Central Venous Access Via External Jugular Vein

Central venous catheterization, or central line placement, was first described in 1929 by Werner Forssman, a surgical intern who catheterized his own heart through his cephalic vein. This bold procedure later earned him the 1956 Nobel Prize and has had a significant impact in the practice of and delivery of modern medicine to both stable and critical patients.

Central venous access has had a great impact on improving longevity and quality of life. Renal replacement therapy, percutaneous coronary interventions, total parenteral nutrition (TPN), and cancer chemotherapy are extreme examples of such advances.

As central vascular access becomes more common and increasingly recognized as a standard requirement in many treatment regimens, the difficulty of obtaining it also grows. Previous attempts at placement of central venous catheters can make further attempts difficult or even preclude its use in the same vascular territory. In addition, modern self-destructive behaviors, such as intravenous (IV) drug abuse, have developed a whole new disease state that has forced medical providers to adapt and take a more innovative approach to vascular access.

The indications for external jugular vein (EJV) central venous access are generally the same as those for all other routes. Although the list below is all-inclusive, not all of these indications are considered prudent or possible in each individual patient (eg, a dialysis catheter may be too large for the caliber of the vessel in some patients).

General indications include the following:

• TPN
• Long-term antibiotic treatment
• Hemodialysis ^[1]
• Hemoperfusion
• Hemodynamic monitoring
• Medication administration
• Implantable port catheters (alternative site) ^[2]
• Retrieval of inferior vena cava (IVC) filter (alternative site) ^[3]

Specific indications include the following:

• Conversion of an (already) indwelling peripheral IV catheter
• Critically ill patients in whom a serious immediate procedural complication may prove fatal ^[4]

Because this procedure is relatively devoid of immediate serious complications, it has very few contraindications. Most arise out of diminished neck mobility, which impairs the practitioner's ability to perform the procedure. ^[5] The presence of a tracheostomy tube has been listed as a contraindication for IJV cannulation because of the risk of catheter-related infections due to proximity; however, this does not appear to be worrisome with EJV cannulations. ^[6]

Absolute contraindications include the following:

• Overlying skin or soft-tissue infection
• External jugular thrombophlebitis
• Ipsilateral thrombosis of the EJV or the subclavian vein (SCV)

Relative contraindications include the following:

• Nonvisible or palpable EJV
• Known or suspected cervical spine injury
• Diminished neck mobility ( ankylosing spondylitis, cervical syndrome)
• Ipsilateral clavicle fracture
• Neck mass or other anatomic distortion
• Cervical hematoma
• Lemierre syndrome
• Venous anatomic variations ^[7]

Best practices

The following technical points should be kept in mind:

• Introducing the wire through a catheter, rather than a needle, may enhance success and is therefore recommended ^[8]
• The Valsalva maneuver is critical for improving success rates ^[9] ; the more distended (and thus visible and prominent) the vein is, the easier both initial cannulation and guide-wire insertion will be ^[4]
• The Trendelenburg position helps engorge the vein and thus facilitates catheterization
• A stethoscope may also be positioned above the clavicle to occlude the vein ^[9]
• If the wire will not pass the level of the clavicle, withdrawing it a few millimeters and rotating it 90-180° before reinsertion may help; some advocate passing the catheter over the wire at this point, with good rates of success in reaching the central circulation ^{[10, 11]}
• A head tilt to the opposite side and shoulder or arm manipulation may improve success rates ^{[12, 13]}
• Shrugging the shoulder towards the patients head, passively or actively, changes the acute angle at the EJV-SCV junction to a more suitable obtuse angle, allowing greater success at guide-wire and catheter passage ^[14]
• The use of ultrasonography (US) has shown potential benefit with respect to vein cannulation, gauging insertion depth, and preventing malplacement ^{[15, 16]}
• Intra-arterial electrocardiography (ECG) may diminish the malpositioning rate and improve the chances of achieving proper catheter depth on the first pass ^[17]

Procedural planning

The EJV is formed primarily by the confluence of the retromandibular and posterior auricular veins near the angle of the mandible (see the first image below). It remains superficial in the neck and is loosely fixed in the subcutaneous tissues, traversing the sternocleidomastoid (SCM) obliquely just deep to the platysma (see the second image below).

As the EJV nears the clavicle, just lateral to the insertion of the lateral head of the SCM, it pierces the deep fascia and receives other tributaries just prior to emptying into the SCV lateral to the termination of the IJV.

The EJV generally has two bicuspid valves, one at the junction with the SCV and the other approximately 4 cm upstream. ^{[18, 4]} In about 4% of patients, the terminal end is a venous plexus instead of a single channel. ^[4] If the vein is not visible, its route can be estimated by extending the line of the deltopectoral groove into the neck. ^[19]

Important anatomic considerations in relation to this procedure vary with each individual. The loosely adherent nature of this superficial vein can make the initial venipuncture difficult. Passage of a guide wire, stiff introducer, or catheter can be troublesome and even impossible at times. Postulated reasons include valves, venous plexus, anatomic variations, and the angulation inherent in its passage through the cervical fascia, as well as the perpendicular termination into the SCV. ^{[9, 4, 8, 12, 17, 7]}

Finally, the caliber of the EJV is thought to be inversely proportional to that of the IJV, which can impose a size limitation on the proposed intravascular implement in certain patients. ^[17]

Complication prevention

One of the greatest benefits of this procedure is the relative lack of serious immediate complications. Reported complications include the following:

• Hematoma formation
• Mild persistent oozing of blood from the puncture site
• Catheter impingement on its introducer, probably due to acute angles
• Vein-wall entrapment between wire and needle, most likely associated with the in-out wire maneuver frequently required for wire passage beyond the valves
• Catheter malfunction from kinking that can occur as a result of the circuitous route to the central circulation
• Catheter malposition ^[20]
• Air embolism ^[21]

Delayed complications tend to mirror those of other access sites, which include infection, thrombosis, and catheter malfunction.

In deciding on a site for vascular access, many things must be considered. Of primary concern is minimizing risks while maximizing patient benefit and comfort. The choice of route depends on patient historical and demographic factors, the plan of care, the device to be used, the provider's experience, and the known success and complications rates of the desired technique.

The IJV, the SCV, and the femoral vein are the typical sites for central line placement; each site has its own risks and benefits. Another viable option for access is through the EJV. Use of the EJV for central venous access has been akin to the swing of a pendulum. Although this approach is not considered a universal favorite, it has certainly gained a following and has proved safe and reliable in appropriately selected populations, including pediatrics. ^{[22, 11]}

Anatomic factors and variability may lead to difficult or even failed catheterization. Numerous individuals do not have a palpable or visible EJV. Also, the presence of an acute angle between the EJV and the SCV, the presence of valves, and constriction of the EJV as it penetrates the fascial layers can contribute to a difficult catheterization. Because the EJV is superficial to the IJV and the carotid artery, it is important to make sure that the skin is entered at a shallow angle (~10-25°).

To prevent pain and movement, anesthetic should be subcutaneously infiltrated at the anticipated site of catheter and suture placement. This can be done after initial venipuncture if the wire-through-catheter method is used.

In a prospective observational human study, Kato et al found that computed tomography (CT) venography was useful for preoperative anatomic estimation of the cervical venous plexus. ^[23] They suggested that the EJV approach with CT venographic guidance is worth considering as the initial method when central venous cannulation must be performed under less than optimal conditions.

Despite an impressive safety profile, EJV cannulation has a lower likelihood of success and a higher malposition rate. ^[9]  US-guided puncture may be superior to blind manual puncture. ^[16]  After three unsuccessful attempts, another site should be considered. In those cases with successful wire passage, point-of-care US (POCUS) imaging of the supraclavicular fossa should be considered to prevent misplacement. ^[15]

In 1974, Blitt described the technique with the use of a J-tip wire guide, citing a success rate of 96% and a 0% complication rate. ^[8] In subsequent studies, technical success rates ranged from 73% to 88%. ^[24] Advantages to using the EJV for central venous access include its superficial position and its distance from vital structures, which decrease the risk of major complications such as pneumothorax.

Ju et al, in a retrospective analysis of the feasibility and safety of EJV cannulation in 9062 surgical patients (9482 cases), found that the only complication related to EJV cannulation was swelling at the insertion site (0.7% of cases); however, this study included only 66 central venous catheter insertions. ^[25]