The internal jugular vein (IJV) and vertebral artery (VA) lie in close proximity in infants and children.1 Because of the small size of the vessels, the proximity of the VA to the IJV, and the morbidity associated with cannulating the VA, it is important to identify the location of the VA before attempting IJV cannulation. An accidental VA puncture behind the IJV under ultrasound-guided IJV cannulation has been reported in a 1-year-old infant.2 Their anatomic relationship to each other may be clearer if in-plane sonographic images of the VA are obtained along with in-plane images of the IJV. Sonography of the VA provides diagnostic information about its origin and course.3
We describe 4 pediatric patients who underwent ultrasound imaging of neck vessels under general anesthesia before cardiac surgery between December 2012 and February 2013. Two of these cases are normal scenarios in infants and children, whereas 2 cases illustrate abnormalities that were better diagnosed using in-plane and out-of-plane ultrasound images.
The general procedure for IJV cannulation was as follows: First, after induction of anesthesia and tracheal intubation, ultrasonography of the neck was performed. A small rolled towel was placed under the patients’ shoulders as they lay in a supine position with their necks extended to the maximum extent and their heads rotated 15° to 30° away from the side to be cannulated. The pathways of the common carotid artery (CCA), IJV, and VA (out-of-plane) were located using a L10-5 MHz ultrasound probe (TiTAN®; FujiFilm SonoSite, Co., Tokyo, Japan), halfway between the clavicle near the IJV and the angle of the mandible, with the ultrasound probe perpendicular to all planes of the skin. The IJV was punctured with a 24-G catheter-over-needle device (Jelco® Plus, Smith Medical, Tokyo, Japan). A 0.018-inch guidewire (Arrow Japan, Tokyo, or SafeGuide®, Covidien Japan, Tokyo) was inserted through the outer catheter. All central venous catheter (CVC) insertions, 3 on the right and 1 on the left side, after guidewire insertion, were confirmed by chest radiography. In case 4, a complication occurred during CVC insertion.
Written informed consent was obtained from the patients’ parents for the publication of these cases.
A 10-day-old boy (height, 48.8 cm; weight, 2.9 kg) was scheduled for an arterial switch operation for type 1 transposition of the great arteries. The right VA was located 13.6-mm deep behind the right CCA by ultrasound (measured out-of-plane). The distance between the IJV and the VA was about 5.4 mm (Fig. 1A). Using in-plane ultrasound imaging and pulsatile color flow Doppler, we followed a vessel determined to be the VA, along 6 consecutive vertebrae. In this plane, it was located 3.1 to 5.1 mm from the IJV (Fig. 1, B–C).
A 7-year-old girl (height, 90.6 cm; weight, 10.3 kg) was scheduled for repair of tetralogy of Fallot. The right brachiocephalic artery was palpated and identified by ultrasound distal to the head of the sternum; it lay 6.3 mm under the skin (Fig. 2A). We detected the origin of the VA from the subclavian artery using an in-plane ultrasound image (Fig. 2B). The VA was located 4 mm from the proximal IJV (Fig. 2C). The IJV was successfully accessed under ultrasound guidance with a skin puncture 28 mm from the clavicle (Fig. 2C).
A 5-year-old girl (height, 106.4 cm; weight, 16.9 kg) was scheduled for repair of right pulmonary vein atresia. The VA was located 1.5 mm behind the 11-mm-wide IJV by ultrasound at a point 20 mm from the clavicle (Fig. 3A). The VA crossed behind the IJV (Fig. 3, A–D, I) and originated from the right CCA (Fig. 3,.E–H). The VA and IJV were imaged simultaneously with an in-plane ultrasound view (Fig. 3J). The IJV was successfully cannulated under ultrasound guidance with a skin puncture 49 mm from the clavicle. The VA was located 4.5 to 6.0 mm from the IJV at a distance of 30 to 35 mm from the clavicle, very close to the IJV puncture site (Fig. 3K).
A 1-month-old girl (height 50.5 cm; weight 3.4 kg) was scheduled for atrioventricular septal defect repair. The VA was behind the 3.4-mm-wide IJV, located by ultrasound. An in-plane ultrasound image of the IJV and VA was visible with color flow Doppler (Fig. 4A1). After puncture of the IJV and good blood return, we could not advance a 0.018-inch guidewire >5 cm into the IJV through the outer catheter. We ceased guidewire placement at the first puncture site. We compressed the puncture site for 2 minutes to achieve hemostasis. Two minutes after compression, we were unable to image the lumen of the IJV by in-plane or out-of-plane mid-neck ultrasound images (Fig. 4, A2, A3, B6, and C1). Decreased color flow Doppler signal in the proximal and distal portions of the IJV was observed several minutes after the observed narrowing of the IJV (Fig. 4A2). The skin was punctured 4 to 5 mm distal to the first puncture site. Blood flow was achieved; however, we could not place the guidewire beyond the clavicle despite use of fluoroscopy. We subsequently imaged and cannulated the left IJV uneventfully. The right IJV returned to normal after the operation (Fig 4A4).
For the first time in our department, we obtained in-plane ultrasound images of the pediatric VA, which lay almost parallel to the IJV in case 1. In-plane imaging of the VA can help in the identification of normally related structures as well as in the diagnosis of certain rare situations such as the anomalous origin and course of the right VA behind the IJV and IJV narrowing after attempted cannulation, as seen in cases 3 and 4.
Penetrating the IJV posterior wall during CVC insertion in children may sometimes be unavoidable.4 To increase the safety of IJV cannulation and avoid puncture of the VA when possible, the relationship of the VA to the IJV should first be identified by ultrasound and optimized by using in-plane as well as out-of-plane views. The course of the VA should be routinely followed from the subclavian artery to the fifth or sixth vertebra by using the out-of-plane approach.1 The transverse cervical artery is also occasionally observed near or just under the IJV in children5 and may be mistaken for the VA.6
We routinely use a 53-mm-wide ultrasound probe to obtain IJV images because of its higher resolution and easier handling than compared with a 30-mm-wide hockey-stick–type probe.7 However, to obtain an in-plane image of the IJV and guidewire, simultaneously with the VA, the short neck of a neonate requires adequate neck extension and rotation of the head away from the side of the puncture.
The right VA normally arises from the subclavian artery.8 In case 3, ultrasound imaging revealed that the right VA arose from the right CCA and passed just behind the IJV, presenting a significant hazard during placement of a CVC. With ultrasound guidance, we were able to avoid puncturing the VA by choosing an IJV puncture site that was distant from the VA.
In a previous study, the mean distance between the IJV and the VA in 55 pediatric cases was 4.6 mm.1 In case 3, the VA was located only 1.5 mm behind the IJV at a point 20 mm away from the clavicle (Fig. 3K). At a site 30 to 35 mm cephalad to the clavicle, where the puncture needle and guidewire penetrated the IJV without complications, the distance between the posterior wall of the IJV and the anterior wall of the VA was 4.5 to 6.0 mm.
In case 4, we speculate that narrowing of the IJV after attempted cannulation was due to vasospasm. In a former patient,9 we obtained only out-of-plane images of the vasospasm. In case 4, we obtained an in-plane image before the IJV puncture (Fig. 4A1). Subsequently, we obtained an in-plane color flow Doppler image of the narrowed IJV (Fig. 4A2) and a simultaneous in-plane image of both the narrowed IJV and the VA (Fig. 4A3). The IJV diameter gradually decreased and increased along its course, away from the puncture site (Fig. 4, B–C). We believe that the decrease in diameter was not caused by either hematoma or compression forces. No hematoma formation was observed; furthermore, minimal compression force was applied on the skin during ultrasound imaging. The muscles above the IJV, as seen in Figure 4A2, did not seem more deformed by the force exerted on the skin than the muscles seen in Figure 4A1. Similarly, we did not observe any compression force on the skin by the probe in Figure 4B6 compared with that in Figure 4B1.
In summary, to improve safety of IJV cannulation and detect anatomic anomalies and potential vasospasm, we recommend that in-plane as well as out-of-plane ultrasound images of the VA be routinely obtained and carefully analyzed to understand the relationship between the VA and the IJV in children. In our first 4 cases, in-plane ultrasound images of the IJV contributed substantially to the diagnosis of an anomalous origin of the right VA from the right CCA in one case and the IJV spasm in another. The benefits and challenges of obtaining in-plane ultrasound images of the VA in children should be investigated further. E
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