Paediatric Anaesthesia 1999 9: 271–272

Case report
Return of the internal jugular vein—development
of collateral drainage following neonatal ligation
of the vein
M.J. MARTIN FRCA∗, T.S.H. ARMSTRONG FRCA∗,
G.M. JOHNSTON FRCA∗ AND G.G. YOUNGSON FRCS †
∗Department of Anaesthesia, Aberdeen Royal Infirmary, Foresterhill Road, Aberdeen AB25
2ZN, Scotland, UK. †Department of Paediatric Surgery, Royal Aberdeen Children’s Hospital,
Cornhill Road, Aberdeen AB25 2ZG, Scotland, UK

Summary
The development of collateral venous drainage in the neck of a
child, who as a neonate had undergone ligation and cannulation of
the right internal jugular vein, is described. The resultant vessels
were of sufficient calibre to be considered as potential sites for
vascular access, although it is possible that their course in the thorax
may preclude correct placement of a central venous catheter.
Nevertheless, we feel that this case further illustrates the benefit of
hand-held ultrasonography in visualizing the vascular structures of
the neck. Moreover, ligation of a vein in the neonatal period should
not be a contraindication to subsequent assessment of that site for
vascular access.

Keywords: anatomy: internal jugular vein; equipment: portable

ultrasound

Case report This was performed by one of the authors (G.G.Y) and
the operation note records a single, easily-identified
A male infant was delivered by emergency caesarean
vein.
section at 31 weeks’ gestation for presumed fetal
Following a difficult neonatal period, the child
distress. The pregnancy had been complicated
made substantial progress and the cannula was
by maternal hypertension, and serial ultrasound
removed uneventfully 23 days later.
examinations had suggested intrauterine growth
Subsequently, at the age of seven years, the boy
retardation. Indeed, at birth, the child’s weight was
presented for elective inguinal herniotomy. Fol-
below the third centile (when corrected for gestational
lowing induction of anaesthesia, as part of an
age).
unrelated research project, the child was positioned
Three days later, a silastic central venous cannula
in a 15 degree head-down tilt. His head was turned
was inserted under direct vision into the right internal
45 degrees to the left and the vascular structures in
jugular vein. The vein was then ligated proximally.
the right side of the neck were visualized by means
of a portable probe (SiteRiteTM, Dymax Corp., USA.)
We were surprised to discover two ‘internal jugular
Correspondence to: M.J. Martin, Department of Anaesthesia,
Aberdeen Royal Infirmary, Foresterhill Road, Aberdeen. AB25 veins’ which sat adjacent to the carotid artery at the
2ZN, Scotland, UK. level of the cricoid cartilage. They lay anteromedial

 1999 Blackwell Science Ltd 271

272 M.J. MARTIN ET AL.
Figure 1
An ultrasonic image of the right side of the neck with the head
tilted at 45° to the left, produced by the SiteRiteTM machine. It
illustrates the common carotid artery (A), the anteromedial (MV)
and anterolateral (LV) internal jugular veins, The scan depth is
2 cm from the skin.
and anterolateral to the artery and were both of
similar calibre to a normal internal jugular vein (see
Figure 1). When the boy’s head was returned to
the neutral position, the veins shifted to lie directly
anterior and anterolateral respectively to the carotid.
Discussion
Central venous cannulation is often required in
critically ill neonates to facilitate fluid and drug
administration. In our unit, the right internal jugular
vein is frequently employed for this purpose and is
cannulated under direct vision, following surgical
dissection. In this case, the vein was also ligated
with a nonabsorbable suture proximal to the site of
cannulation.
Generally, it might be assumed that such surgical
intervention would prohibit future cannulation at this
site. In children, even cannulation without proximal
ligation has been shown to produce a high incidence
of venous thrombosis (1).
However, this boy’s right internal jugular appears
to have reformed as two distinct vessels, presumably
due to development of collateral veins. As the
ultrasound image illustrates, both the veins are a
good size and either one could potentially be used
as a site for percutaneous central venous cannulation.
Without venography, however, we are unable to
predict the course of these veins in the thorax and,
if aberrant anatomy exists, it may prove difficult to
pass a Seldinger wire. Nevertheless, we feel that
vessels such as these would merit an attempt at
percutaneous cannulation, particularly if other sites
are unavailable.
We present this case as an unusual and unexpected
finding which demonstrates the value of ultra-
sonography in assessing venous sites prior to
cannulation. Portable devices are available to aid
the location and reduce the complications of central
venous cannulation (2,3). In children, the relationship
of the internal jugular vein to the carotid artery
can vary considerably, even in those who have not
undergone prior central venous cannulation, and it
has been shown that the routine use of ultrasonic
probes can reduce complications following attempted
cannulation in children (4). Moreover, it has been
suggested that, providing that the vessels can be
visualized, the use of a central vein in an infant
should not preclude future cannulation of the same
site (5).
In addition, our case illustrates that even where
the internal jugular has been previously ligated,
ultrasonography may demonstrate collateral vessels
which may well prove suitable for subsequent
vascular access.
References
1 Rand T, Kohlhauser C, Popow C et al. Sonographic detection of
internal jugular vein thrombosis after central venous cannulation
in the newborn period. Pediat Radiol 1994; 24: 577–580.
2 Armstrong PJ, Cullen M, Scott DHT, The SiteRite ultrasound
machine—an aid to internal jugular vein cannulation. Anaesthesia
1993; 48: 319–323.
3 Denys BG, Utretsky BF, Reddy PS. Ultrasound-assisted
cannulation of the internal jugular vein. Circulation 1993; 87:
1557–1562.
4 Anderson PJ, Burrows FA, Stemp LI et al. Use of ultrasound to
evaluate internal jugular vein anatomy and to facilitate central
venous cannulation in paediatric patients. Br J Anaesth 1993; 70:
145–148.
5 Cassey J, Hendry GM, Patel J. Evaluation of long term central
venous patency in children with chronic venous catheters using
image directed Doppler. J Clin Ultrasound 1994; 22: 315–315.
Accepted 4 June 1998
 1999 Blackwell Science Ltd, Paediatric Anaesthesia, 9, 271–272