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Anesth Analg 2003;97:648-649
© 2003 International Anesthesia Research Society

CARDIOVASCULAR ANESTHESIA

Transesophageal Echocardiography-Guided Placement of Internal Jugular Percutaneous Venovenous Bypass Cannula in Orthotopic Liver Transplantation

Raymond M. Planinsic, MD, Ramona Nicolau-Raducu, MD, John C. Caldwell, MD, Shushma Aggarwal, MD, and Ibtesam Hilmi, MD

Department of Anesthesiology, University of Pittsburgh Medical Center, Pennsylvania

Address correspondence and reprint requests to Raymond M. Planinsic, MD, Director of Hepatic Transplantation Anesthesiology, University of Pittsburgh Medical Center, 200 Lothrop St., Room C-207, Pittsburgh, PA 15213. Address e-mail to planinsicrm{at}anes.upmc.edu


   Abstract
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 Abstract
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Venovenous bypass has improved patient survival and decreased morbidity and mortality in the field of orthotopic liver transplantation. The standard at many transplant centers is the use of the internal jugular percutaneous venovenous bypass cannulae (PVVBC) for venous return to the patient. Placement of these large (18F) PVVBC may lead to several complications and requires confirmation before use. Use of transesophageal echocardiography, an effective and rapid method to guide placement of the PVVBC and minimize potential complications associated with insertion of the device, is described.

IMPLICATIONS: During orthotopic liver transplantation, a venovenous bypass cannula is inserted into the internal jugular vein as a conduit for venous return. This article describes how the use of transesophageal echocardiography can facilitate the insertion and minimize the complications associated with its use.

Venovenous bypass (VVB) was first introduced to the field of orthotopic liver transplantation (OLT) in 1984 at the University of Pittsburgh Medical Center (1). VVB improved patient survival and decreased morbidity and mortality by decreasing visceral congestion, intraoperative bleeding, and postoperative renal dysfunction. It improved intraoperative hemodynamic stability, allowing less volume transfusion and vasopressor use.

In the past, VVB venous drainage cannulae were placed in the external iliac vein to decompress the venous system below the infrahepatic vena cava clamp and the portal vein to decompress the splanchnic venous system, whereas a VVB venous return cannula was placed in the axillary vein. This method was occasionally complicated by injury to axillary structures, such as the brachial plexus, arterial, venous, and lymphatic vessels, infection and wound healing problems (2). As a result, the use of a percutaneous venovenous bypass cannula (PVVBC) has replaced the axillary vein approach via the internal jugular (IJ) vein at many institutions (3). The IJ approach is not without risk and can be complicated by carotid artery injury, pneumothorax, right atrial perforation, or even ventricular perforation (4).

To avoid these complications and to ensure proper placement of the PVVBC, several methods have been developed. These include confirmation of proper positioning of the PVVBC by chest radiograph or fluoroscopic assistance for placement of the cannula (5).

We have found that the most reliable and rapid method for placement of the PVVBC is with the assistance of transesophageal echocardiography (TEE). TEE has been used extensively in the field of hepatic transplantation anesthesiology to aid in diagnosis of intraoperative problems (6). The role of TEE as a tool for PVVBC placement during OLT has not been reported.

Figure 1 shows an 18F PVVBC (Fem-Flex Duraflo Treated Femoral Arterial Cannula®, 18F x 15 cm, Baxter, Irvine, CA) and dilators, which are typically inserted into the IJ vein via the Seldinger technique. It is important that the catheter be placed between the juncture of the superior vena cava (SVC) and the right atrium (RA) and as far as the fosa ovalis (7). Placement of the PVVBC above the juncture of the SVC and RA, in the SVC itself, may lead to erosion of the SVC, depending on the duration the cannula placement. Alternatively, placement of the PVVBC below the fosa ovalis may cause the cannula to abut the tricuspid valve or even damage (perforate) the tricuspid valve. TEE may be used not only to properly position the PVVBC, but also it may be useful in detecting complications arising during cannula placement.



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  		Figure 1. Percutaneous venovenous bypass cannula (PVVBC) and dilators.

 
To avoid these complications, TEE may be used as follows. The TEE probe (Omniplane II®, Hewlett Packard, Palo Alto, CA) should be placed in the long-axis bicaval view available from the mid-esophageal position. The SVC is generally best seen at the omniplane angle of 90–120 degrees, whereas the interior vena cava is best seen at the omniplane angle of 40–80 degrees. To obtain these views, the 4-chamber view of the heart is obtained, and the RA is centered. The TEE probe is then translated and rotated until the long-axis bicaval view is obtained.

Next, the IJ vein is cannulated, and a guide wire (GW) is inserted into the vein. If locating the IJ vein is difficult, use of a high frequency trans-thoracic echocardiography transducer (Philips S 12®, Andover, MA) may be used to locate the IJ vein, ensure its patency and size, and even aid in performing the IJ vein puncture under direct ultrasound guidance. Proper placement of the GW can be confirmed by visualization of the GW passing from the SVC into the RA from the TEE image (Fig. 2). The PVVBC is then inserted into the IJ vein after sequential dilation of the vein and positioned confirmed by TEE (Fig. 3). This technique can easily be performed by one anesthesiologist with the assistance of an anesthesiology technician and accomplished in most cases in less than 5 min. We have found that routine use of chest radiograph is not required, which can save a considerable amount of valuable time (up to 30 min) at the beginning of the OLT procedure when it is important to minimize ischemia time on the donor graft.



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  		Figure 2. Visualization of the guide wire (GW) passing from the superior vena cava (SVC) into the right atrium (RA).

 


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  		Figure 3. Mid-esophageal bicaval view with percutaneous venovenous bypass cannulae (PVVBC) properly positioned.

 
In conclusion, TEE is an effective and rapid method available to the anesthesiologist for placement of PVVBC. In addition, use of the high-frequency transducer on the echocardiography machine may aid in cannulation of the IJ vein when it is difficult to locate. Proper use of TEE can minimize both the potential complications associated with insertion of this device and ischemia time on donor organs, which might occur if other techniques are used to confirm proper placement of the PVVBC. This technique, used by the authors in approximately 100 patients, has been used without major complications.


   References
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 Abstract
 References
 

  1. Shaw BW Jr, Martin DJ, Marquez JM, et al. Venous bypass in clinical liver transplantation. Ann Surg 1984; 200: 524–34.[ISI][Medline]
  2. Hosein Shokouh-Amiri M, Osama Gaber A, Bagous WA, et al. Choice of surgical technique influences perioperative outcomes in liver transplantation. Ann Surg 2000; 231: 814–23.[Medline]
  3. Tisone G, Mercadante E, Dauri M, et al. Surgical versus percutaneous technique for veno-venous bypass during orthotopic liver transplantation: a prospective randomized study. Transplant Proc 1999; 31: 3162–3.[Medline]
  4. Doerfler ME, Kaufman B, Goldenberg AS. Central venous catheter placement in patients with disorders of hemostasis. Chest 1996; 110: 185–8.[Abstract/Free Full Text]
  5. Bermas H, Albrecht RM, Vogt D. An evaluation of two methods for chronic central venous access device placement. Am J Surgery 1999; 178: 560–3.[ISI][Medline]
  6. Maslow A, Bert A, Schwartz C, et al. Transesophageal echocardiography in the noncardiac surgical patient. International Anesthesiology Clinics 2002; 40: 73–132.[Medline]
  7. Heckmann JG, Lang CJ, Kindler K, et al. Neurologic manifestations of cerebral air embolism as a complication of central venous catheterization. Crit Care Med 2000; 28: 1621–5.[ISI][Medline]
Accepted for publication May 7, 2003.




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This Article
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Right arrow Articles by Planinsic, R. M.
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Right arrow Articles by Planinsic, R. M.
Right arrow Articles by Hilmi, I.
Related Collections
Right arrow Cardiovascular
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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press