 1 cm from the IJV, including 150 EtS on the IJV (61.0%), and 66 EtE on the TLF trunk (26.8%). Thirty veins (12.1%) were anastomosed EtE on other cervical veins more than 1 cm from the IJV. Two venous thromboses occurred (0.9%) and were successfully managed after revision surgery. There was no evidence of an increased thrombosis rate in high-risk or pre-irradiated patients. These findings suggest that the internal jugular vein is safe and reliable as a first-choice recipient vessel for free flap transfers in head and neck oncological reconstruction.

Easy and Safe Clamping of the Internal Jugular Vein and Internal Carotid Artery for End-to-Side Anastomosis in the Vessel-Depleted Neck.

BACKGROUND: Damage to the vascular system resulting from radiotherapy and previous surgeries in patients with recurrent neck tumors has a negative impact on secondary reconstructions. In this study, we describe a simple method for occlusion of the great vessels of the neck in patients with difficult access to recipient vessels for anastomosis. METHODS: A 1 or 0 gauge silk ligature is placed at a circumference of 540 degrees around the vessel, holding the base of the suture with a fine hemostatic clamp exerting sufficient pressure to stop the blood flow in the vessel (internal carotid artery or internal jugular vein), to prepare the end-to-side anastomosis to the flap. RESULTS: From 90 head a neck reconstructions for oncologic patients using microvascular flaps performed between April 2011 and April 2021, 8 of them (8.8%) were performed in patients with multiple previous surgeries and/or radiotherapy, with lesion of the arterial thyrolyngopharyngofacial trunk and secondary recipient veins, being the internal carotid and internal jugular the only available recipient vessels in the neck. CONCLUSIONS: Occlusion of the great vessels of the neck with a thick silk at 540 degrees held by a hemostatic clamp at its base is a safe and reproducible method for occlusion of these vessels to perform end-to-side anastomosis in patients with difficult vascular access in the neck without increasing the risk of endothelial damage and thrombosis from the anastomosis.

Anatomical study of the mastoid foramina and mastoid emissary veins: classification and application to localizing the sigmoid sinus.

The mastoid foramen (MF) is located on the mastoid process of the temporal bone, adjacent to the occipitomastoid suture or the parietomastoid suture, and contains the mastoid emissary vein (MEV). In retrosigmoid craniotomy, the MEV has been used to localize the position of the sigmoid sinus and, thus, the placement of the initial burr hole. Therefore, this study aimed to examine the exact location and variants of the MF and MEV to determine if their use in localizing the sigmoid sinus is reasonable. The sample in this study comprised 22 adult dried skulls (44 sides). MF were identified and classified into five types based on location, prevalence, whether they communicated with the sigmoid sinus and exact entrance into the groove of the sigmoid sinus. The diameters and relative locations of the MF in the skull were measured and recorded. Finally, the skulls were drilled to investigate the course of the MEV. Additionally, ten latex-injected sides from human cadavers were also dissected to follow the MEV, especially in cases with more than one vein. We found that type I MFs (single foramen) were the most prevalent (50%). These MFs were mainly located on the occipitomastoid suture; only one case on the right side was adjacent to the parietomastoid suture. Type II (paired foramina) was the second most prevalent (22.73%), followed by type III (13.64%), type 0 (9.09%), and type IV (4.55%). The diameter of the external opening in a connecting MF (2.43 ± 0.79) was twice that of a non-connecting MF (1.14 ± 0.56). Interestingly, on one side, two MFs on the external surface shared a single internal opening; the MEV bifurcated. MFs followed three different courses: ascending, almost horizontal, and descending. Regardless of how many external openings there were for the MF, these all ended at a single opening in the groove for the sigmoid sinus. For cadaveric specimens with multiple MEVs, all terminated in the sigmoid sinus as a single vein, with the more medial veins terminating more medially into the sinus. Based on our study, the MF/MEV can guide the surgeon and help localize the deeper-lying sigmoid sinus. Knowledge of this anatomical relationship could be an adjunct to neuronavigational technologies.

Angiographic evaluation of the distance from the top of the jugular bulb to the inferior petrosal sinus-internal jugular vein junction: simple classification and identification method for the orifice of the non-visualized inferior petrosal sinus during neuroendovascular surgery.

BACKGROUND: The inferior petrosal sinus (IPS) is the transvenous access route for neurointerventional surgery that is occasionally undetectable on digital subtraction angiography (DSA) because of blockage by a clot or collapse. This study was aimed at analyzing the distance from the jugular bulb (JB) to the IPS-internal jugular vein (IJV) junction and proposing a new anatomical classification system for the IPS-IJV junction to identify the non-visualized IPS orifice. METHODS: DSA of 708 IPSs of 375 consecutive patients were retrospectively investigated to calculate the distance from the top of the JB to the IPS-IJV junction, and a simple classification system based on this distance was proposed. RESULTS: The median distance from the top of the JB to the IPS-IJV junction was 20.8 ± 14.7 mm. Based on the lower (10.9 mm) and upper (31.1 mm) quartiles, IPS-IJV junction variants were: type I, 0-10 mm (22.3%); type II, 11-30 mm (45.8%); type III, > 31 mm (23.9%); and type IV, no connection to the IJV (8.0%). Bilateral distances showed a positive interrelationship, with a correlation coefficient of 0.86. The bilateral symmetry type (visualized IPSs bilaterally) according to our classification occurred in 267 of 300 (89.0%) patients. CONCLUSIONS: In this study, the IPS-IJV junction was located far from the JB (types II and III), with a higher probability (69.6%). This distance and the four-type classification demonstrated high degrees of homology with the contralateral side. These results would be useful for identifying the non-visualized IPS orifice.

Surgical experience in repairing the right common carotid artery and the right internal jugular vein after ECMO in neonates: early clinical results.

BACKGROUND: The purpose of this study was to summarize the early clinical results and surgical experience of repairing the right common carotid artery and the right internal jugular vein after ECMO treatment in neonates. METHODS: We retrospectively collected the clinical data of 16 neonates with circulatory and respiratory failure who were treated with ECMO via the right common carotid artery and the right internal jugular vein in our hospital from June 2021 to December 2022. The effects of repairing the common carotid artery and internal jugular vein were evaluated. RESULTS: All 16 patients successfully underwent right cervical vascular cannulation, and the ECMO cycle was successfully established. Twelve patients were successfully removed from ECMO. The right common carotid artery and the right internal jugular vein were successfully repaired in these 12 patients. There was unobstructed arterial blood flow in 9 patients, mild stenosis in 1 patient, moderate stenosis in 1 patient and obstruction in 1 patient. There was unobstructed venous blood flow in 10 patients, mild stenosis in 1 patient, and moderate stenosis in 1 patient. No thrombosis was found in the right internal jugular vein. Thrombosis was found in the right common carotid artery of one patient. CONCLUSION: Repairing the right common carotid artery and the right internal jugular vein after ECMO treatment in neonates was feasible, and careful surgical anastomosis techniques and standardized postoperative anticoagulation management can ensure early vascular patency. However, long-term vascular patency is still being assessed in follow-up.

[Transcriptome sequencing for identification of the genes associated with restenosis of venous grafts in rabbits].

OBJECTIVE: To identify the genes associated with venous graft restenosis in rabbits using transcriptome sequencing. METHODS: Forty New Zealand rabbits were randomly divided into experimental group and control group, and in the experimental group, the left external jugular veins of the rabbits were engrafted to the left common carotid artery with continuous running suture; the rabbits in the control group received no operation. At 2 and 4 weeks after the operation, 10 rabbits from each group were euthanized and the venous grafts (in experimental group) or left external jugular vein (in control group) were harvested for measurement of the intima-media thickness using HE staining. RNA high-throughput sequencing (RNA-seq) was performed to identify the differentially expressed genes (DEGs) between the venous grafts and the control veins, and the biological functions of the DEGs were analyzed using GO and KEEG databases. RESULTS: In the experimental group, intima-media thickening with increased extracellular matrix and vascular smooth muscle cell proliferation occurred in the venous grafts at 2 weeks and aggravated at 4 weeks after the operation. RNA high-throughput sequencing identified 1583 up-regulated genes and 608 down-regulated genes in the venous grafts in the experimental group, and GO and KEGG analysis of the DEGs pinpointed 10 hub genes, namely CD4, ZAP70, SYK, CD28, PIK3CD, CXCR4, CCR5, ITK, CCL5 and BTK. CONCLUSION: CD4, ZAP70, SYK, CD28, PIK3CD, CXCR4, CCR5, ITK, CCL5 and BTK are probably the key genes associated with vein graft restenosis in rabbits.

Preliminary in-silico analysis of vascular graft implantation configuration and surface modification.

Vascular grafts are used to reconstruct congenital cardiac anomalies, redirect flow, and offer vascular access. Donor tissue, synthetic, or more recently tissue-engineered vascular grafts each carry limitations spanning compatibility, availability, durability and cost. Synthetic and tissue-engineered grafts offer the advantage of design optimization using in-silico or in-vitro modeling techniques. We focus on an in-silico parametric study to evaluate implantation configuration alternatives and surface finishing impact of a novel silicon-lined vascular graft. The model consists of a synthetic 3D-generic model of a graft connecting the internal carotid artery to the jugular vein. The flow is assumed unsteady, incompressible, and blood is modeled as a non-Newtonian fluid. A comparison of detached eddy turbulence and laminar modeling to determine the required accuracy needed found mild differences mainly dictated by the roughness level. The conduit walls are modeled as non-compliant and fixed. The shunt configurations considered, are straight and curved with varied surface roughness. Following a grid convergence study, two shunt configurations are analyzed to better understand flow distribution, peak shear locations, stagnation regions and eddy formation. The curved shunt was found to have lower peak and mean wall-shear stress, while resulting in lower flow power system and decreased power loss across the graft. The curved smooth surface shunt shows lower peak and mean wall-shear stress and lower power loss when compared to the straight shunt.

Success rate and safety of totally implantable access ports placed by the cephalic vein cutdown technique in oncological patients - a single-center study.

INTRODUCTION: Totally implantable access ports (TIAPs) are commonly used in oncologic patients undergoing ongoing chemotherapy. The methods of choice for implantation are the subclavian vein puncture approach and the cephalic vein cutdown technique, followed by internal jugular vein access and external jugular vein access.

Extreme lateral infracondylar approach for internal jugular vein compression syndrome: A case series with preliminary clinical outcomes.

BACKGROUND AND OBJECTIVES: Internal jugular vein (IJV) stenosis is associated with several neurological disorders including idiopathic intracranial hypertension (IIH) and pulsatile tinnitus. In cases of extreme bony compression causing stenosis in the infracondylar region, surgical decompression might be necessary. We aim to examine the safety and efficacy of surgical IJV decompression. METHODS: We retrospectively reviewed patients who received surgical IJV decompression via the extreme lateral infracondylar (ELI) approach between July 2020 and February 2022. RESULTS: Fourteen patients with IJV stenosis were identified, all with persistent headache and/or tinnitus. Six patients were diagnosed with IIH, three of whom failed previous treatment. Of the eight remaining patients, two failed previous treatment. All underwent surgical IJV decompression via styloidectomy, release of soft tissue, and removal of the C1 transverse process (TP). Follow-up imaging showed significant improvement of IJV stenosis in eleven patients and mild improvement in three. Eight patients had significant improvement in their presenting symptoms, and three had partial improvement. Two patients received IJV stenting after a lack of initial improvement. Two patients experienced cranial nerve paresis, and one developed a superficial wound infection. CONCLUSION: The ELI approach for IJV decompression appears to be safe for patients who are not ideal endovascular candidates due to bony anatomy. Confirming long-term efficacy in relieving debilitating clinical symptoms requires longer follow-up and a larger patient cohort. Carefully selected patients with symptomatic bony IJV compression for whom there are no effective medical or endovascular options may benefit from surgical IJV decompression.

The External Jugular Vein Cut-Down Method for Chemoport Insertion from a Tertiary Cancer Treatment Center in Central India: A Prospective Study.

INTRODUCTION: In the realm of oncology, the development of TIVAD (chemoport) has been a blessing for cancer patients, freeing them from having to undergo numerous recurrent venepunctures throughout their treatment. The External Jugular Vein cut-down has been the standard procedure for administering chemotherapy to cancer patients at our institution. Here, we discuss our experience with the External Jugular Vein cut-down Chemoport Insertion Technique and the outcomes it produced. MATERIALS AND METHODS: We performed a prospective observational study and included all patients who underwent the open External Jugular Vein cut-down technique of Chemoport Insertion from January 2019 to January 2022 in the Department of Surgical Oncology at our hospital. RESULTS: Out of 136 patients, 3 (2.2%) had failed external jugular vein (EJV) cannulation, and alternative access (Internal Jugular Vein) was chosen for cannulation. The most common indication for chemoport insertion in our study was carcinoma of the breast, around 72.93% (97/133), and hence the majority of patients were females, about 84.21% (112/133). Only 18.04% (24/133) were male patients. The age distribution ranged from 2 years to 84 years. Out of 133 patients, complications were observed in 14 patients (10.52%). Around 6 patients (4.5%) had problems with catheter blockage after one cycle of chemotherapy. 4 patients (3%) had port infections at the chamber region (pectoral region). 3 patients (2.2%) had catheter tip displacement into the brachiocephalic vein. 1 patient (0.75%) had extravasation of chemotherapy. CONCLUSION: In conclusion, our study demonstrates that the External Jugular Vein cut-down technique offers several advantages in the realm of oncology, as it is a safe, efficient, and straightforward technique for chemoport insertion. With its minimal learning curve and simplicity, this technique represents a favorable initial option for successfully implanting chemoports in cancer patients. Further research and comparative studies are needed to validate and further explore the benefits of this technique in diverse patient populations and healthcare settings.

Internal jugular vein reconstruction: An algorithm for reconstructive surgeons.

OBJECTIVES: The internal jugular vein (IJV) provides critical drainage from the brain, skull, and deep regions of the face and neck. Compromise to the bilateral IJVs has severe sequelae, but even unilateral IJV sacrifice or thrombosis after treatment can have sequelae. Despite the potential role of IJV reconstruction for head and neck surgeons, information about the indications, technique, and outcomes of the procedure are sparse. PATIENTS AND METHODS: We present a woman who had IJV sacrifice for an oral cavity cancer along with a contralateral selective neck dissection and adjuvant chemoradiation who developed occlusion of the contralateral IJV after her treatment, resulting in unacceptable cervical lymphedema and extensive neck varicosities. An end-to-side bypass from the superior IJV to the ipsilateral external jugular vein was performed. RESULTS: There were no complications from the procedure, which resulted in dissipation of her preoperative symptoms. We describe the literature surrounding IJV reconstruction, considerations for its use, the technique itself, and advice for perioperative management. CONCLUSION: IJV reconstruction is a valuable but underutilized technique for the head and neck microvascular surgeon in cases of bilateral threatened IJV outflow.

Surgical approach to internal and external jugular venous agenesis: case report.

PURPOSE: During reconstructive planning for mandibular resection and reconstruction, it was noted that the left internal and external jugular veins were absent, with a considerable compensatory internal jugular vein present on the contralateral side. METHODS: An accidental finding in the CT angiogram of the head and neck was assessed. RESULTS: Osteocutaneous fibular free flap is a well-established reconstructive surgery for mandibular defects that can involve anastomosis of the internal jugular vein and its tributaries. A 60-years-old man with intraoral squamous cell carcinoma, initially treated with chemoradiation, developed osteoradionecrosis of his left mandible. The patient then underwent resection of this portion of the mandible with reconstruction by osteocutaneous fibular free flap with virtual surgical planning. During reconstructive planning for the resection and reconstruction, it was noted that the left internal and external jugular veins were absent, and a noteworthy compensatory internal jugular vein was present on the contralateral side. We report a rare case of this combination of anatomical variations within the jugular venous system. CONCLUSION: Unilateral agenesis of the internal jugular vein has been reported, but a combined variation with ipsilateral agenesis of the external jugular vein and compensatory enlargement of the contralateral internal jugular vein has, to our knowledge, not been reported on previously. The anatomical variation reported in our study will be useful during dissection, central venous catheter placement, styloidectomy, angioplasty/stenting, surgical excision, and reconstructive surgery.

Dual spinal accessory nerve: an anatomical anomaly during neck dissection.

The spinal accessory nerve (SAN) is an important cranial nerve encountered during neck dissection. Preservation of this nerve from iatrogenic damage is crucial to avoid debilitating sequalae, which can be made challenging due to variation of its anatomical course. In this case report, we present a patient who underwent supraomohyoid neck dissection, where a rare variation of a dual SAN, traversing the internal jugular vein midway, was encountered. In this case report, we study this anatomical finding, which is undoubtedly a valuable addition to the existing knowledge of the SAN. Ultimately, allowing surgeons to develop further awareness of the variations of the SAN and contributing to favourable postoperative outcomes.