Surgical review of the anatomical variations of the internal jugular vein: an update for head and neck surgeons

Anomalous Posterior Branching of the Internal Jugular Vein: A Report of Two Patients

The internal jugular vein (IJV) is an important vein encountered during most routine major head and neck surgeries. The IJV is known to infrequently present with anatomical variations, commonly duplication and fenestration. This report presents two cases that highlight an unusual anatomical variation of the IJV, namely the posterior tributary, which was encountered during neck dissection for papillary carcinoma of the thyroid and metastatic cervical lymph nodes. The first case was a 50-year-old woman with papillary carcinoma of the thyroid and regional metastasis, who underwent extensive neck dissection. During dissection, an anomalous posterior tributary of the IJV was discovered, originating around 3 cm above the omohyoid tendon-IJV junction. In case 2, a 40-year-old woman with a history of thyroidectomy exhibited a similar anomaly during neck dissection. In both cases, the posterior tributary was observed branching into two divisions. These cases emphasize the significance of recognizing anatomical variations to avoid inadvertent damage during surgical procedures. Anomalies like the posterior IJV tributary could have implications for surgical planning, emphasizing the importance of thorough exploration and understanding of individual variations. Awareness of such variations will help facilitate surgeons in safely performing neck dissections.

Angiographic evidence of an inadvertent cannulation of the marginal sinus following central line migration: illustrative case

BACKGROUND

Central venous catheters (CVCs) play an indispensable role in clinical practice. Catheter malposition and tip migration can lead to severe complications. The authors present a case illustrating the endovascular management of inadvertent marginal sinus cannulation after an internal jugular vein (IJV) catheter tip migration.

OBSERVATIONS

A triple-lumen CVC was inserted without complications into the right IJV of a patient undergoing a repeat sternotomy for aortic valve replacement. Two weeks postinsertion, it was discovered that the tip had migrated superiorly, terminating below the torcula in the posterior fossa. In the interventional suite, a three-dimensional venogram confirmed the inadvertent marginal sinus cannulation. The catheter was carefully retracted to the sigmoid sinus to preserve the option of catheter exchange if embolization became necessary. After a subsequent venogram, which displayed an absence of contrast extravasation, the entire catheter was safely removed. The patient tolerated the procedure well.

LESSONS

Clinicians must be vigilant of catheter tip migration and malposition risks. Relying solely on postinsertion radiographs is insufficient. Once identified, prompt management of the malpositioned catheter is paramount in reducing morbidity and mortality and improving patient outcomes. Removing a malpositioned catheter constitutes a critical step, best performed by a specialized team under angiographic visualization.

Feasibility and Outcome of Transjugular Intracardiac Echocardiography-Guided Transcatheter Aortic Valve Replacement

Background

There are limited data on the impact of intracardiac echocardiography (ICE)-guided transcatheter aortic valve replacement (TAVR) on the new permanent pacemaker implantation (PPMI) rate.

Objectives

This study investigated the feasibility and outcome of transjugular ICE (TJ-ICE) -guided TAVR, by visualizing the relationship between the membranous septum (MS) and the transcatheter aortic valve (TAV).

Methods

Among patients with severe aortic stenosis who underwent TAVR between February 2017 and June 2020, this study enrolled a total of 163 patients with TJ-ICE-guided TAVR. MS length was measured by ICE. The primary endpoint of this study was the incidence of new PPMI at 30 days.

Results

The mean age of the patients in this study was 84.9 ± 4.6 years, and 71.2% of the patients were female. Device success was 96.3% with TJ-ICE guidance. A TJ-ICE-related complication occurred in 1 case (0.6%). The median length of the MS was 5.8 mm (IQR: 5.0-6.9 mm). Excellent intraobserver (intraclass correlation coefficient [ICC]: 0.94; 95% CI:0.79-0.98; P < 0.001) and interobserver (ICC: 0.93; 95% CI: -0.05 to 0.98; P < 0.001) agreements were shown. The new PPMI rate was 6.7% at 30 days without a significant difference between balloon-expandable valves and self-expandable valves (3.4% vs 8.7%; P = 0.226). Patients with a TAV implantation depth less than MS length had a significantly lower incidence of new PPMI compared with patients with a TAV implantation depth greater than MS length (2.1% vs 13.4%; P = 0.005), regardless of baseline right bundle branch block presence (6.7% vs 66.7%; P = 0.004) or absence (1.2% vs 8.2%; P = 0.041).

Conclusions

TJ-ICE-guided TAVR demonstrated remarkable feasibility and safety. The TJ-ICE-guided final TAV position had a significant impact on the new PPMI rate. (Tokai Valve Registry; UMIN000036671).

The external jugular vein is a feasible and safe alternative access for retrieval of inferior vena cava filter

PURPOSE

The purpose is to analyze whether the external jugular vein (EJV) is a feasible and safe alternative access for the retrieval IVCFs designed for the jugular approach.

METHODS

This study was designed as a nonrandomized, controlled study. The patients were divided into two groups: the IJV or EJV access groups. All operations were performed by the vascular surgery team. The main outcome was the technical success rate. The secondary outcomes included (1) the IVCF retrieval rate; (2) the time required to puncture the access vein (min); (3) the number of punctures required for access, and other aspects.

RESULTS

A total of 119 patients were recruited for IVCF retrieval. Seventeen patients refused to join this trial, leaving 58 patients in the IJV group and 44 patients in the EJV group. In the IJV group, technical success was not achieved in one patient who started in the EJV group and was transferred to the IJV group. There was no significant difference in age, comorbidities, or technical success rate between the two groups. Significant differences were observed in puncture time (min), number of punctures, and inadvertent puncture of the carotid artery. All of the patients were discharged 1 or 2 days after the operation.

CONCLUSION

EJV is safe and feasible alternative access for the retrieval of IVCFs that are designed for jugular approaches.

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.

Unilateral Fenestration of Internal Jugular Vein With a Radiological Clue: A Rare Case Report and Literature Review

The intricacies of human anatomy continue to astound, as underscored by this unusual case of a 45-year-old female patient who presented to our esteemed otolaryngology department with T3N1MO squamous cell carcinoma of the lip. The preoperative diagnostic imaging of this patient divulged an enigmatic venous anomaly involving the internal jugular vein (IJV). Our team meticulously orchestrated a wide local excision of the primary tumor and modified radical neck dissection with Abbe Estlander flap reconstruction. Identification of the anomaly during the preoperative phase helped in meticulous planning and preparation. Thus, the surgical team was well-prepared for neck dissection and successfully navigated the rare IJV fenestration without incurring nerve or vascular injuries. This remarkable case accentuates the importance of maintaining a profound understanding of potential anatomical aberrations while performing intricate surgical procedures such as neck dissections. Heightened awareness can circumvent inadvertent damage to critical structures, ultimately safeguarding patient well-being. In this captivating report, we explain the preoperative suspicion, intraoperative identification, and subsequent outcome of a rare fenestration of the IJV encountered during a challenging neck dissection.

Normal reference values for magnetic resonance imaging measurements of the fetal internal jugular veins in middle and late pregnancy

BACKGROUND

At present, there is a lack of normal magnetic resonance imaging (MRI) morphometric reference values for fetal internal jugular veins during middle and late pregnancy.

OBJECTIVE

We used MRI to assess the morphology and cross-sectional area of the internal jugular veins of fetuses during middle and late pregnancy and to explore the clinical value of these parameters.

MATERIALS AND METHODS

The MRI images of 126 fetuses in middle and late pregnancy were retrospectively analysed to determine the optimal sequence for imaging the internal jugular veins. Morphological observation of the fetal internal jugular veins in each gestational week was carried out, lumen cross-sectional area was measured and the relationship between these data and gestational age was analysed.

RESULTS

The balanced steady-state free precession sequence was superior to other MRI sequences used for fetal imaging. The cross section of fetal internal jugular veins was predominantly circular in both the middle and late stages of pregnancy, however the prevalence of an oval cross section was significantly higher in the late gestational age group. The cross-sectional area of the lumen of the fetal internal jugular veins increased with increasing gestational age. Fetal jugular vein asymmetry was common, with the right jugular vein being dominant in the high gestational age group.

CONCLUSION

We provide normal reference values for fetal internal jugular veins measured by MRI. These values may form the basis for clinical assessment of abnormal dilation or stenosis.

Anatomical variations of the internal jugular vein in the context of central line placement: A visual approach to data processing

Central line placement in the internal jugular vein (IJV) can result in complications. Previous studies that examined variations in geometric anatomical parameters in pediatric populations have reduced these risks in children. The aim of this study was to establish possible anatomical variations to improve central line placement in the adult population and demonstrate the use of a correlation heatmap in processing large amounts of data. Twenty-seven volunteers were imaged using ultrasound at three different neck levels on right and left sides and various anatomical parameters were measured. Demographic information was also collected and included in the data processing. The Pearson coefficient was derived from each possible relationship between the measured parameters and was plotted in a correlation heatmap. Strong correlations were observed between the body mass index and the depth of the IJV and common carotid artery (CCA), the relative depth of the IJV to the CCA. No significant correlations were found in the dimensions of both vessels. Anatomical variations were more common than anticipated and should be taken into account when performing central line catheterization in order to minimize post-procedure complications.

Case report: Successful thromboprophylaxis with enoxaparin in a pregnant woman with internal jugular vein agenesis

Internal jugular agenesis is a vascular malformation that is often associated with a history of recurrent headache. Due to the resulting abnormalities in intracranial venous drainage, it may be complicated by neurological dysfunction, such as intracranial hypertension, intracranial micro-thromboses, and neurodegenerative diseases such as multiple sclerosis. The simultaneous presence of jugular vein agenesis and thrombosis is possible in cases of acute illness, hormonal treatment, pregnancy, hypomobility, or venous drainage abnormalities (VDA) (e.g., May-Thurner syndrome). In particular, the literature still lacks data on thromboprophylaxis in pregnant women with jugular vein agenesis. Here, we report a positive experience with prophylaxis using enoxaparin during pregnancy in a patient with internal jugular agenesis.

Ultrasound-Guided Right Internal Jugular Vein Cannulation by Operators of Different Experience: A Randomized, Pilot Study

BACKGROUND AND AIM

Currently, ultrasound-guided (US-guided) internal jugular vein (IJV) cannulation is the recommended technique. However, it has a learning curve and might be unsafe in inexperienced hands. The present study aimed to compare the performance and complications with two levels of experience in performing US-guided right IJV cannulation.

METHODS

With informed consent, 108 procedures were performed after random allocation into two groups based on operator experience. An operator with experience in performing 30 or more ultrasound-guided IJV cannulation was considered an expert. The rate of successful cannulation, the time needed, number of attempts, and complication rate were measured. Quantitative continuous variables were compared using the unpaired student's t-test, and the chi-square test or Fisher's-exact test was used for the comparison of qualitative variables; P-value < 0.05 was considered significant.

RESULTS

The successful cannulation rates were 100% versus 94.44% in the expert and non-expert groups, respectively; (P=0.0803). The mean time for successful cannulation and the percentage of patients who required ≥ two attempts were significantly lower in the expert group (33.28 seconds and 12.96% versus 95.42 seconds and 61.12%). Although the incidence of carotid artery puncture and hematoma (7.4% and 5.56%) was higher in the non-expert group, it was not statistically different; (P=1.00).

CONCLUSION

US-guided right IJV cannulation has a learning curve, and procedures as many as 30 US-guided IJV cannulation need to be observed and performed under the guidance to achieve it.

The Right Internal Jugular at the Cricoid Cartilage Level May Represent the Optimal Central Vein Puncture Site in Pediatric Patients

OBJECTIVE

Internal jugular vein puncture or cannulation is far more difficult in children compared with adults. Anthropometric measures of the internal jugular vein acquired by two-dimensional ultrasound are useful in the practice of puncture and catheterization. The aim of this study is to measure anthropometric parameters of bilateral internal jugular veins in children and to determine the best puncture site based on these parameters.

MATERIALS

A total of 107 pediatric patients undergoing elective operation were included. Ultrasound-visible evaluation of bilateral internal jugular veins was used to obtain the depth from skin, maximum antero-posterior diameter, and cross-sectional area at the levels of the superior border of thyroid cartilage and cricoid cartilage. Statistical analysis was performed using these anthropometric data and demographic variables of all studied pediatric patients, such as age, height, and weight.

RESULTS

A very weak correlation was noted between the depth, maximal antero-posterior diameter, and cross-sectional area of both internal jugular veins and the age, height, weight, and body surface index of all included children. All Pearson's R correlation coefficients were <0.45. The largest diameter and cross-sectional area were in the right internal jugular vein at the cricoid cartilage level (p < 0.01) followed by the left internal jugular vein at this level (p < 0.01). In addition, the internal jugular vein at the cricoid cartilage level was more superficial than that of the superior border of the thyroid cartilage (p < 0.01).

CONCLUSION

The right internal jugular vein at the cricoid cartilage level is the best site for puncture. The most appropriate alternative site is the left internal jugular vein on the same level. Better correlation was not observed between the anthropometric parameters of the internal jugular vein and children's biological characteristics. This finding should be confirmed in a larger-scale demographical study in the future.

Duplication of the internal jugular vein: a rare presentation during neck dissection

The anatomical variations of the internal jugular vein (IJV) is a well-documented phenomenon which may depend on the course of drainage, fenestration in the vein, bifid formation, variations in the tributaries and so on. However, a true duplication of the IJV is a rare entity on its own and is seldom reported in the literature. We report a case of true duplication of IJV which is an incidental discovery during the course of neck dissection.

Internal Jugular Vein Fenestration and Duplication: Anatomical Findings, Prevalence, and Literature Review

Background: Comprehensive knowledge of the internal jugular vein (IJV) regarding its anatomical variations and the pattern of its course is valuable for preventing unexpected injuries during surgical procedures or central venous access. IJV anatomical anomalies such as fenestration and duplication are rare, mainly represented by case reports, and intraoperative findings.

Objective: To present two additional cases of IJV anomalies and highlight its clinical presentation, anatomical characteristics, management, and prevalence through an extensive literature review.

Methods and Case Reports: From January 2017 to December 2018, we retrospectively collected data of 221 patients undergoing neck dissection (ND) procedures and identified two patients with IJV anomalies (fenestration and duplication) providing a clinical prevalence of ~0.9%. The IJV fenestration referred to an IJV bifurcation that reunites proximal to the subclavian vein, whereas in the IJV duplication both branches remain separated. In both of our cases, the spinal accessory nerve (SAN) crossed the window between the IJV branches.

Conclusion: Anatomical variations are more likely to be identified intraoperatively or incidentally, and due to the risk of SAN and vascular injury, special attention should be taken to identify them preoperatively in order to reduce the risk of iatrogenic injury and unexpected complications.

The effect of increased abdominal pressure on internal jugular vein catheterization under ultrasound-guidance on conscious patients: A randomised controlled trial

BACKGROUND

The shape and cross-sectional area (CSA) of internal jugular vein (IJV) are easily affected by external factors. That causes venous collapsibility. We tried to distend IJV by increasing the pressure on patients' abdomen in order to improve the success rate of internal jugular vein catheterization (IJVC).

MATERIALS AND METHODS

Patients undergoing IJVC were randomly allocated to two groups: Group 1 and Group 2. For patients in Group 1, the pressure on abdomen was increased by placing a 3000 ml bag of normal saline (NS). No special treatment was arranged for patients in Group 2. Transverse images of right IJV were captured at the outer edge which was parallel to the cricoid by ultrasonography. CSA, circumference (CF), transverse diameter (TD) and anteroposterior diameter (APD) of right IJV were measured and compared. All patients underwent ultrasound-guided short-axis puncturing. The success rates of one-off puncturing in two groups were recorded and compared.

RESULTS

The results under ultrasonography assessments show that CF, CSA, APD and success rate of puncturing in Group 1 were significantly higher than that of Group 2 (P < 0.05), while TD was not significantly increased (P > 0.05). There was no significant difference in complications between two groups (P > 0.05).

CONCLUSION

Pressure on the abdomen could significantly increase CSA of IJV. That helps improving the success rate of one-off puncturing.

Anatomic variant of the internal jugular vein and its importance in vascular access for hemodialysis

The right internal jugular vein is considered the best route for vascular access, because of low complication rates and satisfactory flow during hemodialysis, due to its straight route to the right atrium. This paper reports the identification, prior to puncture, of an anatomic variant position of the internal jugular vein in relation to the common carotid artery. The benefit of this prior identification is highlighted, emphasizing the importance of performing vascular Doppler ultrasound rather than using only external anatomical observation for puncture of the internal jugular vein.

Central Line Catheters and Associated Complications: A Review

The use of a central line or central venous catheterization was brought to attention in 1929 when Dr. Werner Forssmann self-inserted a ureteric catheter through his cubital vein and into the right side of his heart. Since that time the central line technique has developed further and has become essential for the treatment of decompensating patients. Central lines are widely used for anything from rapid fluid resuscitation, to drug administration, to parenteral nutrition, and even for administering hemodialysis. Central lines come in different sizes, types, and sites of administration. Sometimes their use can be associated with complications as well. The following review article addresses these parameters of central lines and goes into detail regarding their complications.

Ultrasonic identification of internal jugular vein fenestration

OBJECTIVE

Anatomic variations have curicial importance during neck surgery. We present a fenestrated internal jugular vein variation and the accessory nerve passing through it. Also, we discuss preoperative diagnosis of this variation using ultrasonography.

METHOD

The possible recognition of this variation by ultrasonography is introduced.

RESULTS

The accessory nerve in an internal jugular vein fenestration can be seen using ultrasonography.

CONCLUSION

Preoperative identification of this rare variation may secure surgeon from potential complications.