|Year : 2014 | Volume
| Issue : 2 | Page : 97-101
Ultrasonographic study of anatomical characteristics of internal jugular vein in relation to common carotid artery
Saya Raghavendra Prasad, Jarad Sudheer Kumar, Chennareddy Kailashnath Reddy, Matam Uma Maheshwar
Department of Anaesthesiology & Critical Care, Kurnool Medical College and Government General Hospital, Kurnool, Andhra Pradesh, India
|Date of Web Publication||20-Jun-2014|
Saya Raghavendra Prasad
Department of Anaesthesiology & Critical Care, Kurnool Medical College and Government General Hospital, Kurnool - 518 002, Andhra Pradesh
Source of Support: SGR Hospital, Gipson colony, Kurnool (portable
ultrasound GE LOGIQ e machine)., Conflict of Interest: None
Context: Cannulation of internal jugular vein (IJV) by using the anatomical landmarks is associated with a significant complication rate of up to 15%.
Aim: The aim of our study was to determine the anatomical characteristics of IJV in relation to common carotid artery (CCA) using ultrasonography (USG).
Materials and Methods: This prospective observational study was carried out in a tertiary care teaching hospital. A total of 120 healthy volunteers aged between 20 and 60 years were enrolled in our study. The subjects were placed in the supine position with 15° trendelenberg tilt and neck rotated 30° to the contralateral side. Ultrasound probe was placed at the apex of the clavicle-sternocleidomastoid triangle. Location of IJV was recorded as lateral, anterolateral, anterior, anteromedial, medial and posterolateral, posteromedial and posterior. Diameter and depth of IJV was recorded. Any position other than lateral and anterolateral was defined as dangerous position. Maximum diameter of IJV ≤7 mm was defined as small sized.
Statistical Analysis Used: Data was analyzed using GraphPad prism software 6.03 (GraphPad software, Inc. USA). P < 0.05 was considered to be significant.
Results: The most common position of IJV in relation to CCA was anterolateral; 81.66% on the right side and 78.33% on the left side. Dangerous position of IJV was found in 13.33% on the right side and 15% on the left side. Mean transverse diameter of IJV was 13.2 (3.1) mm on the right side and 10.4 (2.9) mm on the left side of neck (P < 0.0001). Small sized IJV was found in 1.6% on the right side and 4.16% on the left side.
Conclusion: Due to the anatomical variations found in a significant number of the population, we recommend using USG for IJV cannulation.
Keywords: Anatomy, common carotid artery, internal jugular vein, ultrasonography
|How to cite this article:|
Prasad SR, Kumar JS, Reddy CK, Maheshwar MU. Ultrasonographic study of anatomical characteristics of internal jugular vein in relation to common carotid artery. J NTR Univ Health Sci 2014;3:97-101
|How to cite this URL:|
Prasad SR, Kumar JS, Reddy CK, Maheshwar MU. Ultrasonographic study of anatomical characteristics of internal jugular vein in relation to common carotid artery. J NTR Univ Health Sci [serial online] 2014 [cited 2020 Jul 15];3:97-101. Available from: http://www.jdrntruhs.org/text.asp?2014/3/2/97/134847
| Introduction|| |
Internal jugular vein (IJV) cannulation is carried out in many intensive care units by anatomical landmark guidance. IJV is preferred because it is easily accessible due to its superficial anatomical position and low risk of pneumothorax. Seldinger technique of catheterization of the IJV has got a success rate of 85-99% and complication rate of 15%.  The landmark technique for IJV cannulation is based on anterolateral position of IJV in relation to carotid artery. Anatomical variations of IJV in relation to common carotid artery (CCA) results in accidental puncture of carotid artery and increases the number of attempts required for IJV cannulation. Significant anatomical variations are reported in up to 12% patients in the western population. , Risk of carotid artery puncture, hematoma formation and obliteration of external landmarks favor the use of ultrasonography (USG) for IJV access.  National Institute of Clinical Excellence recommends the use of ultrasound for central venous cannulation due to high success rate and less complications.  The aim of the present study was to determine the anatomic characteristics of IJV in relation to CCA using ultrasound.
| Subjects and Methods|| |
With the approval of institutional review board, the present prospective observational study was carried out in a tertiary care hospital between January 2013 and November 2013. 120 healthy volunteers of either sex, aged between 20 and 60 years were selected after obtaining informed written consent. Patients with neck scars, neck swelling, short neck, obesity, previous neck surgery, prior IJV cannulation and refusal to the procedure were all excluded from the study.
The subject was placed in the supine position with 15° trendelenberg tilt and the neck was rotated 30° to the contralateral side. The degree of head rotation was measured using a protractor by measuring the angle at which the tip of the nose was turned away from the midline. A portable ultrasound GE LOGIQ e machine with a linear probe (vascular) of 13-6 MHz was used. All examinations were performed with a setting of 10 MHz. External landmarks were identified and the transducer was placed perpendicular to the floor [Figure 1] at the apex of the triangle formed by the two head of the sternocleidomastoid muscle and the clavicle. The IJV was identified based on its morphological structure (thin-walled, oval or round shape) non-pulsatality and compressibility. The CCA was identified based on its morphological structure (thick-walled, round shape) pulsatality and resistance to compression. After proper transducer orientation, images were recorded. The transducer was placed such that the medial side of right neck corresponds to the left side of the image and the medial side of left neck corresponds to the right side of the image.
|Figure 1: Illustration of the directions of ultrasound transducer probe when positioned over the apex of the clavicle-sternocleidomastoid triangle. Greater anterolateral and total overlap of the internal jugular vein relative to the carotid artery is shown when the ultrasound transducer is directed perpendicular to the neck skin (B) compared to when the ultrasound is directed perpendicular to the floor (A). The figure is reproduced with permission from MEJA. Sibai et al. M.E.J. ANESTH 19 (6) 2008: 1305-1320|
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In each subject, the following were recorded:
- The middle of IJV (intersection of anteroposterior and mediolateral diameters) was used to define its position in relation to CCA. The position of IJV described as lateral, anterolateral, anterior, medial and posterior.
- Anteroposterior and transverse diameters of IJV.
- The depth of IJV (distance from skin to middle of IJV).
The above observations were recorded on both sides of the neck. Anterolateral and lateral positions of IJV in relation to CCA were considered as safe positions and rest all other positions were considered as anatomical variations and dangerous positions. IJV was considered as small when the diameter was ≤7 mm.
Data was analyzed using the GraphPad prism software version 6.03 (GraphPad software, Inc. USA). Quantitative data was analyzed using Student's t-test and qualitative data using Fishers exact test. P < 0.05 was considered as statistically significant.
| Results|| |
A total of 120 volunteers participated in the study. IJV and CCA were visualized on USG in all volunteers. Demographic data of the volunteers are given in [Table 1]. Mean age of the volunteers was 32 years. Of the 120 volunteers, 58 were male and 62 were female. Mean height and weight of the volunteers was 165 cm and 63 kg respectively.
The most common position of IJV in relation to CCA was anterolateral; [Figure 2] 81.66% on the right side and 78.33% on the left side of the neck and the difference was not significant statistically [Table 2]. IJV was found lateral to CCA in a small percentage of volunteers; 6% on the right side and 6.66% on the left side of the neck and anterior (dangerous position) to CCA in 13.33% of volunteers on the right side and 15% of volunteers on the left side of the neck [Figure 3] and [Figure 4]. None of the volunteers in our study had anteromedial, medial, posterior, posteromedial or posterolateral position of IJV in relation to CCA.
|Figure 2: Anterolateral position of internal jugular vein to common carotid artery|
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|Figure 3: Anterior position of internal jugular vein to common carotid artery|
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|Figure 4: Lateral position of internal jugular vein to common carotid artery|
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The mean transverse diameter of IJV was 13.2 (3.1) mm on the right side and 10.4 (2.9) mm on the left side of the neck and the difference was highly significant statistically (P < 0.0001) [Table 3]. The mean anteroposterior diameter of IJV was 9.5 (2.5) mm on the right side and 9.3 (2.4) mm on the left side of the neck. IJV was smaller (≤7 mm) in 1.6% of volunteers on the right side and 4.16% of volunteers on the left side of neck [Table 4].
| Discussion|| |
Two different methods of placing the ultrasound probe are described for study of anatomy of IJV in relation to CCA. , One is by placing the ultrasound probe perpendicular to the floor. This method is preferred because it depicts the position of IJV in relation to CCA appropriately. The other method is by placing the transducer probe laterally along the contour of neck. The lateral scanning method provides better coupling of transducer to the skin but it falsely depicts the IJV as more anterior to the CCA [Figure 1]. 
In our study we placed the ultrasound probe perpendicular to the floor as it is appropriate in depicting the relation of IJV. Sibai et al.  placed the ultrasound probe perpendicular to the floor at the apex of clavicle-sternocleidomastoid triangle.
Studies by Sulek et al.,  Parmar et al.,  Lieberman et al.,  Troianos et al.  and Apiliogullari et al.  have shown that rotation of head of more than 30-45° increases the overlap of CCA and IJV and increases the risk of puncture of CCA. In our study the subject was placed in supine position with 15° trendelenberg tilt and 30° rotation of head to contralateral side which is the optimal position for cannulation of IJV.
In our study, IJV was found in safe position (lateral and anterolateral) in 86.66% of volunteers on right side and 85% of volunteers on left side of neck and the commonest position was anterolateral [Table 2]. Parmar et al.  has found that the commonest position of IJV was anterolateral in up to 72-85% of volunteers. Maecken et al.  found that the anterolateral position of IJV was found in 35.7-54.3% of patients. This large difference was because Maecken et al.  have placed the ultrasound probe laterally, so the IJV is depicted more anteriorly than anterolaterally.
Anatomical variation of IJV in terms of size and position were 13.66% on right side and 15% on left side of neck (P = 0.8534). Several studies ,,, have found that anatomical variation of IJV in relation to CCA ranged from 9.4% to 29%.
However, Maecken et al.  found that 43% of patients on right side and 62.3% of patients on left side of neck had anatomical variations of IJV. This significant anatomical variation was due to the lateral position of ultrasound probe used during their study.
In our study the mean transverse diameter of IJV [Table 3] was significantly more on right side compared to left side of neck (P < 0.0001). Parmar et al.  and Parry  found that mean diameter of IJV was more on right side compared to left side of neck. The mean anteroposterior diameter of IJV in our study was 9.1 (1.5) mm on right side and 8.9 (1.4) mm on left side of neck which was comparable with study by Lorchirachoonkul et al. 
In our study, small sized IJV (≤7 mm) was found in 1.66% of volunteers on right side and 4.16% of volunteers on left side of neck. Studies by Parmar et al.  and Denys and Uretsky  have found that small sized IJV was found in 1-8% of patients. Lorchirachoonkul et al.  found that 15% of patients in their study had small IJV. This relatively high percentage of small IJV compared to our study can be explained by the fact that we included healthy volunteers in our study whereas Lorchirachoonkul et al.  included elective cardiac patients in their study whose intravascular volume is affected by medications.
In our study, the mean depth of IJV from skin was 14.5 (2.7) mm on right side and 14.2 (2.5) mm on left side of neck [Table 4] which was comparable with study by Lorchirachoonkul et al.  (14.8 [3.2] mm and 13.8 [3.3] mm on right and left side of neck respectively). However, Parmar et al.  found that IJV was more superficial (9.75 [1.88] mm and 10.3 [1.87] mm on right and left side of neck respectively). It was not clear whether Parmar et al.  considered anterior wall of IJV or centre of IJV to measure its depth from the surface of skin.
Because of the significant incidence of anatomical variations in position of IJV (9.4-29% ,,, ), USG becomes an indispensable tool in the armamentarium for IJV cannulation. Several studies ,, have concluded that USG guided IJV cannulation is easier, quicker and safer than landmark approach and it should become the standard of care in intensive care unit. National Institute for clinical excellence  and the American Society of Anaesthesiologists Task Force  recommend USG guidance for central venous access in most clinical situations both elective and emergency.
The limitations in our study were we included healthy volunteers only and critically ill patients, geriatric and paeditric population were not included. Also the position of IJV was assessed at the apex of the clavicle-sternocleidomastoid triangle only. Authors scan along the course of vein to identify the optimal position for cannulation.
| Conclusion|| |
The commonest position of IJV in relation to CCA was anterolateral followed by anterior, then lateral. The mean transverse diameter of IJV was significantly more on right side. During IJV cannulation, the needle seldom needs to be advanced beyond 2 cm due to its superficial location. Due to the anatomical variations found in significant number of population we recommend using USG for IJV cannulation.
| References|| |
|1.||McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33. |
|2.||Denys BG, Uretsky BF. Anatomical variations of internal jugular vein location: Impact on central venous access. Crit Care Med 1991;19:1516-9. |
|3.||Mey U, Glasmacher A, Hahn C, Gorschlüter M, Ziske C, Mergelsberg M, et al. Evaluation of an ultrasound-guided technique for central venous access via the internal jugular vein in 493 patients. Support Care Cancer 2003;11:148-55. |
|4.||National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for placing central venous catheters. NICE Technical Report Number 49; September 2002. |
|5.||Maecken T, Marcon C, Bomas S, Zenz M, Grau T. Relationship of the internal jugular vein to the common carotid artery: Implications for ultrasound-guided vascular access. Eur J Anaesthesiol 2011;28:351-5. |
|6.||Sibai AN, Loutfi E, Itani M, Baraka A. Ultrasound evaluation of the anatomical characteristics of the internal jugular vein and carotid artery - Facilitation of internal jugular vein cannulation. Middle East J Anesthesiol 2008;19:1305-20. |
|7.||Sulek CA, Gravenstein N, Blackshear RH, Weiss L. Head rotation during internal jugular vein cannulation and the risk of carotid artery puncture. Anesth Analg 1996;82:125-8. |
|8.||Parmar S, Mehta H. Neutral versus 45 degree rotated position of head for internal jugular vein cannulation: A comparative study based on ultrasonography. Int J Med Sci Public Health 2013;2:349-53. |
|9.||Lieberman JA, Williams KA, Rosenberg AL. Optimal head rotation for internal jugular vein cannulation when relying on external landmarks. Anesth Analg 2004;99:982-8. |
|10.||Troianos CA, Kuwik RJ, Pasqual JR, Lim AJ, Odasso DP. Internal jugular vein and carotid artery anatomic relation as determined by ultrasonography. Anesthesiology 1996;85:43-8. |
|11.||Apiliogullari B, Kara I, Apiliogullari S, Arun O, Saltali A, Celik JB. Is a neutral head position as effective as head rotation during landmark-guided internal jugular vein cannulation? Results of a randomized controlled clinical trial. J Cardiothorac Vasc Anesth 2012;26:985-8. |
|12.||Parmar S, Parikh S, Mehta H. Anatomical variations of the internal jugular vein in relation to carotid artery: An ultrasound study. Int J Med Sci Public Health 2013;2:223-8. |
|13.||Lorchirachoonkul T, Ti LK, Manohara S, Lye ST, Tan SA, Shen L, et al. Anatomical variations of the internal jugular vein: Implications for successful cannulation and risk of carotid artery puncture. Singapore Med J 2012;53:325-8. |
|14.||Chandrasekaran S, Chandrasekaran VP. Anatomical variations of the internal jugular vein in relation to common carotid artery in lesser supra clavicular fossa - A colour Doppler study. Int J Basic Med Sci 2011;1:235-41. |
|15.||Lin BS, Kong CW, Tarng DC, Huang TP, Tang GJ. Anatomical variation of the internal jugular vein and its impact on temporary haemodialysis vascular access: An ultrasonographic survey in uraemic patients. Nephrol Dial Transplant 1998;13:134-8. |
|16.||Parry G. Trendelenburg position, head elevation and a midline position optimize right internal jugular vein diameter. Can J Anaesth 2004;51:379-81. |
|17.||Caridi JG, Hawkins IF Jr, Wiechmann BN, Pevarski DJ, Tonkin JC. Sonographic guidance when using the right internal jugular vein for central vein access. AJR Am J Roentgenol 1998;171:1259-63. |
|18.||Palepu GB, Deven J, Subrahmanyam M, Mohan S. Impact of ultrasonography on central venous catheter insertion in intensive care. Indian J Radiol Imaging 2009;19:191-8. |
|19.||Agarwal A, Singh DK, Singh AP. Ultrasonography: A novel approach to central venous cannulation. Indian J Crit Care Med 2009;13:213-6. |
|20.||American Society of Anesthesiologists Task Force on Central Venous Access, Rupp SM, Apfelbaum JL, Blitt C, Caplan RA, Connis RT, et al. Practice guidelines for central venous access: A report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology 2012;116:539-73. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]