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).

External jugular venous anatomy.

Anatomy of major vessels in neck.

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]  

The equipment needed for central venous cannulation via the external jugular vein (EJV) is widely available as a prepackaged kit (see the image below).

Central venous access kit.

The basic materials include the following:

• Povidone-iodine or chlorhexidine solutions to swab and prepare the venipuncture site
• Sterile drapes and towels
• Sterile gloves
• Gown, mask, and cap
• Lidocaine 1%
• 27-gauge needle with 2- to 5-mL syringe for injecting local anesthetic
• 20- to 22-gauge needle with 10-mL syringe to access the EJV
• 16-gauge Angiocath (BD, Franklin Lakes, NJ) to cannulate the EJV
• Flexible guide wire with a maximum diameter of 0.35 mm and with a J tip 3 mm or less in radius 
• No. 11 scalpel
• Dilator device for the skin and soft tissue overlying the vein
• Single-lumen or multilumen catheter
• Silk or nylon sutures
• Needle holder
• Suture scissors
• Dressings (plastic tape, antibiotic patch, gauze pads)

Anesthesia

Because this is initially peripheral venous access, local anesthesia by infiltration is generally unnecessary and is not recommended, because it can obscure the surface anatomy and thereby render the venipuncture more difficult. If time permits, a topical anesthetic can be applied before the skin is punctured. However, local anesthetic should be used before the incision is made and the dilator employed.

Sedation or analgesia may be necessary for certain patients, such as those with procedural anxiety or differing levels of pain tolerance. Of note, 10-20 mg of preservative-free lidocaine can be slowly infused to diminish any discomfort associated with passing the guide wire and catheter.

Positioning

The patient should be positioned so as to optimize venous distention and thus allow easier cannulation.[9]  He or she should lie supine, with 10-30° of Trendelenburg and with the head tilted contralaterally from the vein being cannulated. The operator should stand at the head of the bed.

A cardiac monitor should be used to observe for cardiac dysrhythmia that could arise if the guide wire or catheter enters the right atrium.

Central venous access via the external jugular vein (EJV) is depicted in the video below.

Place the patient in supine position, preferably in the Trendelenburg position. Tilt the head to the side opposite that of the vein being cannulated. Position for maximal venous distention.

For vessel occlusion, the second operator may place a forefinger parallel and immediately superior to the clavicle, where the EJV dives into cervical fascia. A stethoscope may be positioned to occlude the vein.[9] The patient should be instructed to perform a Valsalva maneuver.

After landmarks and the EJV are optimally visualized, decontaminate the area by painting it widely with povidone-iodine or chlorhexidine solution. Employ full sterile technique by donning gown, mask, cap, and sterile gloves. Apply a sterile drape.

The EJV begins at the level of the mandible and runs obliquely across and superficial to the sternocleidomastoid (SCM). Taking care not to obscure the vein, place a wheal of anesthetic at planned venipuncture and suture sites.

Stabilize the vein with the nondominant hand (thumb), applying traction to the skin distal to the chosen site of insertion to prevent the vein from rolling away from the needle. Stabilization should be maintained throughout the procedure.

The EJV is usually superficial and is best accessed at a 10-25° angle. Upon entry into the vein, the practitioner might feel a “giving way” sensation, and blood should appear in the chamber of the venous access device (ie, flashback). Once flashback is obtained, the angle of the venous access device should be reduced to prevent puncturing the posterior wall of the vein. It should be gently and smoothly advanced an additional 2-3 mm into the vein.

While maintaining skin traction with the nondominant hand after the hub of the venous access device is lowered to the skin level, slide the hub of the catheter over the needle and into the vein.

While using the nondominant middle finger to apply pressure over the catheter to prevent blood spill and holding the hub in place with the nondominant index and thumb fingers, use the dominant hand to withdraw the needle and secure it in its safety cover, a dedicated biohazard sharps container, or both.

Since its first description in 1953 by Seldinger as a method of vascular access for percutaneous arteriography, the Seldinger technique has become the most widely used technique for virtually all vascular access. The method has proved to be reliable and easily mastered, with an acceptable safety profile.

Appropriate patient and practitioner preparation and positioning are carried out as previously described. With the catheter in place, thread the flexible J-tip wire through the lumen of the catheter to lie inside the vein lumen. Gently advance the guide wire until approximately one fourth to one third of its length is within the lumen of the vein.

If resistance is encountered in advancing the guide wire, rotate it and then advance. Do not force it. If the wire will not advance, several measures can be tried. The wire can be withdrawn a few millimeters and rotated 90-180° before reinsertion. If the wire is not passing the junction of the EJV and the superior vena cava, an attempt to advance the triple-lumen catheter can be made.[10] Anteriorly manipulate the shoulder,[12]  or attempt the "shrug technique."[14]  If none of these measures are successful, a catheter can be left in place and secured for use as peripheral access.

With the wire in place, remove the catheter by threading it backward over the wire. The skin and soft tissue adjacent to the wire can be anesthetized at this time, if this has not already been done.

A nick made adjacent to the wire with a No. 11 blade may permit easier passage of the dilator. Thread the dilator over the wire, and use it to create a tract in the skin and soft tissue to allow easy passage of the catheter.

Remove the dilator, and thread the catheter over the wire until the wire emerges from the distal end of the catheter. Grasp the distal end of the wire, and thread the catheter forward into the vein. Once the catheter is in place, remove the wire completely. Confirm intraluminal placement by aspirating venous blood from each port, and flush with sterile saline solution.

Secure with sutures or staples. Apply sterile dressing. Obtain a chest radiograph to confirm proper placement.

With this technique, once the needle is in the lumen and confirmed by aspiration, the J-tip wire is advanced through the needle. The needle is then removed, and subsequent steps are essentially the same as those described above.