Anesth Analg 2004;99:1625-1629
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000138038.33738.32
CARDIOVASCULAR ANESTHESIA
The Anterior Jugular Venous System: Variability and Clinical Impact
Wolfram Schummer, MD, DEAA, EDIC*,
Claudia Schummer, MD*,
Don Bredle, PhD , and
Rosemarie Fröber, MD
Department for *Anesthesiology and Intensive Care Medicine and the
Institute of Anatomy I, Friedrich-Schiller University of Jena, Germany; and
Department of Kinesiology, University of Wisconsin-Eau Claire
Address correspondence and reprint requests to Wolfram Schummer, MD, DEAA, EDIC, Department of Anesthesiology and Intensive Care Medicine, Friedrich Schiller-University of Jena, Erlanger Allee 103, 07747 Jena, Germany. Address e-mail to cwsm.schummer{at}gmx.de
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Abstract
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The anterior jugular venous system, with its interconnections to the subclavian and deep jugular veins, provides a collateral venous network across the midline of the neck area, which is especially important in unilateral occlusion of an innominate vein. We illustrate the variability of this system and its clinical impact on catheterization by three cases of landmark-guided central venous cannulation. Case 1: Cannulation of the left internal jugular vein with a central venous catheter and of the left innominate vein (LIV) with a pulmonary artery catheter resulted in correctly positioned catheter tips. However, these catheters were actually not placed in the innominate vein but coursed through the jugular venous arch. Case 2: Cannulation of the left subclavian vein was complicated by resistance of guidewire advancement at 13 cm. Occlusion of the LIV and enlargement of the jugular venous arch were present. Case 3: Insertion of a pulmonary artery catheter and a central venous catheter through the LIV. The pulmonary artery catheter was correctly placed. The tip of the central venous catheter was mistakenly positioned in the left anterior jugular vein. We describe the normal anatomy of the anterior jugular venous system and its role as a major collateral. Correct placement of central venous catheters may be possible via the anterior jugular venous system. Conversely, central venous catheters malpositioned in the anterior jugular vein can increase the risk for complications and should be removed.
IMPLICATIONS: The anterior jugular venous system provides an important collateral venous network with the subclavian and deep jugular veins, especially in unilateral occlusion of an innominate vein. In such cases, central venous catheters may be correctly placed via the anterior jugular venous system. However, central venous catheters malpositioned in the anterior jugular vein can increase the risk for complications and should be removed.
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Introduction
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Central venous catheters (CVC) are inserted into the veins of patients on a routine basis. The most common routes of insertion include the internal jugular, external jugular, subclavian, basilic, and femoral veins via a percutaneous approach (1).The optimal location of a CVC is within the long axis of the superior vena cava (SVC) outside the right atrium (2). Ultrasound-guided technique offers both safety and convenience in inserting catheters into the internal jugular vein (IJV). Correct CVC positioning can be assisted by means of chest radiography (CXR), intravascular electrocardiogram (ECG), and transesophageal echocardiography (TEE) (3–5). Radiography is also helpful in diagnosing complications such as pneumothorax or hematothorax. Incorrectly positioned CVC, whether in a vessel other than the SVC or impinging the wall of the SVC, may cause serious complications (6,7). With this case series, we remind the readers of the importance of the anterior jugular venous system (AJVS), which is part of a venous collateral network that at times may provide an alternative route for cannulation but may also be a possible route for malpositioned CVC.
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Case Reports
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Case 1
A 79-yr-old woman with an continuing myocardial infarction was scheduled for emergency coronary revascularization. After the induction of general anesthesia, right IJV (RIJV) cannulation by landmarks was attempted but failed. Subsequently, landmarks were used to insert a triple-lumen catheter (7F; 30 cm; Certofix® Trio SB 730, B. Braun Melsungen AG, Melsungen, Germany) into the left IJV at a midcervical level and an introducer sheath into the innominate vein at the base of the neck (8.5F, Percutaneous Sheath Introducer Set, REF Product No SI-09875-E, Arrow Deutschland, Erding, Germany). The Seldinger technique was used in both cannulations. With this approach, no problems were obvious during cannulation. The catheter tip of the CVC was positioned by ECG guidance with the correct position confirmed by obtaining an increase in P-wave size. The guidewire served as an exploring electrode. During TEE, the CVC could be visualized in the distal SVC. A pulmonary artery catheter (PAC) (7.5F; Swan-Ganz CCOmbo V CCO/SvO2/CEDV REF 774 HF 75, Edwards Lifesciences, Germany) was inserted through the sheath introducer into the pulmonary artery without any problems. During sternotomy a vein cranial and superficial to the innominate vein was injured. Surprisingly, this vein had been cannulated by the CVC and the PAC (Fig. 1). The vessel could not be sutured because of the strain exerted by the PAC and introducer sheath in situ. It was decided to remove and replace the PAC and introducer sheath; the triple-lumen catheter remained, serving as a guide. Before the cannulation of the RIJV was attempted again, information regarding location and patency was obtained by Doppler ultrasonography. This time cannulation of the RIJV with a triple-lumen catheter and the right innominate vein (RIV) with the introducer sheath was successful (Fig. 2).
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Figure 1. Case 1: Open chest via median sternotomy. The chest is retracted to the left side using chest wall retractor. Forceps point in cranial direction towards the left innominate vein (LIV). Central venous catheter (CVC) and pulmonary artery catheter (PAC) are visible in the injured vessel, or the jugular venous arch (JVA). The caudal course of the JVA might be caused by an enlarged thyroid gland.
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Figure 2. Case 1: Anterior-posterior chest radiograph (CXR) taken after surgery. A left-sided central venous catheter (CVC) runs via the jugular venous arch (JVA) into the superior vena cava (black arrow heads). Note that its course is similar to the normal course via a left innominate vein (LIV). A second CVC is inserted through the right internal jugular vein (RIJV). The pulmonary artery catheter (PAC) had been repositioned into the right innominate vein (RIV). Note that on this chest radiograph (CXR) the left-sided CVC seems to take the same route as the LIV.
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Case 2
In a 56-yr-old woman with retroperitoneal abscesses caused by necrotizing pancreatitis, multiple CVC had been placed during the course of 7 wk. Among these was a triple-lumen CVC inserted via the left IJV for 3 wk, with the catheter tip placed in the confluence of the innominate veins. Next, a CVC was inserted via the RIJV. Because of a local infection, the latter was replaced by a CVC in the left femoral vein. Three days later, the patient was scheduled for abscess drainage. After the induction of general anesthesia, another attempt was made to place a CVC from the left side. The left subclavian vein was cannulated, but the J-wire met resistance at about 7 cm distally from the tip of the cannula. The cannula was replaced by an indwelling flexible IV cannula (6 cm). After placement of a triple-lumen catheter and a percutaneous introducer sheath (8.5F, Percutaneous Sheath Introducer Set REF, Product No SI-09875-E, Arrow) via the RIJV (all CVC: Certofix® Trio SB 730, B. Braun), contrast material was injected through the cannula in the left subclavian vein. On the CXR, a collateral vessel (the jugular venous arch) could be seen (Fig. 3).
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Figure 3. Case 2: Central venous catheter (CVC) in left subclavian vein met resistance at 7 cm distally from the cannula. The steel cannula was replaced by an indwelling flexible IV cannula. After placement of a CVC and introducer sheath through the right internal jugular vein (RIJV), contrast material was injected through the indwelling cannula in the left subclavian vein. Only an enlarged venous jugular arch (black arrows) is visible, and the left IJV and left innominate vein (LIV) are occluded.
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Case 3
A 49-yr-old man suffered from subarachnoid hemorrhage. The aneurysm was localized by angiography and occluded by endovascular coiling. For management of cardiovascular and respiratory problems, a PAC was inserted at the confluence of the left subclavian vein and IJV through the innominate vein without difficulties (Swan-Ganz CCOmbo V CCO/SvO2/CEDV REF 774 HF 75, Edwards Lifesciences). At the same site, a CVC was placed (Certofix® Mono, B. Braun) by the Seldinger technique. During insertion of the guidewire, no resistance was encountered, but advancement of the catheter differed slightly from the norm. A decision was made to inject contrast material through the CVC that had been inserted 18 cm. The left IJV, external jugular vein (EJV), and the single-lumen catheter with its tip in the anterior jugular vein (AJV) were displayed on the radiograph (Fig. 4).
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Figure 4. Case 3: A pulmonary artery catheter (PAC) and a central venous catheter (CVC) were inserted at the confluence of the left subclavian and left internal jugular vein (IJV) through the left innominate vein (LIV) without difficulties. The chest radiograph (CXR) shows the left IJV and left external jugular vein (EJV) filled with contrast material and a single-lumen catheter running from the jugular-subclavian confluence up into the anterior jugular vein (AJV). The PAC is correctly placed. The left IJV and left EJV are illustrated by contrast material injected through the CVC placed in the AJV, indicating anastomotic connections between the AJV, IJV, and EJV.
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Discussion
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There is considerable variation in the venous anatomy of the neck between the right and left sides, as well as between individuals (8). The venous drainage of the head and neck is mainly provided by a paired triple jugular system (Figs. 5 and 6). It is composed of both deep and superficial vessels, with the deep IJV being the dominant one because it drains the brain (9). The superficial system includes the EJV and AJV. The EJV usually begin below the ear from the retromandibular and the posterior auricular tributaries and extend along the lateral aspect of the sternocleidomastoid muscle (10). There are some anastomoses with the deep venous system; the most common one is located near the level of the superior thoracic aperture. Here the EJV drains into the jugulo-subclavian confluence (in 60% of patients), the subclavian vein (in 36%), or directly into the IJV (in 4%) (9).
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Figure 5. Gadolinium-enhanced magnetic resonance angiography showing venous neck and thoracic anatomy of a 36-yr-old woman. Contrast medium was injected through the left antecubital vein. LAJV = left anterior jugular vein; LIJV/RIJV = left/right internal jugular vein; LEJV = left external jugular vein; LIV/RIV = left/right innominate vein; SVC = superior vena cava; and LSV = left subclavian vein.
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Figure 6. Schematic diagram of a typical jugular venous system in the neck, showing the triple pairs with anastomoses between the right and left sides. AJV = anterior jugular vein; JVA = jugular venous arch; SV = subclavian vein; SVC = superior vena cava; EJV = external jugular vein; IJV = internal jugular vein; L = left. superior thyroid vein, ; middle thyroid vein, inferior thyroid plexus, facial vein, retromandibular vein, posterior auricular vein, transverse cervical vein, and suprascapular vein.
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The AJV usually begins in the suprahyoid region through the confluence of several superficial veins. It has variable communications with the retromandibular or the facial vein and the IJV and descends between the median line and the anterior border of the sternocleidomastoid muscle. Near the thoracic level of the neck, the AJV passes beneath that muscle to open into the subclavian vein (in 54% of patients) or into the termination of the EJV (in 46%) (9,10). The AJV varies considerably in size, usually in an inverse proportion to the EJV (10). Most frequently, there are two AJV (right and left), but sometimes there is a single, often median localized AJV. Just above the sternum the two AJV communicate by a transverse trunk, the jugular venous arch (JVA), which traverses the midline of the neck between the superficial and the pretracheal layer of the cervical fascia. The JVA is sometimes also referred to as the anterior jugular arch (11). It is one of the vessels encountered in a low tracheostomy (12).
The IJV have rich anastomotic channels over the thyroid gland through the superior and middle thyroid veins (13). The inferior thyroid veins often confluence and terminate unpaired in the left innominate vein (LIV) providing an anastomotic channel between the thyroid venous plexus between both innominate veins. Small branches of the inferior thyroid veins sometimes drain into the JVA (10).
In unilateral occlusion of an innominate vein, one of these anastomotic channels over the anterior neck area is used as a collateral pathway to the opposite side (13). Enlargement and tortuosity of collateral vessels (e.g., JVA) are signs of associated venous obstruction (14).
CVC malpositioning into the AJVS usually occurs when the catheter enters the horizontal component of the AJVS, the JVA, by the EJV, which is the most common origin of the horizontal aspect of the AJVS (Fig. 6) (11).
The great variability of the AJVS and its clinical implications are illustrated by our three cases. In Case 1 (PAC via LIV and CVC via left IJV in JVA), it is striking that both catheters were placed in the JVA, and no unusual resistance was met during insertion. As described above, the JVA is a connecting vein between the AJV that frequently drains into the subclavian or EJV. Under typical anatomical conditions, it is impossible to correctly place a CVC by the pathway of the JVA. Therefore, we assume that in this patient, the anatomical variation is a JVA terminating in the RIV, allowing proper positioning of CVC and PAC. The most likely explanation is an obstruction of the LIV combined with a caudal course of the JVA, which probably arises from the confluence of the left sub-clavian and left IJV. Unfortunately, we do not have the radiological evidence to verify this. Ultrasound-guided cannulation procedures will allow the clinician to distinguish the AJV from the IJV. The addition of Doppler wave form analysis to the ultrasound examination virtually excludes the possibility of a more central venous occlusion or stenosis more than 80% if the wave pattern is normal (15). But even the combination of these two techniques does not identify the confluence of the vessels or predict the termination of the AJV. As a consequence, CVC tip positioning will be unpredictable.
In Case 2, the LIV was obstructed after 3 wk of CVC placement via the left IJV. Apparently, the AJVS had developed as a major collateral pathway (Fig. 3). In Case 3, the PAC had been placed correctly via the pathway of the LIV. However, the CVC was malpositioned in the AJV (see the horizontal and vertical aspects of the AJVS in Fig. 4). Placement of a catheter tip in vessels of small diameter increases the risk of catheter wedging, endothelial injury, thrombus formation, and vascular stenosis or perforation with extravasation of the infusate. Such positioning should be avoided, particularly when the catheter is used for infusion of hypertonic or hyperosmolar solutions that require vessels with larger blood flow for rapid dilution (16,17).
There are two take-home messages from these case reports on CVC placed in the AJVS. The AJVS, with its interconnections to the subclavian and deep jugular veins, provides an important collateral venous network across the neck, especially in unilateral occlusion of an innominate vein. Thus, correct placement of CVC via the AJVS may be possible. Conversely, CVC malpositioned in the AJV increase the risk for complications and should be removed.
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Acknowledgments
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The authors thank Jens Geiling for providing the illustration of the AJVS.
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Accepted for publication June 17, 2004.
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Abstract
Introduction
