Sir,
Ultrasound has been the gold standard in cannulating central veins and now has been incorporated as a mandatory standard.[1] The use of ultrasound has resulted in enhanced safety and reduced complications.[2,3,4] Despite using ultrasonography, rare abnormal anatomy can misguide the clinician if he is not aware about the underlying anatomic pathology.[5]
We present a case of a 65-year-old patient with sub-acute intestinal obstruction who underwent colonic bypass (antesternal route) for oesophageal stricture following corrosive injury 30 years ago and needing a central line for total parenteral nutrition.
After the routine protocol (consent, asepsis, etc.), a linear probe covered with a sterile sheath was placed on the right side of the neck to identify the internal jugular vein (IJV). Three hypoechoic circular structures were visualised, out of which two were easily compressible with the probe (jugular veins), and the third was pulsating. The carotid artery was most medial.
After local anaesthesia was administered using a 26 G long needle, and when the central line puncture needle was about to be introduced using the ultrasonography guide, it was noted that the lateral hypoechoic circular shadow moved medially, but was easily compressible. It was suspected to be the colonic shadow mimicking the IJV. Needle insertion was avoided, and expert help and opinion called for. It was confirmed that the hypoechoic compressible shadow was indeed the colonic shadow. The IJV was compressed antero-laterally and was confirmed by colour Doppler [Figures 1 and 2]. Successful cannulation of the right IJV was completed without any complications subsequently.
Figure 1.
Colonic hypoechoic shadow following colonic pull-up mimicking vascular structures
Figure 2.
Distended bowel loops in the neck with central venous catheter inserted
Ultrasound is thus an invaluable tool for all central venous cannulations as it helps in delineating not only the anatomical variants but also the abnormal post-surgical anatomy; however, clinical correlation should not be ignored.
One has to be aware that not all compressible structures in the neck are vascular structures. It is important to understand the underlying pathology and identify the coincidental pathologies like cystic lesions in the neck which may mimic vascular structures to avert central line insertion-related complications.
Understanding the altered post-surgical sono-anatomy to avert major complications is an important lesson learnt from this case. Ultrasound is an invaluable tool to detect anatomical aberrations and to minimise central venous cannulation-related complications. Nevertheless, in the case presented, despite using ultrasound, there was a potential to puncture the colon with the introducer needle or entering the IJV through the colon and the possibility of the ensuing cascade of complications.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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