2. Objective
• Overview of the anatomical variations,
morphometrics based on various imaging
modalities, and the clinical anatomy of IJV
cannulation.
• Additionally, the anatomical basis of
complications, techniques to avoid
complications, and cannulation in special
instances .
3. • The internal jugular vein (IJV) is a paired vessel found
within the carotid sheath on either side of the neck.
• The internal jugular vein receives eight tributaries
(Inferior petrosal sinus, vein of cochlear duct, meningeal
veins, pharyngeal venous plexus, lingual vein, common
facial vein, sternocleidomastoid vein, superior and
middle thyroid vein) along its course.
• Drains into brachiocephalic vein
• Its function is to drain the venous blood from the
majority of the skull, brain,and superficial structures of
the head and neck.
5. Relevant Anatomy for Internal Jugular
Vein Cannulation
• The anterior cervical triangle is bordered by the clavicle
inferiorly and by the sternal and clavicular heads of the
sternocleidomastoid muscle medially and laterally.
• The carotid artery is usually palpated near the lateral side
of the sternal head of the sternocleidomastoid, and the
internal jugular vein usually lies superficial and lateral
(often minimally lateral) to the carotid artery.
• The right internal jugular vein is usually preferred over
the left for cannulation because it has a larger diameter
and affords a straighter path to the superior vena cava
6. ANATOMICAL VARIATIONS
• Embryologically, the IJV develops from the right
and left cardinal veins at eight weeks of gestation
• Developmental abnormalities may result in a
variety of anatomical variations, which range
from
Complete agenesis
Bifurcation
Duplication
Fenestration
Trifurcation
8. • Three approaches are used for IJV cannulation: central,
anterior, and posterior .
• The location of the carotid artery is felt by palpation in the
space between the trachea and SCM, and then the IJV is
found lateral to the carotid pulse
• Most commonly, the central approach to the internal
jugular vein is used, which may decrease the chance of
pleural or carotid arterial puncture.
• The central/ middle approach utilizes Sedillot’s triangle,
which is a triangle formed by the sternal and clavicular
heads of the SCM, and the needle is inserted at the apex of
the triangle
9. • In the anterior approach, the needle is
inserted along the medial border of SCM, 2-3
finger breadths superior to the clavicle. This
approach accesses the IJV at a slightly higher
level than the low approach in central
approach;
• In the posterior approach, the needle is
inserted along the lateral border of the SCM,
halfway between the mastoid process and the
clavicle
11. COMMON APPROACHES AND
LANDMARKS
INTERNAL JUGULAR
POSITION NEEDLE INSERTION ANGLE OF NEEDLE
ANTERIOR -Trendelenburg
-Head turned to
opposite side
Anterior border of
SCM midway
between angle of
mandible & clavicle
Advance needle
towards medial
aspect of ipsilateral
nipple at 30-45˚
MIDDLE -Trendelenburg
-Head turned to
opposite side
Apex of the triangle
formed by the two
heads of SCM
Advance needle
towards ipsilateral
nipple at 30-45˚
POSTERIOR -Trendelenburg
-Head turned to
opposite side
1cm above the point
where external
jugular vein crosses
lateral edge of SCM
Advance needle
towards sternal notch
at 30˚
12. • Ultrasound-guided cannulation of the internal
jugular vein is the real-time procedure to guide
venipuncture and a guidewire (Seldinger technique)
to thread a central venous catheter through the
internal jugular vein and into the superior vena cava.
• An internal jugular central venous catheter (CVC) or
a peripherally inserted central catheter (PICC) is
usually preferred to a subclavian CVC (which has a
higher risk of bleeding and pneumothorax) or a
femoral CVC (which has a higher risk of infection).
13. • Seldinger technique: Needle puncture with subsequent guidewire
introduction into vessel through needle;
• Needle exchanged for sheath/catheter over wire
– Jugular vein access:
• Most frequent access site for procedures and catheter placements
• □ Internal jugular (IJ) typically preferable to external jugular
• □ External jugular often enlarged in cases of IJV occlusion
• □ Right is preferable to left
• □ Shortest distance to central veins for catheter placement
• □ Most direct path to superior vena cava (SVC), right heart, and
pulmonary vasculature
• □ Direct path to inferior vena cava (IVC)
• □ Anatomically most suitable route for hepatic vein
16. Positioning for Internal Jugular Vein
Cannulation
• Raise the bed to a comfortable height for you (i.e, so
you may stand straight while doing the procedure).
• Place the patient supine and in Trendelenburg position
(bed tilted head down 15 to 20°) to distend the internal
jugular vein and prevent air embolism.
• Turn the patient's head only slightly (or not at all) to
the contralateral side to expose the internal jugular
vein but not cause overlap with the carotid artery.
• Stand at the head of the bed.
19. • Equipment list
• ○– 5- to 8-MHz US probe, cover, gel
• ○ Elements for maximum sterile barrier technique
• – Sterile gown and gloves, cap, mask, eyewear
• ○ Preparatory solution for cutaneous antisepsis
• ○ Sterile barrier drape
• ○ Microaccess set
• – 21-g access needle (long for transhepatic and translumbar technique)
• – 0.018" microwire
• – Microaccess dilator/sheath combination
• 0.035" guidewires and short angled catheter may be required if there is stenosis
or tortuous target vein
• anatomy
• ○ Scalpel: #11 blade
• ○ Dilators
• ○ Sheath
20. ○ US guidance
• – Allows real-time visualization of vein, artery, and
• needle
• □ Highest rate of successful access
• □ Decreased risk of access site complications
• □ Decreased risk of artery puncture
• – Scan to identify target vein and adjacent arterial
• Structures(Diameter ,cross sectional area ,any anatomical
variations)
• □ Pressure with transducer should easily compresses vein
• □ Artery is less compressible, pulsatile
21. Axial US with needle lateral to target vein (image
perpendicular to target vein)
• □ Vein seen in cross section, possibly off to one
side
• □ Needle inserted parallel to transducer and
remains in plane of scan
• □ Needle enters from side of screen and seen in
• entire length
• □ Needle indents side of vein during access
• □ Can be challenging to determine needle depth
22.
23. Axial US with needle over target vein (image
perpendicular to target vein)
• □ Vein seen in cross section in middle of screen
• □ Needle inserted directly over target vein, in
parallel
• with target vein, accessing skin at midpoint of
transducer
• □ Needle angled to plane of scan and only
segmentally visualized
• □ Needle indents top of vein during access
• □ Can be challenging to advance wire down
vessel lumen
24.
25. Longitudinal US with needle over target vein
(image parallel to target vein)
• □ Transducer parallel over target vein
• □ Needle inserted parallel to transducer and
remains in plane of scan
• □ Needle enters from side of screen and seen in
• entire length
• □ Needle inserted directly over target vein
• □ Needle indents top of vein during access
• □ Can be challenging to track needle and vessel
simultaneously
26.
27. IJV access
• ○ Identify IJV
• ○ Determine "low" or "high" access
• – Low access
• □ Preferred for tunneled catheters, port catheters
• □ Access from side (laterally) allows gentle
curvature of tunneled catheters and ports
• □ Place transducer just above clavicle transverse
and slightly lateral relative to vein
28. • High access
• □ Preferable for nontunneled catheters and
most interventions
• □ Access from top (anteriorly) generally
easiest
• □ Place transducer superior to clavicle, axial
over to target
29. Venous Puncture Technique
• Administer local anesthetic to skin over target vein– Adequate
cutaneous wheal allows elevation of skin from vein in thin patients for
safe skin incision
• – Caution
• □ Choose needle trajectory away from artery; prevents inadvertent
arterial puncture
• □ Do not aim needle steep inferiorly; reduces risk of pneumothorax
• – After tenting wall, advance needle meaningfully and rapidly with
"pop" until wall releases, needle enters vein lumen
• – Visualize needle tip within lumen
• ○ Confirm blood return at needle hub
• – If no spontaneous return, may try aspiration
• – If no aspiration, inject saline to clear needle and then aspirate again
• – Venous blood dark red; arterial blood bright red
30. • ○ Introduce 0.018" guidewire through needle
• – Should not encounter resistance to wire passage
• □ Consider removing wire and aspirating blood to
confirm location within vessel
• □ Consider changing microwire (e.g., gold-tipped
Nitrex, Covidien)
• □ Caution: If resistance met pulling wire back, stop
and remove needle and wire as unit; prevents shearing
portion of wire with sharp needle bevel
31. Fluoroscopically monitor guidewire
insertion
• – Advance into SVC near cavoatrial junction
• – Wire must stay to right of midline; wire left of midline
may indicate arterial placement, persistent left SVC,
extraluminal location
• – If wire will not advance centrally, consider possible
central venous tortuosity or occlusion
• □ Venography may be performed via access
needle/microaccess sheath to assess IJ/central venous
patency
• □ If IJV occluded inferiorly, consider external jugular access
• □ If central veins occluded, consider alternate access sites
32. • Remove needle, introduce transitional dilator (microaccess sheath) over
0.018" guidewire
• Remove inner dilator and microwire from sheath
• – Caution: Do not leave needles/sheaths/catheters open to air; occlude
with thumb/digit, clamp, stopcock, or wire to prevent air embolism
• ○ Introduce 0.035" guidewire, advance into SVC, further Advance into IVC
for stability
• – Monitor guidewire passage fluoroscopically
• – Guidewire in atrium may cause cardiac arrhythmia;
• retract/reposition guidewire if cardiac arrhythmia induced
• – Caution: Do not advance dilator past end of guidewire; may result in
life-threatening vascular injury, mediastinal hemorrhage, pericardial
tamponade
• ○ Introduce appropriate sheath/catheter over wire under fluoroscopy
• – Gentle traction to wire will improve trackability of catheter/sheath
• – Align sheath or catheter with venous axis to avoid wire
• kinking
33. COMPLICATION
Early
Arterial puncture- 10%
Pneumothorax- 1-3%
Bleeding
Cardiac arrhythmias
Injury to the thoracic duct
Injury to surrounding
nerves
Air embolism - 0.1%
Catheter embolus
• Late
– Venous thrombosis
– Cardiac perforation
and tamponade
– Infection
– Hydrothorax
34. Management of Complications
• Arterial puncture
• ○ Remain calm
• ○ Do not withdraw access needle/sheath/catheter until considering
options
• ○ Treatment dependent on diameter of access device and location of
access
• ○ Potential treatment
• – Needle: Consider removal with digital pressure untilhemostasis
• – Dilator/sheath: Consider emergent conversation with vascular surgery
prior to withdraw of access device
• □ Surgical repair may be necessary/preferable
• □ Arteriography with occlusion of inadvertent accesswith balloon or
covered stent may be necessary/preferable
• – Carotid: Consider CTA neck
35. Pneumothorax
• ○ Evaluate size of pneumothorax
• – Fluoroscopically during procedure
• – AP upright chest expiratory/inspiratory radiographs
• immediately post procedure if needed
• – CT thorax as needed
• ○ Stable small pneumothorax can be managed
conservatively
• ○ Moderate or increasing pneumothorax of any size;
• consider small bore chest tube placement
• – Attach to water seal, Heimlich valve, wall suction (-20
mm Hg)
36. Air embolism
• ○ Turn patient left decubitus (left side down) or
partial left decubitus (Durant maneuver) position
and allow bed rest for 2 hours or
• until stable Institute high-flow oxygen
• In decompensating patients, air embolus can be
aspirated via catheter
• ○ Cardiopulmonary resuscitation may be required
with massive venous air embolism
37. Take home message
• A detailed understanding of the neck anatomy
surrounding the IJV, complications associated
with IJV cannulation, and the best approach and
imaging modality aid in successful cannulation.
• While cannulation can be done by the landmark
technique or the USG-guided technique, it is
important to be comfortable utilizing the
landmark technique in cases when USG is not
available
38. References
•Alderson P, Burrows F, Stemp L, Holtby H. Use of ultrasound to
evaluate internal jugular vein anatomy and to facilitate central
venous cannulation in paediatric patients. Br J Anaesth.
1993;70(2):145-8.
•Wible interventional Radiology
•Anatomical review of internal jugular vein cannulation
PMID: 36794685 DOI: 10.5603/FM.a2023.0008 ,Natalie Kosnik1, Taylor
Kowalski 1, Lorraine Lorenz1, Mer
cedes Valacer 1, Sumathilatha Sakthi-Velavan 2023 Feb 16.
42. EQUIPMENTS
• Tilting table
• Sterile pack and antiseptic solution
• Local anaesthetic
• Appropriate CV catheter for age/route/purpose
• Syringes and needles
• Saline
• Suture material
• Sterile dressing
• Facility for chest X-ray if available
43.
44. INTERNAL JUGULAR VEIN
CANNULATION
• Most commonly chosen;
Consistent and predictable anatomic
location,
Palpable surface landmarks,
Short, straight and valveless course to
SVC and right atrium.
45. • TURN THE HEAD
SLIGHTLY TO LEFT (
20-30 degrees)
• GENTLY PALPATE THE
CAROTID ARTERY
46. • Infiltrate the skin at the
level of cricoid with local
anaesthetic
• 25 g locator needle at 30
degree angle to skin in
sagittal plane
• At the medial border of
lateral head of
sternomastoid pointing
towards the ipsilateral
nipple
47. • Negative pressure to
be maintained in
syringe
• IJV is encountered at a
depth of 2-4 cm
• Blood splash may not
occur until the needle
is withdrawn
48. • Once IJV is located,
18G needle is placed
immediately adjacent
to locator needle
• Continuous aspiration
technique employed
49. • Once position
confirmed a guide-
wire is placed through
it ;not more than 18
cms
• Monitor pulse & ECG
tracing
Remove the needle
over guide-wire
50. • A dilator is introduced
and removed
• Catheter is threaded
over the guide-wire to a
depth of 12-15 cms
• Monitor pulse & ECG
tracing
• Guide-wire is
withdrawn
51. • Aspirate blood from catheter
• Attach a three-way connector & tubing
• Suture in place and apply sterile dressing
• Get x-ray chest to rule out pneumothorax
and to localize tip of catheter.
52. SUBCLAVIAN VEIN CANNULATION
• Infra-clavicular and supra-clavicular approach,
• Position – head down with head turned towards
contralateral side ; rolled up sheet between
shoulder blades longitudinally ; arms by side
assistant giving traction to arm of same side,
53. COMMON APPROACHES AND LANDMARKS
SUBCLAVIAN
POSITION NEEDLE INSERTION ANGLE OF NEEDLE
INFRACLAVICULAR -Trendelenburg
-Head turned to
opposite side
-Ipsilateral arm
adducted
2 cm inferior to
midportion of the
clavicle, ”walk” down
clavicle and advance
just deep to the
clavicle
Advance the needle
under the clavicle
towards the sternal
notch
SUPRACLAVICULAR -Trendelenburg
-Head turned to
opposite side
-Ipsilateral arm
adducted
Just above the
clavicle , lateral to the
clavicular head of the
SCM
Advance the needle
at a 45˚ angle, just
under the clavicle
towards the
contralateral nipple
55. STEPS
– Local infiltration 1-2
cms below inferior
border of clavicle in
midclavicular line,
– 18 G needle inserted at
infiltrated site 2 cm
inferior to midportion of
the clavicle, ”walk” down
clavicle and advance just
deep to the clavicle
56. • Advance the needle
under the clavicle
towards the sternal
notch
• Needle is kept
horizontal at all times
(10 degree upward
bend on needle adjacent
to hub maybe applied)
• Continuous aspiration
technique applied
62. • Advantages of USG guided CVP
cannultion
Easy identification of any variation in anatomy
Direct visualization of important structures
Decreases the rate of complications.
Ensures faster placement of central catheters
63.
64. CVP MEASURMENT
• Indirect calculation of CVP
through physical
examination of the neck
veins is a fundamental
aspect of cardiovascular
assessment, but the bedside
diagnosis of low, normal, or
high CVP is often
inaccurate, particularly in
critically ill patients.
65. PROCEDURE FOR CVP MEASUREMENT IS
ZERO MANOMETER AT THE LEVEL
OF RT. ATRIUM
[level of the 4th intercostal space
in the mid-axillary line while the
patient is lying supine]
FILL MANOMETER WITH SALINE
USING A THREE WAY TAP
66. • CLOSE OFF TAP FROM
SOLUTION BAG
• OPEN TAP TO PATIENT
• OBSERVE FALLING FLUID IN
MANOMETER
• RECORD MEAN LEVEL
67. PERIPHERALLY INSERTED CENTRAL CATHETER
• Originally used by cardiologists,
adapted for intensivist usage.
• Inserted via basilic or cephalic
veins in the ante-cubital fossa
• The catheter is advanced upto the
central veins
• Conflicting studies regarding
superiority as compared to
centrally inserted catheters
68. ADVANTAGES AND DISADVANTAGES OF PERIPHERALLY INSERTED
CENTRL CATHETERS
• ADVANTAGES
– Easy placement
– Faster
– Long lasting
– Low infection
– Ambulatory
– Low cost
– Low complications
• DISADVANTAGES
– CVP monitoring
inadequate
– Inadequate for rapid
bolus injections
– Inadequate for
resuscitation
