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Anatomical variation of left internal jugular vein: Clinical significance for an

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Article  in  European Journal of Anaesthesiology · May 2008

DOI: 10.1017/S0265021508003700 · Source: PubMed

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 European Journal of Anaesthesiology 2008; 25: 314–318
r 2008 Copyright European Society of Anaesthesiology
doi: 10.1017/S0265021508003700

Original Article

Anatomical variation of left internal jugular vein: clinical

significance for an anaesthesiologist

I. Asouhidou*y, K. Natsis*, T. Asteriy, P. Sountoulides*, K. Vlasis*, P. Tsikaras*

Aristotle University of Thessaloniki, *Department of Anatomy, Medical School, y G. Papanikolaou Hospital Exohi,
Department of Cardioanaesthesiology, Thessaloniki, Greece

Summary
Background and objectives: Cannulation of a central vein is an everyday procedure in anaesthesiology. However,
anatomical variations of the size and/or location of the internal jugular vein might prevent cannulation, while
repeated efforts might lead to severe complications. The aim of this retrospective study was to explore anatomical
abnormalities of the internal jugular vein with regard to diameter of the vein’s lumen and to define their clinical
significance. Methods: The cervical regions of 93 cadavers, 186 sides in total, were dissected and the anatomical
variations of internal jugular vein diameters in relation to the external jugular vein and to the common carotid
artery were recorded and photographed. Results: The diameter of the veins in three cases were less than 6 mm,
while ipsilateral external jugular veins were larger than average (3/93). Conclusions: Anatomical variations of the
internal jugular veins are clinically significant, especially in cases where venous access is important.

Keywords: ANATOMY; VEINS, internal jugular.

Introduction down to the superior vena cava, thus reducing the risk
of misplacement of the catheter [2], and possibly the
Cannulation of a central vein (internal jugular vein
risk of central venous obstruction [3–5]. However,
(IJV), subclavian vein and femoral vein) is a very
when the right IJV is not available for central venous
common procedure. Catheters are inserted for several
access, then the left IJV is often used. Placement of
reasons, including haemodynamic monitoring, delivery
these catheters has been associated with significant
of blood products and drugs, total parenteral nutrition,
complications, including arterial puncture, pneu-
haemodialysis and management of perioperative fluids.
mothorax, haemothorax, chylothorax, haematoma for-
Cannulation of the IJV has been popularized based
mation, brachial plexus injury, air embolus, catheter
on the assumption that this procedure, being per-
displacement, knotting of the catheter, dysrhythmia,
formed at the base of the neck, eliminates the risk of
arteriovenous fistula, rupture of the right atrium, vocal
pneumothorax, major arterial bleeding and the possi-
cord paralysis and severe airway obstruction [6–12].
bility of failure. Cannulation of the right IJV is pre-
Sometimes, several attempts are necessary in order
ferable to the left IJV because of the absence of the
to place central venous catheters and several sites may
thoracic duct, the straight path to the right atrium and
be tried before achieving success. Despite significant
the low level of the pleural dome [1]. It runs straight
progress, vascular access remains a major concern.
Cannulation is not always successful and is uneventful
Correspondence to: Irene Asouhidou, Department of Cardioanaesthesiology, often due to anatomical variations of the size and/or
G. Papanikolaou Hospital Exohi, 15-17 Agiou Evgeniou street, Kalamaria position in relation to the common carotid artery. This
55133, Thessaloniki, Greece. E-mail: petro-s@otenet.gr; Tel: 130 23104
52560; Fax: 130 23102 50608
retrospective study aims to reveal anatomical abnorm-
Accepted for publication 1 January 2008 EJA 4577
alities of the IJV with regard to diameter of the vein’s
First published online 21 February 2008 lumen and to discuss their clinical significance.
 Anatomical variation of left internal jugular vein 315

Method
Ninety-three adult cadavers of either gender were
prepared in the Department of Anatomy, Medical
School, Aristotle University of Thessaloniki. The
cervical regions of the 93 cadavers, 186 sides in
total, were dissected and the anatomical variations
of IJVs diameter in relation to the external jugular
vein (EJV) and to the common carotid artery were
recorded and photographed.

Results Figure 1.
We found a hypoplastic left IJV in three out of the Diameter of the jugular vein in the first case.
186 sides studied. In the first case, the diameter of the
left IJV was very small, approximately 4 mm (Fig. 1),
and the left EJV was unusually dilated. On the right
side of the neck, the right IJV was larger than usual.
In the second case, the left IJV diameter was 6 mm,
about one-third of the diameter of the corresponding
common carotid artery (Fig. 2). In the third case,
the diameter of the left IJV was about 5 mm (Fig. 3)
while the size of the left EJV was extremely large, at
least four times wider than the IJV.
In all three cases there was no other morphol-
ogical abnormality of the IJV or the vein’s course,
and no signs of thrombosis. Also, in all three cases
the left EJVs were larger than average. In the first
case, there was a local haematoma formation near
the intact left IJV, possibly due to unsuccessful
attempts at cannulation. In the other two cases,
there was no evidence, at the skin, of previous recent
cannulating attempts.
The three left IJVs were atrophic throughout their
length and not just stenotic at one site, showing that
the atrophy was not due to previous cannulation.
Previous placement of central venous catheters or
attempts to cannulate a central vein narrows the vessel
lumen but the vessel’s diameter around the site of the Figure 2.
obstruction is frequently large [13]. Diameter of the jugular vein in the second case.

Discussion
IJV catheterization is a common procedure in anaes-
thesiology and critical care in everyday practice.
Hermosura first proposed the use of the IJV in the
critical care settings, and after English and colleagues
[14] published their large series in 1969, IJV cannu-
lation gained popularity. Besides the other advantages
of IJV catheterization, the growing trend for IJV
access is likely to continue because practice guidelines
defined by the Dialysis Outcomes Quality Initiative
(DOQI) states that the IJV is the preferred route for
dialysis catheter placement [15].
The IJV lies laterally and slight anteriorly to Figure 3.
the carotid artery in the neck, passes below the Diameter of the jugular vein in the third case.

r 2008 Copyright European Society of Anaesthesiology, European Journal of Anaesthesiology 25: 314–318
316 I. Asouhidou et al
sternocleidomastoid muscle to join the subclavian
vein, at the root of the neck, to form the innominate
vein, which drains through the superior vena cava
into the right atrium. Cannulation of the IJV with
the aid of skin marks is achieved by puncturing at
the apex of the angle formed by the division of the
sternocleidomastoid muscle. However, anatomical
variations of the IJV might prevent cannulation
while repeated efforts might lead to severe and life-
threatening complications [6–12,16].
Anatomical variations of the IJV position in
relation to the common carotid artery have been
described by a number of authors [13,17–22]. The
IJV location around the artery is not the same and
shows variations among individuals. It lies anterior
and slightly lateral relative to the common carotid
artery in the majority (77%) of patients [23] while
at the root of the neck the left IJV usually overlaps
with the artery [24]. There have also been reports of
bilateral duplicated IJV during cadaveric dissection.
Both right and left IJVs, under the level of the
hyoid bone, are divided into medial and lateral
veins [25].
To our knowledge, this is the first study in
cadavers that investigates the anatomical abnorm-
alities of the size of the IJV. Normally, the IJV is at
least double in size with regard to the common
carotid artery and the normal venous diameter is
about 9.1–10.2 mm [21] (Fig. 4). The great varia-
bility of the IJV and its clinical implications are
demonstrated in our cases. In all three cases, the IJV
was too small (one even smaller than half its normal
diameter), so it might be difficult, or even impos-
sible, to be cannulated. Moreover, the ipsilateral
EJV sizes were larger proportionally to the IJV size,
probably as a form of compensation.
In the literature, there are only a few reports
regarding anatomical variations of the IJV in rela-
tion to its size and most of them were based on
ultrasound findings. Lin and colleagues [21] used
ultrasonographic devices to inspect the anatomical
structure of the IJV in 104 uraemic patients.
A small IJV (,5 mm in diameter), located in its
normal position, was found in 8.7% of both right
and left veins. The IJV was unusually small (4.8%
for the right and 1% for the left) and overrode the
carotid artery. In one patient (1.0%), the left carotid
artery was visualized without any venous structures
surrounding the artery. Overall, the right and left
IJVs appear to be abnormal in size in 13.5% and
10.6% of cases, respectively [21].
Alderson and colleagues [26] studied a group of
children under the age of 6 and found 4% to have
very small diameters of the right IJV. Small-sized IJV
(,5 mm), located in its normal position, was found
in 8.7% of both the right and the left IJVs [26].
r 2008 Copyright European Society of Anaesthesiology, European Journal of Anaesthesiology 25: 314–318
Figure 4.
Diameter of a normal internal jugular vein.
Nakayama and colleagues [27] found in their study
that 8% of children had a small right IJV. None of
the patients had previous right IJV cannulation. In a
study by ultrasound image scanner carried out on
96 children, Denda and colleagues [28] found that the
left IJV diameter was less than 4.5 mm in three cases.
Koja and colleagues [16] report the creation of a
pseudoaneurysm at the left subclavian artery due to
atrophic left IJV (diameter 2 mm).
Denys and Uretsky [29] also observed in their
adult series unusually small IJVs (<5 mm) in six
(3%) patients; in all cases the IJV did not increase in
diameter during the Valsalva manoeuvre. Venography
in 69 patients identified anatomical abnormalities in
as many as a third of patients with no previous
catheter placement. Nevertheless, the stenosis was
about 50% of normal size, none of these patients had
clinical signs of central vein stenosis (i.e. upper limb
or facial oedema; superficial vein distention). Thus,
all the abnormalities identified were clinically unex-
pected [30].
A study of central venous access by an ultra-
sound-guided technique in 493 patients reported on
direct cross-correlation of failure and complication
rate with regard to the internal diameter of the vein
[31]. The mean value measured was 1.0 cm (range
0.46–3.6 cm). The study revealed 47 IJVs (47/493,
9.5%) to have diameters less than 7 mm without
mentioning the number of right or left IJV. It also
revealed that especially with very small veins
(<7 mm in diameter), the failure rate for the
placement of a catheter increased greatly (14.9%)
and so did the complication rate (8.5%). Successful
puncture was statistically significantly (P 5 0.001)
dependent on vein size [31].
In another study, from a total of 176 right and
left IJV, which were retrospectively evaluated using
computed tomography (CT) imaging, seven IJVs
were found to be hypoplastic, and in one case

this was seen bilaterally in both the right and left
IJVs [32].
Variation in size of the IJV may result in compli-
cations. According to Lin and colleagues [21], IJV
diameter less than 5 mm might make cannulation
difficult, especially with the external landmark-guided
technique. These patients should be considered at high
risk for complications using external landmark-guided
cannulation of the IJV [21]. It could be recommended
to try manoeuvres that may increase IJV size, such
as Valsalva manoeuvre, abdominal pressure or the
Trendelenberg position [33,34]. However, most
patients cannot tolerate these manoeuvres or they
cannot be applied during surgery.
Our study is certainly limited by its retrospective
nature. From the medical history/data of cadavers,
we were not able to obtain either reliable informa-
tion about the number of cannulation attempts
or specific details about approaches in the land-
mark technique at first case. The discovery of this
anatomical variation has practical significance,
particularly in complicated cases (e.g. thrombocyto-
paenia, obesity, dyspnoea, ankylosing spondylitis),
where an anomalous venous anatomy could increase
the complication and failure rate. Knowledge of the
anatomy of the IJV and taking into consideration
the frequency of anatomical variations of the IJV,
this study underscores the present guidelines for
the use of ultrasound-guided puncture for safe and
effective cannulation of these veins, especially in
children and in patients with a bleeding tendency.
Ultrasonography is helpful in puncturing the IJV
and is likely to reduce both the time and the
number of attempts required to accomplish jugular
venous access and decrease the incidence of com-
plications [35,36]. Ultrasonography imaging can
evaluate the anatomic structures before attempting
puncture, which helps the operator to locate the
carotid artery and the IJV.
In conclusion, we have found that the IJV
presents with a wide variation regarding not only
the position and the course but also the size of the
lumen. Anatomical variations of the IJV do exist,
and become clinically significant in cases where
venous access is important. Abnormalities of the
location and the diameter of these veins may be
associated with an increased risk of vascular trauma
during attempts at catheterization, and may partly
account for the failure to cannulate the IJV in a
number of patients.
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