Intraluminal extension of papillary thyroid carcinoma into the Internal Jugular Vein; a case report.

BACKGROUND: Papillary thyroid carcinoma (PTC), being the most common thyroid malignancy, is a slow-growing tumor and is usually limited to the thyroid. Extra thyroid extension is uncommon; besides, invasion to the vasculature seems to be extremely rare and usually indicates aggressive nature of the disease. CASE PRESENTATION: We present a case of a 40-year-old lady who referred with a palpable neck mass a month after total thyroidectomy which its histopathologic examination revealed follicular variant of PTC; the same variant as prior thyroidectomy. Preoperative ultrasonography failed to comment on the intravascular component of the mass. Surgical procedure confirmed a mass attaching and infiltrating to the internal jugular vein, which turned out to be persistent disease. CONCLUSIONS: Awareness of this entity is important for surgeons, oncologists and radiologist as it can influence patient management.

Lung cancer with bilateral internal jugular vein thrombosis.

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Estimation of Right Atrial Pressure by Ultrasound-Assessed Jugular Vein Distensibility in Patients With Heart Failure.

BACKGROUND: Clinical evaluation of central venous pressure is difficult, depends on experience, and is often inaccurate in patients with chronic advanced heart failure. We assessed the ultrasound-assessed internal jugular vein (JV) distensibility by ultrasound as a noninvasive tool to identify patients with normal right atrial pressure (RAP ≤7 mm Hg) in this population. METHODS: We measured JV distensibility as the Valsalva-to-rest ratio of the vein diameter in a calibration cohort (N=100) and a validation cohort (N=101) of consecutive patients with chronic heart failure with reduced ejection fraction who underwent pulmonary artery catheterization for advanced heart failure therapies workup. RESULTS: A JV distensibility threshold of 1.6 was identified as the most accurate to discriminate between patients with RAP ≤7 versus >7 mm Hg (area under the receiver operating characteristic curve, 0.74 [95% CI, 0.64-0.84]) and confirmed in the validation cohort (receiver operating characteristic, 0.82 [95% CI, 0.73-0.92]). A JV distensibility ratio >1.6 had predictive positive values of 0.86 and 0.94, respectively, to identify patients with RAP ≤7 mm Hg in the calibration and validation cohorts. Compared with patients from the calibration cohort with a high JV distensibility ratio (>1.6; n=42; median RAP, 4 mm Hg; pulmonary capillary wedge pressure, 11 mm Hg), those with a low JV distensibility ratio (≤1.6; n=58; median RAP, 8 mm Hg; pulmonary capillary wedge pressure, 22 mm Hg; P<0.0001 for both) were more likely to die or undergo a left ventricular assist device implant or heart transplantation (event rate at 2 years: 42.7% versus 18.2%; log-rank P=0.034). CONCLUSIONS: Ultrasound-assessed JV distensibility identifies patients with chronic advanced heart failure with normal RAP and better outcomes. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03874312.

Challenges of Post-Venipuncture Jugular Venous Thrombosis in Patients with Secondary Hyperparathyroidism: A Case Report.

BACKGROUND Hyperparathyroidism is a common issue in patients on long-term hemodialysis, necessitating parathyroidectomy with deep venipuncture. These patients frequently exhibit a heightened incidence of vascular calcification, complicating deep venipuncture and increasing the risk of associated complications. Therefore, a crucial aspect of preoperative assessment in this population involves identifying vascular calcification, with a preference for ultrasound-guided intraplane puncture. Special care is required to prevent blood vessel injuries and postoperative complications such as deep vein thrombosis. CASE REPORT We present the case of a 66-year-old woman with secondary hyperparathyroidism who encountered challenges during an internal jugular vein puncture, leading to subsequent thrombosis. Initial attempts were hindered by calcification of the internal jugular vein's vascular wall, resulting in stratified damage to the vessel's wall. However, the ultrasound-guided in-plane puncture technique successfully allowed the insertion of a central venous catheter without further damage to the vascular wall. On the postoperative fourth day, thrombus formation was observed in the damaged vascular wall from the initial puncture. CONCLUSIONS The ultrasound-guided in-plane puncture technique is advantageous in overcoming the difficulties associated with puncturing through deep vein calcification in patients with secondary hyperparathyroidism. This technique also diminishes the likelihood of complications such as venous thrombosis.

Differential Assessment of Internal Jugular Vein Stenosis in Patients Undergoing CT and MRI with Contrast.

OBJECTIVE: Internal Jugular Vein Stenosis (IJVS) is hypothesized to play a role in the pathogenesis of diverse neurological diseases. We sought to evaluate differences in IJVS assessment between CT and MRI in a retrospective patient cohort. METHODS: We included consecutive patients who had both MRI of the brain and CT of the head and neck with contrast from 1 June 2021 to 30 June 2022 within the same admission. The degree of IJVS was categorized into five grades (0-IV). RESULTS: A total of 35 patients with a total of 70 internal jugular (IJ) veins were included in our analysis. There was fair intermodality agreement in stenosis grades (κ = 0.220, 95% C.I. = [0.029, 0.410]), though categorical stenosis grades were significantly discordant between imaging modalities, with higher grades more frequent in MRI (χ2 = 27.378, p = 0.002). On CT-based imaging, Grade III or IV stenoses were noted in 17/70 (24.2%) IJs, whereas on MRI-based imaging, Grade III or IV stenoses were found in 40/70 (57.1%) IJs. Among veins with Grade I-IV IJVS, MRI stenosis estimates were significantly higher than CT stenosis estimates (77.0%, 95% C.I. [35.9-55.2%] vs. 45.6%, 95% C.I. [35.9-55.2%], p < 0.001). CONCLUSION: MRI with contrast overestimates the degree of IJVS compared to CT with contrast. Consideration of this discrepancy should be considered in diagnosis and treatment planning in patients with potential IJVS-related symptoms.

Ultrasound-guided central venous catheterization around the neck: Systematic review and network meta-analysis.

BACKGROUND: Ultrasound-guided central venous catheterization (CVC) has become the standard of care. However, providers use a variety of approaches, encompassing the internal jugular vein (IJV), supraclavicular subclavian vein (SupraSCV), infraclavicular subclavian vein (InfraSCV), proximal axillary vein (ProxiAV), distal axillary vein (DistalAV), and femoral vein. OBJECTIVE: This review aimed to compare the first-pass success rate and arterial puncture rate for different approaches to ultrasound-guided CVC above the diaphragm. METHODS: In May 2023, Embase, MEDLINE, CENTRAL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Platform were searched for randomized controlled trials (RCTs) comparing the 5 CVC approaches. The Confidence in Network Meta-Analysis tool was used to assess confidence. Thirteen RCTs (4418 participants and 13 comparisons) were included in this review. RESULTS: The SupraSCV approach likely increased the proportion of first-attempt successes compared to the other 4 approaches. The SupraSCV first-attempt success demonstrated risk ratios (RRs) > 1.21 with a lower 95% confidence interval (CI) exceeding 1. Compared to the IJV, the SupraSCV approach likely increased the first-attempt success proportion (RR 1.22; 95% confidence interval [CI] 1.06-1.40, moderate confidence), whereas the DistalAV approach reduced it (RR 0.72; 95% CI 0.59-0.87, high confidence). Artery puncture had little to no difference across all approaches (low to high confidence). CONCLUSION: Considering first-attempt success and mechanical complications, the SupraSCV may emerge as the preferred approach, while DistalAV might be the least preferable approach. Nevertheless, head-to-head studies comparing the approaches with the greatest first attempt success should be undertaken.

Central venous catheter tip misplacement: A multicentre cohort study of 8556 thoracocervical central venous catheterisations.

BACKGROUND: There is a paucity of data on the incidence of central venous catheter tip misplacements after the implementation of ultrasound guidance during insertion. The aims of the present study were to determine the incidence of tip misplacements and to identify independent variables associated with tip misplacement. METHODS: All jugular and subclavian central venous catheter insertions in patients ≥16 years with a post-procedural chest radiography at four hospitals were included. Each case was reviewed for relevant catheter data and radiologic evaluations of chest radiographies. Tip misplacements were classified as 'any tip misplacement', 'minor tip misplacement' or 'major tip misplacement'. Multivariable logistic regression analyses were used to investigate associations between predefined independent variables and tip misplacements. RESULTS: A total of 8556 central venous catheter insertions in 5587 patients were included. Real-time ultrasound guidance was used in 91% of all insertions. Any tip misplacement occurred (95% confidence interval) in 3.7 (3.3-4.1)% of the catheterisations, and 2.1 (1.8-2.4)% were classified as major tip misplacements. The multivariable logistic regression analyses showed that female patient gender, subclavian vein insertions, number of skin punctures and limited operator experience were associated with a higher risk of major tip misplacement, whereas increasing age and height were associated with a lower risk. CONCLUSIONS: In this large prospective multicentre cohort study, performed in the ultrasound-guided era, we demonstrated the incidence of tip misplacements to be 3.7 (3.3-4.1)%. Right internal jugular vein catheterisation had the lowest incidence of both minor and major tip misplacement.

Optimal Insertion Depth of Central Venous Catheter through the Right Internal Jugular Vein, Verified by Transesophageal Echocardiography: A Prospective Observational Study.

This prospective observational study investigated the optimal insertion depth of the central venous catheter through the right internal jugular vein using transesophageal echocardiography. After tracheal intubation, the anesthesiologist inserted a probe for esophageal echocardiography into the patient's esophagus. The investigators placed the catheter tip 2 cm above the superior edge of the crista terminalis with echocardiography, which was defined as the optimal point. We measured the inserted length of the catheter. Pearson correlation tests were performed with the measured optimal depth and some patient parameters. We made a new formula for placing the catheter at the optimal position. A total of 89 subjects were enrolled in this trial. The correlation coefficient between the measured optimal depth and the patient's parameters was the highest for patient height (0.703, p < 0.001). We made a new formula of 'height (cm)/10 - 1.5 cm'. The accuracy rate of this formula for the optimal zone was 71.9% (95% confidence interval; 62.4 - 81.4%), which was the highest among the previous formulas or guidelines when we compared. In conclusion, the central venous catheter tip was evaluated with transesophageal echocardiography, and we could make a new formula of 'height (cm)/10 - 1.5', which seemed to be better than other previous guidelines.

The Effects of Free Breathing on Cerebral Venous Flow: A Real-Time Phase Contrast MRI Study in Healthy Adults.

Quantifying the effects of free breathing on cerebral venous flow is crucial for understanding cerebral circulation mechanisms and clinical applications. Unlike conventional cine phase-contrast MRI sequences (CINE-PC), real-time phase-contrast MRI sequences (RT-PC) can provide a continuous beat-to-beat flow signal that makes it possible to quantify the effect of breathing on cerebral venous flow. In this study, we examined 28 healthy human participants, comprising of 14 males and 14 females. Blood flows in the right/left internal jugular veins in the extracranial plane and the superior sagittal sinus (SSS) and straight sinus in the intercranial plane were quantified using CINE-PC and RT-PC. The first objective of this study was to determine the accuracy of RT-PC in quantifying cerebral venous flow, relative to CINE-PC. The second, and main objective, was to quantify the effect of free breathing on cerebral venous flow, using a time-domain multiparameter analysis method. Our results showed that RT-PC can accurately quantify cerebral venous flow with a 2 × 2 mm2 spatial resolution and 75 ms/image time resolution. The mean flow rate, amplitude, stroke volume, and cardiac period of cerebral veins were significantly higher from the mid-end phase of expiration to the mid-end phase of inspiration. Breathing affected the mean flow rates in the jugular veins more than those in the SSS and straight sinus. Furthermore, the effects of free breathing on the flow rate of the left and right jugular veins were not synchronous. These new findings provide a useful reference for better understanding the mechanisms of cerebral circulation.

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.

Detailed Anatomy of Bridging Veins Around the Foramen Magnum: a Multicenter Study Using Three-dimensional Angiography.

BACKGROUND AND PURPOSE: There has been limited literature regarding the bridging veins (BVs) of the medulla oblongata around the foramen magnum (FM). The present study aims to analyze the normal angioarchitecture of the BVs around the FM using slab MIP images of three-dimensional (3D) angiography. METHODS: We collected 3D angiography data of posterior fossa veins and analyzed the BVs around the FM using slab MIP images. We analyzed the course, outlet, and number of BVs around the FM. We also examined the detection rate and mean diameter of each BV. RESULTS: Of 57 patients, 55 patients (96%) had any BV. The median number of BVs was two (range: 0-5). The BVs originate from the perimedullary veins and run anterolaterally to join the anterior condylar vein (ACV), inferior petrosal sinus, sigmoid sinus, or jugular bulb, inferolaterally to join the suboccipital cavernous sinus (SCS), laterally or posterolaterally to join the marginal sinus (MS), and posteriorly to join the MS or occipital sinus. We classified BVs into five subtypes according to the draining location: ACV, jugular foramen (JF), MS, SCS, and cerebellomedullary cistern (CMC). ACV, JF, MS, SCS, and CMC BVs were detected in 11 (19%), 18 (32%), 32 (56%), 20 (35%), and 16 (28%) patients, respectively. The mean diameter of the BVs other than CMC was 0.6 mm, and that of CMC BV was 0.8 mm. CONCLUSION: Using venous data from 3D angiography, we detected FM BVs in most cases, and the BVs were connected in various directions.

Low Posterior Internal Jugular Vein Approach for Tunnelled Haemodialysis Catheter Insertion: A Report on Outcomes at a Single Centre.

AIM: The impact of technical differences in cannulation technique for tunnelled haemodialysis catheter insertion is undetermined. We aimed to assess clinical outcomes of the low posterior approach for internal jugular vein tunnelled catheter placement. METHODS: A retrospective audit was undertaken on consecutive tunnelled catheter procedures performed at a single centre between January 2016 and June 2022. Only catheters specifically placed with a low posterior internal jugular approach were included. The study's primary outcome was 12-month catheter survival, evaluated using the Kaplan-Meier survival curve and log-rank test. Secondary outcomes included catheter performance and procedure-related complications. RESULTS: During the study period, 391 tunnelled internal jugular haemodialysis catheters were inserted in 272 patients using the low posterior technique. The 12-month primary patency rate was 68%. Catheter insertion was successful in 96% of cases. Peri-procedural complications occurred in 4% of cases, most frequently bleeding. The most common reasons for catheter loss were dysfunction (10%) and bacteraemia (6%). The best predictors of catheter failure were advanced age (HR 1.02, 95% CI 1.00-1.04) and in-centre dialysis treatment locality (HR 2.04, 95% CI 1.19-3.45). CONCLUSION: The low posterior approach for internal jugular vein tunnelled catheter insertion is effective and safe. We demonstrated a 12-month catheter survival rate of 68%. Further research comparing the low posterior approach with other internal jugular vein cannulation techniques is warranted.

First assessment of flow phenomena of acute and chronic thrombosis in the jugular veins using new ultrasound vector-flow imaging.

AIM: First assessment of flow changes in the jugular veins using high resolution ultrasound vector flow. MATERIAL UND METHODS: 15 patients (8 males, 7 females) with an age range of 35 to 82 years (mean age 58.53±12.26 years) were examined by an experienced examiner using high power ultrasound equipment (Resona R9, Mindray) with probe technology (Mindray L9-3U Linear Array transducer, 2.5 to 9.0 MHz). This group was compared with five healthy subjects (mean age 35.4±13.79 years) as a reference. To assess flow changes, the color-coded duplex sonography and the novel vector flow technique were used. The evaluation was performed of vector morphology changes, turbulence, and wall resistance measurements. RESULTS: There were changes after acute and chronic thrombosis in 9 cases, and venous compression in 7 cases. Turbulence was measurable from 0.01 % to 64.44 %, the average turbulence was 19.73±22.06 %. Wall resistance measurement showed values from 0.01 Pa to 3.14 Pa, depending on the age of the thrombosis or compression. The reference veins showed turbulence of 0.94±1.5 % and a mean wall resistance of 0.05±0.05 Pa. There are statistically significant differences between normal and thrombotic or compressed veins in terms of maximum wall stress (p = 0.006) and mean degree of turbulence (p = 0.012), while the difference in mean wall stress is not statistically significant (p = 0.058). CONCLUSION: Despite still existing technical limitations, the combination of V-flow and wall stress measurements in jugular vein changes suggests a high diagnostic potential.

A neonate with aseptic cutaneous necrosis related to the migration of the proximal central venous catheter infusion port.

We report a case of aseptic cutaneous necrosis from extravasation of calcium chloride at the proximal port of a central venous catheter (CVC). A right internal jugular CVC was placed with ultrasound guidance using contemporary guidelines for size and insertion site. Catheter migration occurred concurrent with development of postoperative anasarca. Four days later, leakage of infusate with skin necrosis was noted at the insertion site. Despite initial proper positioning, catheter ports can migrate out of intravascular structures due to postprocedural subcutaneous edema. Intravascular confirmation should be performed regularly for infants with localized or generalized edema.

Ultrasound for Venous Local Pulse Wave Velocity: Comparison of Pulse Transit Time Methods.

Venous pulse wave velocity (vPWV) is a potential marker for determining the state of venous hemodynamics, venosclerosis, and vascular filling. Although there have been several studies on pulse wave velocity through blood vessels, the majority have focused on arteries, with only limited studies on veins. To our knowledge, this study is the first to compare the local vPWV estimation metrices. An in vivo study was conducted on 10 participants where the jugular venous pulses (JVP) from two proximal sites were simultaneously acquired using a dual-element high frame rate system. The local vPWV was computed using different transit time-based techniques. The study demonstrates the comparison between vPWV ranges computed using thresholding, fiduciary point (c and v) and correlation-based approaches indicated as vPWV|th, vPWV|c, vPWV|v and vPWV|Xcorr respectively. High fidelity echo frames were acquired from the jugular vein (JV) at a temporal resolution of 2 ms and an amplitude resolution of 10 µm. The study findings indicated that the vPWV computed using various transit time metrics were comparable without significant bias (p > 0.05). Among the VPWV metrices, vPWV|th had the lowest beat-to-beat variation (CoV = 18 %). The mean deviations in vPWV|c, vPWV|v and vPWV|Xcorr values from vPWV|th were 0.28, 0.17 and 0.22 m/s respectively, where the average beat-to-beat variation was minimal. The results suggested that the thresholding and cross-correlation metrices offered better performance in comparison with the fiduciary point techniques for vPWV estimation.Clinical Relevance- The study demonstrated the potential of direct transit time methods to reliably estimate the local vPWV on the internal jugular vein.