The Journal of Laryngology & Otology (2011), 125, 643–648.

CLINICAL RECORD
© JLO (1984) Limited, 2011
doi:10.1017/S0022215110003038

Internal jugular vein reconstruction: application

of conventional type A and novel type K methods

K KAMIZONO, M EJIMA, M TAURA, M MASUDA

Department of Otorhinolaryngology and Head and Neck Surgery, Kyushu Koseinenkin Hospital, Kitakyushu,
Fukuoka, Japan

Abstract
Background: During neck dissection, the current practice is to preserve the internal jugular vein in the majority of cases.
However, sacrifice of bilateral internal jugular veins is required in rare cases. Simultaneous excision of both internal
jugular veins is known to frequently cause fatal complications. Even if staged, bilateral internal jugular vein sacrifice
still occasionally leads to fatal complications (in 2 per cent). We report two different methods of unilateral internal
jugular vein reconstruction, in two cases requiring excision of bilateral internal jugular veins, and we review the
significance of this reconstruction procedure.
Method: The first patient underwent conventional type A reconstruction (using Katsuno’s classification): end-to-end
anastomosis of the internal jugular vein to the external jugular vein. For the second patient, we anastomosed the
internal jugular vein to the anterior jugular vein, preserving the flow of the external jugular vein. This method, termed
type K, had two main expected benefits: facial drainage via the preserved external jugular vein; and provision of a
built-in safeguard in the case of occlusion (via the preserved venous networks between the internal jugular vein and
the external jugular vein, e.g. the facial vein).
Results: In both cases, the reconstructed internal jugular vein was patent and the post-operative course was uneventful,
with no severe complications.
Conclusion: The current and previous findings strongly indicate that the reconstruction of at least one internal jugular
vein is highly recommended for patients requiring bilateral internal jugular vein sacrifice. Our type K method may
represent a useful technique for this procedure.

Key words: Complications; Neck Dissection; Jugular Veins

Introduction does not guarantee the development of sufficient collateral

The standard surgical management for neck metastasis has
shifted over the last two decades, from the classical radical
neck dissection to the modified neck dissection.
Accordingly, our department has adopted an organ preser-
vation policy during neck dissections, and in the majority
of cases the internal jugular vein is now spared.
However, although rare, we still encounter patients in
whom the sacrifice of both internal jugular veins is inevita-
ble. It is well known that simultaneous excision of bilateral
internal jugular veins leads to acute reduction of cerebral
venous drainage and resultant serious morbidity, including
facial oedema (in approximately 30 per cent of cases), blind-
ness (in approximately 1 per cent), inappropriate anti-diuretic
hormone hypersecretion, laryngeal oedema, carotid artery
rupture, cerebral vessel complications (in approximately 5
per cent) and death (in approximately 10–13 per cent).1–4
Thus, it is recommended to leave an interval of at least one
month before ligating the second internal jugular vein, to
promote the formation of collateral drainage. However,
even when thus staged, the sacrifice of both internal
jugular veins occasionally still leads to grave complications,
including stroke (in 1.3 per cent) and death (in 1.6 per cent).4
Notably, leaving a longer interval between staged procedures
venous drainage, as reported by Dulguerov et al.4 (who
described a peri-operative death after a staged bilateral
neck dissection with an interval of six months).
In view of these risks, we opted to undertake unilateral
internal jugular vein reconstruction in two patients in whom
bilateral internal jugular vein excision was inevitable. In the
first case, the internal jugular vein was anastomosed to the
external jugular vein using the type A method, according
to the classification proposed by Katsuno et al. (Figure 1).5
In the second case, we anastomosed the internal jugular
vein to the anterior jugular vein, preserving the venous flow
of the external jugular vein. We termed this method type K
(Figure 1). In both cases, the post-operative course was
uneventful and the reconstructed vessels were functional.
We herein report the procedures used in both cases, and we
also review the significance of internal jugular vein
reconstruction.
Case reports
Case one
A 73-year-old man was diagnosed with supraglottic laryn-
geal carcinoma (tumour (T) node (N) metastasis (M)

Accepted for publication 27 August 2010 First published online 1 April 2011
644 K KAMIZONO, M EJIMA, M TAURA et al.

FIG. 1
Previously and currently proposed methods of internal jugular vein reconstruction. Type A: end-to-end anastomosis between the internal jugular
vein (IJV) and the external jugular vein (EJV). Type B: the internal jugular vein is reconstructed via an interposition, using either an autograft or
an artificial vein graft (VG). Type C: either an autograft or an artificial vein graft is interposed between the internal jugular vein and the external
jugular vein. Type K: end-to-end anastomosis between the internal jugular vein and the anterior jugular vein (AJV). Methods A, B and C were
originally proposed by Katsuno et al.5

staging cT3 N2c M0) following staging investigations.
Computed tomography (CT) images with contrast demon-
strated multiple cervical lymph node metastases which com-
pressed both internal jugular veins, indicating extra-nodal
extension of the tumour to these vessels.
The primary tumour demonstrated a good response to 30
Gy of chemoradiation (consisting of S-1, vitamin A and
external radiation).6 However, the metastatic lymph nodes
remained unchanged in size (Figure 2a).
At this point, we decided to perform bilateral neck dissec-
tion, as per our treatment protocol, and to preserve the
patient’s larynx by further administering the same form of
chemoradiotherapy up to 70 Gy. Considering the risks
associated with bilateral internal jugular vein excision, a
staged bilateral neck dissection was planned.
A left neck dissection was carried out first, with the inten-
tion of preserving the internal jugular vein. However, the left
internal jugular vein was seen to be densely involved by the
inferior cervical lymph node (Figure 2b), and so was sacri-
ficed. We reconstructed the internal jugular vein using the
type A method (according to Katsuno and colleagues’ classi-
fication), i.e. end-to-end anastomosis of the internal jugular
vein to the external jugular vein (Figure 1).5 Since there
was a considerable difference between the diameter of the
two veins, we employed a fish-mouth method to achieve ana-
stomosis (Figure 2c).
CLINICAL RECORD 645

FIG. 2
Case one. (a) Axial, contrast-enhanced computed tomography image after 30 Gy chemoradiation treatment, showing metastatic lymph node
(LN) densely adherent to both internal jugular veins. (b) Left neck dissection. The internal jugular vein (IJV) was involved by the lymph
node (LN). The external jugular vein (EJV) was spared for reconstruction. (c) Internal jugular vein reconstruction using type A method (see
Figure 1).

After confirming the patency of the reconstructed Case two

internal jugular vein using Doppler ultrasound, the patient
underwent a staged right neck dissection two weeks after
the initial, left neck dissection. As expected, preservation
of the right internal jugular vein was also difficult. We
used a classical radical neck dissection, requiring sacrifice
of both the right internal jugular vein and the right external
jugular vein.
After the second procedure, there were no signs of serious
complications associated with increased intracranial venous
pressure. However, facial oedema was initially prominent and
lasted a few weeks; this was probably due to reduced facial drai-
nage caused by the sacrifice of both external jugular veins.
A 77-year-old man with subglottic laryngeal cancer (staged
as cT2 N1 M0) was treated with 30 Gy of chemoradiotherapy
as above. Since both the primary tumour and the left meta-
static lymph nodes displayed a poor response, we decided
to proceed to total laryngectomy plus type III left modified
radical neck dissection, preserving the left internal jugular
vein, the spinal accessory nerve and the sternocleidomastoid
muscle.7
However, during operation, the metastatic lymph node
were found to be tightly adherent to the left internal
jugular vein, necessitating excision of this vessel.
Histopathological examination revealed considerable
646 K KAMIZONO, M EJIMA, M TAURA et al.

amounts of residual viable tumour cells in both the primary
site and the lymph node.
Considering the risk of tumour cell dissemination, we rec-
ommended the patient undergo post-operative chemoradia-
tion; however, he refused.
Two months after the initial operation, a rapidly growing
mass appeared in the patient’s right lower neck. Contrast-
enhanced CT images showed a metastatic lymph node
strongly compressing the right internal jugular vein
(Figure 3a). Hence, right-sided neck dissection was urgent,
and preservation of the right internal jugular vein seemed
likely to be difficult. Since the metastatic lymph node
(located at lower level IV) and the patient’s anterior jugular
vein were prominent, we planned to anastomose the internal
jugular vein to the anterior jugular vein, preserving the flow
of the right external jugular vein, in order to maintain facial
drainage (Figure 3b). Adopting this method, we also antici-
pated that the venous networks between the external
jugular vein and the upper internal jugular vein (including
vessels such as the facial vein) would act as a safeguard
should the reconstructed internal jugular vein occlude for
any reason.
At operation, the metastatic lymph node was tightly adher-
ent to the internal jugular vein, as expected, and intra-luminal
invasion was suspected (Figure 3c). The internal jugular vein
was sacrificed, and reconstructed using end-to-end

FIG. 3
Case two. (a) Axial, contrast-enhanced computed tomography image, showing the right internal jugular vein strongly compressed by a meta-
static lymph node (LN). (b) Pre-operative planning for internal jugular vein (IJV) reconstruction. Since the metastatic lymph node (located in the
lower neck) and the anterior jugular vein (AJV) was both prominent, we planned to anastomose the IJV to the AJV, preserving the venous flow
of the external jugular vein (EJV) (termed method K). (c) Right neck dissection. (d) End-to-end anastomosis between the IJV and the AJV.
CLINICAL RECORD 647

anastomosis of the internal jugular vein to the anterior Discussion

jugular vein, as planned. A fish-mouth method was
employed to overcome the discrepancy in diameter
between these two veins (Figure 3d).
This patient’s post-operative results were more favourable
than those of our first patient. There was no facial oedema
(Figure 4a), nor any more serious complications. The
patency of the reconstructed internal jugular vein was con-
firmed by Doppler ultrasound and contrast-enhanced CT
(Figures 4b, 4c and 4d) conducted approximately one
month after surgery.
To our knowledge, 25 cases of internal jugular vein recon-
struction have previously been reported in the English
language literature.2,4,5,8 Katsuno et al. have classified recon-
struction methods into three types – methods A, B and C
(Figure 1) – and have reported the use of these methods in
four cases.5 Another three reports have described the use
of the type B method, using either autologous or artificial
vein graft.2,4,8
We applied the type A method in our first patient, and sat-
isfactorily reconstructed a functional internal jugular vein.

FIG. 4
Case two. (a) The patient on post-operative day one. (b) Axial, contrast-enhanced computed tomography scan, and (c) & (d) colour Doppler
ultrasonography images, all taken approximately one month after internal jugular vein (IJV) reconstruction.
648
However, this patient suffered from prominent facial oedema
which lasted a few weeks. This was probably because his left
external jugular vein had been utilised as a counterpart vessel
to reconstruct the internal jugular vein, and his right external
jugular vein had been sacrificed during neck dissection,
resulting in marked reduction of facial drainage bilaterally.
Katsuno et al. did not comment on facial oedema in their
original paper.5 However, none of their three methods main-
tains the facial drainage system of the reconstructed side (as
indicated in Figure 1). Thus, when the external jugular vein
on the non-reconstructed side is sacrificed during neck dis-
section, consequent facial oedema would seem to be inevita-
ble, as occurred in our first patient.
• Even when staged, the sacrifice of bilateral internal
jugular veins occasionally causes fatal
complications
• A new method of internal jugular vein
reconstruction (termed method K) is presented,
separate from Katsuno and colleagues’ previously
categorised methods
• Method K has at least two theoretical advantages
over previously described reconstruction
techniques: preservation of facial drainage; and
provision of an alternative venous drainage route
(via preserved venous collaterals between the
internal and anterior jugular veins) should the
reconstructed internal jugular vein occlude
• Reconstruction of at least one internal jugular vein
is highly recommended in patients requiring
bilateral internal jugular vein excision
For our second patient, we employed a new method (termed
type K) for the reconstruction of the internal jugular vein,
undescribed by Katsuno et al. (Figure 4).5 The internal
jugular vein was anastomosed to the anterior jugular vein,
preserving the venous flow of the external jugular vein.
We anticipated two benefits from this method. First, the pre-
served venous flow of the external jugular vein would help
reduce facial oedema. Second, the preserved external
jugular vein would act as a safeguard if the reconstructed
internal jugular vein occluded for any reason (this required
preservation of the venous networks between the internal
jugular vein and the external jugular vein, during neck dis-
section). Thus, in our second case we carefully preserved
the facial and retromandibular veins, in addition to the exter-
nal jugular vein, during neck dissection. Presumably as a
consequence, this patient did not suffer from post-operative
facial oedema (although it is possible that collateral venous
drainage, apart from the external jugular vein, may have
developed during the two-month interval between the first
and second procedures).
We believe that our type K method enables preservation of
the venous networks between the internal and external
jugular veins, which act as a safeguard in the event of internal
jugular occlusion; however, we cannot confirm the function-
ality of this alternative venous pathway, since our second
patient’s reconstructed internal jugular vein was patent and
functional.
Nevertheless, we believe that our type K method has at
least two theoretical advantages compared with the
K KAMIZONO, M EJIMA, M TAURA et al.
conventional type A, B and C methods, as described
above. Thus, we would encourage further validation of the
utility and safety of our type K method, for selected patients
in whom this method is feasible.
Comerota et al.8 measured the pre-bypass stump pressure
of the internal jugular vein before reconstruction, in a series
of 11 cases, and found that reconstructed internal jugular
veins with a venous pressure of less than 30 mmHg had a ten-
dency to collapse and thrombose. In our two cases, we were
able to satisfactorily reconstruct the internal jugular vein
despite the considerable discrepancy in diameter between
the internal jugular vein and the counterpart vessel. This
was probably because the reconstructed internal jugular
veins had high venous pressures of more than 30 mmHg;
however, we did not measure these pressures.
As described above, even when staged, the sacrifice of
both internal jugular veins occasionally leads to grave com-
plications (including stroke and death). Moreover, a longer
staging interval does not guarantee the development of suffi-
cient collateral venous drainage.4 Including the current two
patients, 27 cases of internal jugular vein reconstruction
have now been reported in the English language literature.
No grave complications have occurred in any of these
cases, including stroke or death.2,4,5,8 These findings
strongly indicate that the reconstruction of at least one
internal jugular vein is highly recommended for patients
requiring excision of both internal jugular veins, in order
to obviate the risk of critical complications.
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Address for correspondence:
Dr Muneyuki Masuda,
Department of Otorhinolaryngology and Head and Neck Surgery,
Kyushu Koseinenkin Hospital,
1-8-1, Kishinoura, Nishiku,
Kitakyushu, Fukuoka 806-8501, Japan
Fax: +81 93 642 1868
E-mail: muneyuki.masuda@qkn-hosp.jp
Dr M Masuda takes responsibility for the integrity of the
content of the paper
Competing interests: None declared
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