Obstacles to ultrasound-guided internal jugular vein central venous catheter insertion.

To the editor, Central venous catheter (CVC) insertion is commonly performed under real-time echo guidance, and its advantages include fewer complications, such as arterial puncture, hematoma, hemothorax, and pneumothorax, as well as fewer punctures.[1] We present here a case that required careful attention when inserting a CVC through the right internal jugular vein (IJV) due to an obstacle located directly above the puncture site. Written informed consent was obtained from the patient for publication. A 66-year-old female patient was scheduled to have a CVC inserted into the right IJV after induction of general anesthesia. Preoperative computed tomography (CT) showed a calcified lesion in the neck that compressed the right IJV, indicating that it would be difficult to puncture the IJV [Figure 1].Figure 1: Preoperative CTAfter induction of general anesthesia, tracheal intubation was performed, and a linear echocardiography probe of the right IJV revealed a varicose vein with an acoustic shadow on the ventral side of the right IJV [Figure 2]. A sweep scan with the echo probe revealed that the IJV on the cephalocaudal side of the calcified lesion was not collapsed, and a CVC could be inserted by advancing the needle from the cephalic side of the IJV to avoid the calcified lesion using the out-of-plane technique.Figure 2: Intraoperative ultrasonography imageThis case points out the importance of real-time echo-guided CVC insertion. It was difficult to confirm the lumen of the IJV with preoperative CT alone due to the calcified lesion. However, with the use of real-time echo guidance, it was confirmed that the lumen of the IJV was preserved, although the calcified lesion was located directly above the vein. In real-time echo-guided IJV catheter insertion, it is important to understand the possible abnormalities of the vein to be punctured and its accompanying artery,[2] as well as its three-dimensional positional relationship with surrounding structures. In the present case, preoperative CT revealed an abnormal structure, which is one of the representative factors where real-time echo guidance makes it possible to safely insert the CVC. Declaration of patient consent Written consent for the presentation of this case was obtained from the patient. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.