Internal Jugular Vein Occlusion Research Articles

Use of Jugular Venous Pressure to Optimize Outcomes of Vestibular Schwannoma Resection: A Review of the Literature and Proof of Concept

Abstract Background Surgical resection of vestibular schwannoma (VS) and other benign posterior fossa tumors is often curative if gross total resection is achieved; however, these lesions pose unique challenges due to their intricate location and proximity to critical structures. Approaches for resection often utilize lateral head rotation and neck flexion to optimize the surgical field. However, this may inadvertently occlude cerebral venous drainage, elevating intracranial pressure (ICP) and increasing intraoperative bleeding, potentially increasing the operative risk to patients. Methods We review relevant literature regarding the effects of head rotation and neck flexion on internal jugular vein (IJV) occlusion and ICP and highlight the notion that head rotation and flexion may occlude the ipsilateral IJV, increasing ICP. Subsequently, we propose a novel technique using continuous, real-time monitoring of jugular bulb pressure (JBP) to detect obstructions in jugular venous flow and guide optimal head positioning prior to VS resection. Results As proof of concept, we present a single-patient case in which JBP monitoring was employed to optimize head positioning prior to a VS resection, which shows a significant reduction in JBP compared with traditional positioning. Conclusion This innovative approach offers promise in enhancing the safety and efficacy of intracranial surgery for VS and other neurosurgical procedures.

P.083 Use of jugular venous pressure to optimize outcomes of vestibular schwannoma resection: a review of the literature and proof of concept

Background: Surgical resection of vestibular schwannoma (VS) is often curative if gross total resection is achieved, however, it is a delicate procedure with high risk to the facial nerve. With retrosigmoid approach for resection, the head is positioned to maximize lateral head rotation and neck flexion in order to optimize the surgical field. However, this may inadvertently occlude cerebral venous drainage, elevating intracranial pressure (ICP) and increasing intraoperative bleeding. Methods: Here, we review relevant literature regarding the effects of head rotation and neck flexion on internal jugular vein (IJV) occlusion and ICP, and highlight the notion that head rotation and flexion may occlude the ipsilateral IJV, increasing ICP. Subsequently, we propose a novel technique using continuous, real-time monitoring of jugular bulb pressure (JBP) to detect obstructions in jugular venous flow and guide optimal head positioning prior to VS resection. Results: As proof of concept, we present a case in which JBP monitoring was employed to optimize head positioning prior to a VS resection, which shows a significant reduction in JBP compared to traditional positioning. Conclusions: This innovative approach offers promise in enhancing the safety and efficacy of intracranial surgery for VS and potentially other neurosurgical procedures.

Remodeling of extracranial veins and venous-arterial imbalance in extrinsic stenosis and hypoplasia of the internal jugular veins

The aim of the study was to compare hemodynamic parameters, the sequence of remodeling of the jugular and extrajugular outflow tracts of cerebral venous circulation in extrinsic stenosis and hypoplasia of the internal jugular vein (IJV). Material and methods. Groups with external compression and IJV stenosis (n = 50), with IJV hypoplasia (n = 27), and after IJV ligation/resection (n = 6) as a model of IJV occlusion with a minimal cerebral venous insufficiency and venous encephalopathy and control group (n = 31) were compared. All patients underwent a neurological examination, ultrasound duplex scanning of the IJV (J2 and at the level of stenosis), common carotid and vertebral artery (V2), 2DToF or 3DToF magnetic resonance venography of the neck veins. The degree of stenosis of the IJV, the crosssectional area and the time average blood flow velocity, the calculated indicator of the venous-arterial balance (VAB) were determined according to the modified formula. Results and discussion. In the group of external compression of the IJV, stenosis averaged 64.52 %. The area of the IJV at the site of stenosis was 6 times, and at the standard place (J2) – 3 times less than the area of the opposite IJV. The hypoplastic IJV throughout its entire length (from J1 to J3) had the same area (0.21 ± 0.12 cm2 ), smooth contours, without local expansions or narrowings. A very low blood flow velocity (10.2 ± 11.67 cm/s) is characteristic for stenosis, in contrast to the normal velocity in the hypoplastic vein and in the control group. The blood flow velocity in the contralateral IJV with external stenosis does not differ from normal, but it is increased with hypoplasia (34.62 ± 12.23 cm/s). With MR venography, it is possible to detect a stenosing factor, symptoms of a filling defect, a decrease or loss of a blood flow signal, and an assessment of the overall picture of remodeling of the venous network of the neck. A decrease in the IJV area on the side of the lesion/anomaly corresponds to negative remodeling, while an expansion of the opposite IJV corresponds to positive remodeling. If the obstruction persists, the homolateral, then the contralateral external jugular vein expands, then the vertebral veins and plexuses, spinal epidural veins, anterior jugular and posterior cervical veins expand too. The magnitude of the IJV on the side of the anomaly/pathology with hypoplasia did not differ from the value with stenosis (9 %), but was slightly less than on the opposite IJV (53.39 ± 13.40 and 67.24 ± 18.02 %, respectively, p < 0.06) and significantly less compared to the control (24.16 ± 8.06 % on the left and 33.15 ± 8.27 % on the right, p < 0.0001), which makes this indicator a good additional criterion for outflow abnormality according to the IJV of one side.

Ventriculo-atrial shunt with occlusion of the internal jugular vein: operative experience and surgical technique

BackgroundVentricular shunts are one of the most frequent techniques used for the management of hydrocephalus. The ventriculoperitoneal shunt (VPS) is the most commonly performed procedure, and the ventriculoatrial shunt (VAS) is the second option in most medical centers. The main objective of this study is to introduce and describe a surgical approach for VAS outlining our experience and comparing it with traditional shunting techniques.MethodsIn this retrospective cohort comparison study, we included patients with hydrocephalus treated with a surgical procedure between January 2010 and February 2021 at a single academic institution. We categorized the procedures into two groups: patients with VPS and conventional VAS grouped together into the conventional technique (CT) group, and the second group was patients with whom we performed VAS with complete internal jugular vein occlusion (IJVOT). We compared the surgical time, postoperative complications, and occurrence of shunt failure among the groups by performing univariate analysis using the Fisher exact test.ResultsOut of the 106 patients included in the analysis, IJVOT was performed in 66 patients, and CT in 40 patients. The median surgical time was 60 min (IQR 60–90) for IJVOT versus 100 min (IQR 60–120) for CT (p < 0.01). In the follow-up a month after the procedure, 83.3% of patients with IJVOT and 62.5% of patients with CT did not require shunt removal or shunt revision (p < 0.01). Shunt revision rates were 12.5% and 1.5% for CT while 1.5% and 2.5% for IJVOT at 1 and 6 months after the procedure.ConclusionOur findings demonstrate that VAS with IJVOT is a safe method that exhibited shorter surgical times and outcomes comparable to CT. However, since the present study represents the first cohort evaluating IJVOT, it is imperative to conduct larger prospective studies, along with clinical trials, to fully explore and establish efficacy, long-term outcomes, and an in-depth comparison among shunting techniques.

Endovascular treatment of a Right Internal Jugular Vein occlusion in a hemodialysis patient with severe neurological symptomatology

In the last decade, Internal Jugular Vein (IJV) obstructive disease has been gaining increasing attention due to different confounding symptoms that impair patients’ quality of life and cannot be explained by other established causes. The most common clinical symptoms associated with IJV stenosis are tinnitus and sleep disturbances (60.5%), headache (48.8%), visual disturbances (39.5%), hearing disorders (39.5%) and anxiety or depression (37.5%). We report a complex case of a woman with a wide range of severe neurological inexplicable disorders. Using Duplex Ultrasound, an IJV occlusion was successfully diagnosed and the patient was then treated using endovascular techniques. IJVs occlusion and outflow alteration were detected by the means of Duplex Ultrasound (DUS) demonstrating the need of a carefully assessment of neck vessels in patients with drug-resistant neurological symptomatology as headache, tinnitus and sleep disturbances.

Assessment of Patency of Internal Jugular Vein in Carcinoma Oral Cavity Patients Undergoing Neck Dissection: A Prospective Observational Study

ABSTRACT Background: Neck dissections in carcinoma oral cavity are associated with various postoperative comorbidities. Internal jugular vein (IJV) occlusion and stenosis is a rare serious complication, which leads to serious clinical sequalae. Existing medical literature reports an incidence of this complication varying from 0% to 30%. Lacunae exist regarding any correlation between clinicopathological parameters and treatment options, of such patients, with the incidence of this complication, which might aid in adapting a preventive approach accordingly. Aims and Objectives: a. Primary objective: To study the patency of IJV postoperatively with preoperative status b. Secondary objective: Correlation of postoperative IJV patency with clinicopathological parameters (age, subsite, and pathological nodal status) and treatment options offered (neck dissection, radiotherapy, and reconstruction). Subject and Methods: Patency of IJV was analyzed preoperatively and postoperatively and correlated with various parameters, after neck dissection in 50 carcinoma oral cavity patients. Settings and Design: Prospective observational study at a tertiary care hospital done over 2 years. Statistical Analysis Used: Data were recorded in Excel data sheet and statistically analyzed by using the SPSS Ver 22.0. Results: IJV occlusion was demonstrated in 2 (4%) patients and IJV stenosis in 7 (14%) patients. Postradiotherapy patients had higher incidence of occlusion compared to patients who did not undergo radiotherapy (11.7% vs. 0%; P &lt; 0.05). The incidence of stenosis and occlusion was significantly higher in left side neck dissection (20.6%; P &lt; 0.05). Conclusion: Radiotherapy and left sided neck dissection are statistically significant risk factors for postoperative IJV occlusion in carcinoma oral cavity patients.

The Role of Intra-Operative Duplex Ultrasonography Following Translabyrinthine Approach for Vestibular Schwannoma.

ObjectiveSigmoid sinus (SS) stenosis is a complication of translabyrinthine approach. Velocity changes in the SS measured by intra-operative doppler ultrasound may help in identifying patients at risk for sinus occlusion.PatientsSS velocity was measured using doppler ultrasound prior to opening dura and again prior to placement of the abdominal fat graft.InterventionData collected included: patient age, surgical side, sinus dominance, tumor volume, intra-operative doppler ultrasound measurements, post-operative venous sinus imaging, anticoagulation, and morbidities and mortalities.Main Outcome MeasureSS patency and velocity.ResultsEight patients were included in the analysis (22 to 69 years). Four had left-sided and four had right-sided craniotomies. Sigmoid sinuses were either right-side dominant or co-dominant. The mean velocity ± standard deviation (SD) prior to dura opening and abdominal fat packing was 23.2 ± 11.3 and 25.5 ± 13.9 cm/s, respectively, p = 0.575. Post-operative Magnetic Resonance Venography (MRV) imaging showed four sigmoid sinus occlusions; seven patients showed sigmoid sinus stenosis, and one internal jugular vein occlusion. One patient had post-operative Computed Tomography Venography (CTV) only. Of the four patients with MRV occlusions, CTVs were performed with three showing occlusion and all four-showing stenosis. One patient with internal jugular vein occlusion on MRV received warfarin anticoagulation. There was one cerebrospinal fluid leak requiring ear closure, one small cerebellar infarct, and one with facial nerve palsy (House-Brackman Grade 3).ConclusionSS velocity changes before and after tumor resection were not predictive of sinus occlusion. We hypothesize that sinus occlusion may be caused by related factors other than thrombosis, such as external compression of the sinus secondary to abdominal fat grafting.

Anticoagulation in the Treatment of Pulsatile Tinnitus Caused by Internal Jugular Vein Stenosis: A Rare Case Report

Background: Anticoagulation is considered as a first line treatment of pulsatile tinnitus caused by internal jugular vein thrombosis. We present a case of non-thrombotic internal jugular vein occlusion which responded to Apixaban (Eliquis) therapy. Case Presentation: A 54-year-old female with no significant past medical history presented with debilitating pulsatile tinnitus for two months. Her symptoms included inability to sleep, lower appetite, and intense pressure and throbbing in the face and ears. She described it as a ‘whooshing sound’ exacerbated in the supine position. She admitted to occasional episodes of neck throbbing and forceful heart beat over the years and had undergone multiple workups including Echocardiograms and Holter monitoring, with no apparent abnormalities. The recent workup, including coagulation studies, Computed Tomography (CT) scans and Magnetic Resonance Imaging (MRI) of the head and neck, yielded negative findings. However, a CT angiogram revealed an isolated non-thrombotic occlusion of the most proximal aspect of the left Internal Jugular Vein (IJV), with extensive occipital and sub occipital collateral flow. She had been taking antihypertensive and diuretic medications without much effect. She was then prescribed anticoagulation therapy initially with IV enoxaparin (30 milligrams for two weeks) and then oral Apixaban (5 milligrams b.i.d.). Eliquis 5 milligrams bid was continued for 8 months and tapered down to 2.5 milligrams bid for 4 months to completely off in 12 months. Her symptoms improved after eight weeks and were completely gone within a year. Repeat MR angiography showed improved flow in the jugular venous system. Conclusions: A trial of anticoagulation is warranted and can be beneficial in patients with non-thrombotic internal jugular vein occlusion causing pulsatile tinnitus refractory to other treatments.

Catheter-directed venography for evaluating internal jugular vein pseudo-occlusion

The incidence and effects of stenosis of the cerebral venous system are poorly understood. When noninvasive computed tomography venography (CTV) of the head and neck suggests complete internal jugular vein (IJV) occlusion, invasive catheter-directed venography can discordantly show venous patency. We compared CTV vs digital subtraction venography (DSV) in the evaluation of patency/occlusion in the suspected IJV and contralateral IJV. We queried the venous intervention database of our U.S. academic tertiary-care hospital to identify patients with complete or near-complete IJV occlusion per CTV from March 1, 2019 to March 1, 2020. We included patients with both noninvasive and invasive imaging of the target segment and the contralateral IJV. Four patients had suspected occlusion of the IJV at the skull base. Invasive catheter-directed venography consisted of DSV to assess direction of flow and vessel caliber, as well as manometry proximal and distal to areas of suspected stenosis. DSV showed patency in all 4 IJVs for which CTV had shown suspected occlusions. CTV findings of the contralateral IJVs were patency (n = 2), moderate stenosis (n = 1), and severe/critical stenosis (n = 1). Contralateral IJV caliber, measured by DSV, was concordant with CTV findings. Median mean-pressure gradients across the apparent occlusion and contralateral segments were 1 (range, 1–4) mmHg and 0 (range, 0–5) mmHg, respectively. Although noninvasive CTV may suggest absence of or attenuated flow within the IJV, this technique may be insufficient to establish complete occlusion. Catheter-directed venography can be used to evaluate patency, vessel caliber, and mean-pressure gradient.

The inside-out technique for tunneled dialysis catheter placement with central venous occlusion

The “inside-out” technique eliminates the need for subclavian or femoral catheter placement by placing a supraclavicular catheter via a percutaneous femoral vein access. Few reports of its use in vascular surgery exist. The purpose of this article is to describe our version of the technique and report results. Between 2016 and 2017, the inside-out technique was performed on eight patients. All patients had more than four prior access sites and bilateral internal jugular vein occlusion. The technical success rates were 100% with no periprocedural complications and success in achieving dialysis access. One patient required catheter replacement within 48 hours, one catheter was used as a bridge to Hemodialysis Reliable Outflow (Hemosphere, a Cryolife Inc Company, Eden Prairie, Minn) graft placement, and one patient died of sepsis unrelated to their catheter. Our data show the inside-out technique to be safe and effective, removes the need for subclavian or femoral catheter placement, and should be a component of treatment algorithms for complex dialysis patients, which is consistent with National Kidney Foundation's Kidney Disease Outcomes Quality Initiative recommendations.

Studying alternative approaches for placement of cuffed hemodialysis catheters in hemodialysis patients with bilateral internal jugular vein occlusion.

Internal jugular vein occlusion often makes necessary the use of less desirable routes as external jugular, subclavian, and femoral vein approaches in addition to inferior vena cava approaches. This a prospective cross-sectional follow-up study of the alternative approaches for placement of cuffed hemodialysis catheters in end-stage renal disease patients with bilateral internal jugular vein occlusion from the interventional nephrology point of view. The study was conducted on 134 end-stage renal disease patients who were referred for insertion of a challenging hemodialysis catheter due to bilateral internal jugular vein occlusion. Ultrasound Doppler guided catheter insertion was used as a routine practice in addition to fluoroscopy or post insertion X-ray to localize catheter tip position and exclude complications. Follow-up of patients was conducted until the end of the study or catheter removal. The most highly prevalent alternative approach is the trans-external iliac vein inferior vena cava approach (43.28%) followed by external jugular vein approach (14.93%), innominate vein approach (10.18%), internal jugular vein collaterals by interventional radiology (7.46%), femoral vein approach (7.46%), transhepatic approach (5.97%), subclavian vein approach (5.22%), and finally the retrograde femoral vein approach (1.49%). End-stage renal disease patients maintained on regular hemodialysis who have bilateral internal jugular vein obstruction and non-functioning arteriovenous fistula/graft is a daily scenario in nephrology practice. Our study showed that there is a variety of approaches for the insertion of cuffed hemodialysis catheters other than occluded internal jugular veins. Interventional nephrologists have a major role in solving the problem of poor hemodialysis vascular access. These alternative approaches can conserve the anatomically limited number of percutaneous access sites in each patient.

Surgical repair of PTA-related internal jugular vein occlusion in multiple sclerosis: report of four cases with chronic cerebrospinal venous insufficiency

Surgical repair of PTA-related internal jugular vein occlusion in multiple sclerosis: report of four cases with chronic cerebrospinal venous insufficiency

Asymptomatic superior vena cava thrombosis as a manifestation of secondary antiphospholipid syndrome in a female presenting with anemia and bad obstetric history

Abstract We report a case of a 34 −year −old lady who presented with anemia and bad obstetric history. She was diagnosed to have Systemic Lupus Erythematosus (SLE) with Antiphospholipid Antibodies (APLA) Syndrome. She also had dilated and tortuous veins over the chest and upper abdomen. CT Venography was done, and she was detected to have complete thrombotic occlusion of superior vena cava, right brachiocephalic and right internal jugular veins, with multiple systemic venous collaterals. Patient was started on steroids and anticoagulation therapy which resulted in improvement of her general condition. This case is noteworthy as the patient was asymptomatic for extensive major vessel thrombosis and SVC syndrome.

Variability in the Cross-Sectional Area and Narrowing of the Internal Jugular Vein in Patients Without Multiple Sclerosis

Chronic cerebrospinal vascular insufficiency is a proposed condition of intraluminal stenosis of the internal jugular vein (IJV) that impedes venous flow from the brain. Calculations of IJV stenosis are vague and described in veins with at least a 50% reduction in IJV caliber at a specific level. The purpose of this study was to assess normal changes in anatomic caliber of the course of the IJV in a generalized population. Images from 500 consecutive contrast-enhanced neck CT studies performed in January-July 2011 were reviewed. Cross-sectional areas of the IJV were calculated at the jugular foramen, C1-C7 levels, and jugular angles bilaterally. Patients were excluded if they had severely motion-limited studies; limited clinical data; a history of multiple sclerosis, neck mass, or neck dissection; or known IJV occlusion. Normalized IJV cross-sectional areas at each level were compared with an averaged normalized cross-sectional area from all patients at each level. Greater than 50% narrowing compared with a normalized average was found in 133 of 363 patients (36.6%) and was seen at all IJV levels. In 36.1% of patients this narrowing occurred at the C1 level. Most of the areas of narrowing greater than 50% occurred above the C4 level. The IJV has marked variability in its course in the neck. Areas of narrowing greater than 50% occur most commonly in the upper cervical and skull base regions. Given the normal anatomic variations in IJV caliber, caution should be used when making the diagnosis of and treating IJV stenosis.

Factors influencing internal jugular vein patency after neck dissection in oral cancer

The objective was to investigate factors influencing internal jugular vein stenosis or occlusion after neck dissection, including the reconstructive procedure. The subjects were 73 patients (81 veins) who underwent a modified radical neck dissection, in which the internal jugular vein was preserved, or an extended supraomohyoid neck dissection (E-SOHND). All procedures were performed by the same surgeon. Internal jugular vein patency was evaluated by contrast-enhanced computed tomography. Patency was evaluated in relation to gender, side of dissection, number of pathological lymph node metastases, extracapsular spread of lymph node metastases, radiotherapy, and the reconstruction method (no reconstruction, free flap, or pedicle flap). All internal jugular vein occlusions were on the left side and all except one of these patients underwent radiotherapy. Thus, radiotherapy and left side dissection were significant risk factors for occlusion. Free flap reconstruction was not a risk factor for vein stenosis or occlusion. Patients undergoing reconstruction with pedicled musculocutaneous flaps or E-SOHND were less likely to have vein occlusion. Particular care is required for left neck dissection in patients who have undergone radical neck dissection on the right side. This study suggests that covering the internal jugular vein with the muscle might prevent vein occlusion.

血管内ステント留置が有効であった乳癌皮膚転移による内頸静脈閉塞の1例

症例は53歳の女性で，術後再発乳癌に対し外来化学療法施行中，頸部皮膚転移による内頸静脈の閉塞をきたした．上大静脈の末梢側に位置する内頸静脈が，皮膚転移の悪化により閉塞し，上大静脈症候群と類似した顔面・口腔などの著明な腫脹が出現した．放射線照射による喉頭浮腫の既往があり，外来にて化学療法を継続していたが治療効果を認めなくなったため，症状の緩和を企図しステント留置を選択した．本症例では血管内ステント留置による症状改善が得られたため，文献的考察を加えて報告する．

A failure of internal jugular vein catheterization caused by the internal jugular vein occlusion

Central venous catheterization is frequently used as the procedure for preparation of major surgery, chemotherapy, total parenteral nutrition, and etc [1]. Usually, the catheterization sites are femoral vein, subclavian vein, and internal jugular vein (IJV). Because the right IJV has easy accessibility, and it gives direct route for right atrium [2], the right IJV is a popular site of central venous catheterization. Generally, landmark technique with a seeker needle is used for right IJV catheterization. It is a blind technique. Imagine if you are performing an IJV catheterization, and there is no blood aspiration in the seeker needle. What are the possible causes? And what do you do? Our case may offer a little help. The patient was a 43 year-old male. He had been diagnosed with esophageal cancer and tracheal invasion (stage IVA, T3N1M1a) 2 years ago. Since then, he had 5 times of palliative chemotherapy and 6300 cGy of palliative radiotherapy on his neck. This patient needed general anesthesia for an Ivor-Lewis operation because of dysphasia and tracheo-esophageal fistula. In the operation room, we tried to find the right IJV with seeker needle aspiration. Despite of several trials, the aspiration failed. So, we used the ultrasound to find the right IJV. However, the ultrasound showed that the IJV lumen was distended with hypo-echoic thrombus or something, and flow was not detected in the IJV. Lastly, we cannulated the right femoral vein and the surgery proceeded. During the operation, we reviewed the neck CT images that were taken one and half years before the surgery when the patient had local infection on the right neck. Further, the CT review revealed that there was an occlusion in the right IJV (Fig. 1). We thought the cause of occlusion was tissue granulation or thrombosis. The radiologist's opinion was thrombosis or thrombophlebitis. Fig. 1 A neck CT image examined one and half years before surgery. The patient had local infection history at that time. The arrow indicates a thrombus within the right internal jugular vein. As we mentioned earlier, the IJV has easy accessibility, and the procedure has performed with blind technique traditionally. Khatri and Espinosa [1] shows 29 cases of difficult circumstances encountered on the right side, out of 320 cases. The ratio is 9%. Venous thrombosis was 9 cases out of 29 difficult cases. IJV thrombus is caused by catheterization history of central venous catheter, malignancy, long term catheterization, thrombophillia, local infection, and spontaneous occlusion [3]. This patient had history of malignancy (esophageal cancer) and local infection on the neck. Those were maybe the cause of thrombosis, which made us be unable to cannulate with traditional landmark guided technique. Ultrasound guided internal jugular catheterization has the advantage to detect anatomical variation or distortion, since ultrasound provides real time visualization. Ultrasound shows what is happened under the patient's skin. Ultrasound guided catheterization has higher success rate, lower attempt times, and lower complication rate than that of the traditional landmark guided catheterization [4,5]. In other words, if we use ultrasound guided technique, we can detect the difficult cases quickly and makes these to easier and safer cases. We revealed IJV thrombus on a CT review, after failure of several approaches. Because the patient had a history of local infection and malignancy, we should anticipate difficulty of the right IJV catheterization, and we should have to review the patient's neck before the attempting several approaches, but we did not. If the patient had a history of neck related disease and the right IJV catheterization is necessary, preoperative patient review is needed. Therefore, we suggest the use of the ultrasound guided as a routine procedure while catheterization of the IJV. It makes catheterization easer, and lowers possible complications. Additionally, when the patient has a history of neck infection, malignancy or the prior catheterization of the IJV, a neck CT review is very helpful.

Biophysics of Venous Return from the Brain from the Perspective of the Pathophysiology of Chronic Cerebrospinal Venous Insufficiency

This article discusses the biophysical aspects of venous outflow from the brain in healthy individuals and in patients with chronic cerebrospinal venous insufficiency. Blood flows out of the brain differently, depending on body position. In the supine position it flows out mainly through internal jugular veins, while in the upright position it uses the vertebral veins. This phenomenon is probably not due to the active regulation of the flow but instead results from the collapse of jugular veins when the head is elevated. Such a collapse is associated with a significant increase in flow resistance, which leads to redirection of the flow towards the vertebral pathway. Theoretical calculations respecting the rules of fluid mechanics indicate that the pressure gradients necessary for moving blood from the brain toward the heart differ significantly between the supine and upright positions. The occlusion of internal jugular veins, according to fluid mechanics, should result in significant increase in the flow resistance and the restriction of cerebral flow, which is in line with clinical observations. Importantly, the biophysical analysis of cerebral venous outflow implies that the brain cannot easily compensate for increased peripheral venous resistance (namely, an occlusion of the large extracranial veins draining this organ), either by elevating the pressure gradient or by decreasing the vascular resistance through the recruitment of additional drainage pathways. This may mean that chronic cerebrospinal venous insufficiency may cause the destruction of the delicate nervous tissue of the central nervous system.

Dural sinus thrombosis - A rare manifestation of internal jugular venous occlusion

The dural sinus thrombosis is an uncommon complication of a commonly done procedure of central venous catheterisation. We present a case of massive hemorrhagic venous infarct with gross cerebral edema due to dural sinus thrombosis along with right internal jugular vein thrombus. A 21-year-old male patient presented to the emergency department with fever and swelling of the right neck four days following discharge after his prior hospitalization two weeks ago for acute renal failure due to severe gastroenteritis, when he underwent hemodialysis through right internal jugular access. On presentation, he was conscious, with swelling on right side of the neck, which was diagnosed as right internal jugular vein occlusion. However, he rapidly deteriorated and developed signs of raised intracranial pressure despite being on treatment with heparin. He was diagnosed as having massive hemorrhagic cerebral venous infarct with gross cerebral edema complicated with shift of the ventricles to the left due to dural sinus thrombosis. Despite emergency decompressive craniotomy, he succumbed in the next two days due to coning. Asymptomatic catheter-related thrombosis is frequent in the intensive care units, but major complications like retrograde extension into dural sinus causing thrombosis is rare. A high index of suspicion is required to diagnose this major catastrophe for an early and meaningful intervention.

Modified Use of the HeRO Device for Immediate Salvage of a Threatened Dialysis Graft

The Hemodialysis Reliable Outflow (HeRO) device provides an additional access option for hemodialysis in patients with central venous occlusions. The HeRO device is a subcutaneously tunneled dialysis access device comprised of a standard 6mm ePTFE graft coupled to a nitinol reinforced 5mm venous outflow component. Standard placement involves tunneling the venous outflow component to the right atrium via the internal jugular vein and anastamosing the graft component to the brachial artery. This case illustrates a modified technique, employing the device for immediate salvage of a malfunctioning upper extremity dialysis graft with ipsilateral central venous occlusion. We report successful salvage of a failing arteriovenous graft by utilizing a HeRO device anastomosed to the graft and tunneled to the contralateral internal jugular vein. A 69-year-old male on hemodialysis for five years presented complaining of right upper extremity edema and pain worsened during hemodialysis. His dialysis access consisted of a right upper extremity 4-7 mm tapered brachio-axillary arteriovenous ePTFE graft (AVG) created two years prior to this admission (Figure, AVG). He had previously undergone a left basilic vein transposition and left brachio-axillary graft with subsequent removal of the graft due to infection. Despite adequate flow rates through the existing dialysis graft, his symptoms prompted a diagnostic fistulogram that demonstrated a patent right axillary vein (Figure, AXV), and occlusion of the right subclavian vein. Endovascular attempts at recanalization of the subclavian vein were unsuccessful. Central venography from a femoral vein approach demonstrated a right internal jugular vein occlusion, but patent superior vena cava, left innominate vein, and left internal jugular vein. Using ultrasound, the left internal jugular vein was accessed and a wire was passed into the right atrium under fluoroscopy. After establishing central venous access to the superior vena cava, the venous outflow component of the HeRO device was introduced following serial dilation of the tract. The device was then tunneled subcutaneously along the anterior chest wall to a counter incision at the right (contralateral) deltopectoral groove where the 6mm HeRO ePTFE graft was coupled to the venous outflow component (Figure, arrow). A 2.5 cm incision was made at the distal (venous) end of the AVG, and the HeRO ePTFE graft was further tunneled from the coupler incision site to the AVG incision site. The new ePTFE-HeRO system was finally anastamosed in end-to-side fashion to the AVG. A completion fistulogram was performed through the fistula, which revealed brisk flow via the HeRO, into the central venous system and right atrium (Figure, composite fistulogram). Dialysis was instituted the following day with flow rates of approximately 400 ml/min. The patient has successfully continued hemodialysis via his HeRO device for eight months without complications and with relief of his preoperative symptoms. This unique approach with the HeRO device allows graft salvage with immediate use while obviating the need for complex surgical reconstruction for dialysis access.