Right Internal Jugular Vein Approach as an Alternativein Balloon Pulmonary Valvuloplasty

George Joseph, * MD, DM, K.P. Suresh Kumar, MD, DM, Paul V. George, MD, DM,and Subodh Dhanawade, MD, DM

Transjugular balloon pulmonary valvuloplasty was safely and successfully performed infive patients, two of whom had severe right heart failure. Crossing the stenotic pulmonaryvalve from the right internal jugular vein was consistently easy and quick. This approachshould be considered whenever difficulties are experienced or anticipated in the femoralapproach. Cathet. Cardiovasc. Intervent. 46:425–429, 1999. r 1999 Wiley-Liss, Inc.

Key words: pulmonary valve stenosis; balloon dilatation; heart catheterization

INTRODUCTION

Balloon pulmonary valvuloplasty (BPV) is the treat-ment of choice of isolated valvar pulmonary stenosis, beingassociated with minimal complications and excellentimmedi-ate and long-term results [1–5]. Although the procedure isusually simple, crossing the pulmonary valve from thefemoral vein can be difficult in patients with right ventricularfailure, severe tricuspid regurgitation, andmarkedly dilatedright atrium. In such patients, crossing the pulmonaryvalve can be simplified by using a right internal jugularvein approach and a balloon floatation catheter, given thatthis is easily done at the bedside without fluoroscopicguidance in patients with normal valves. Recourse to suchan alternative approach to BPV, when a stenotic pulmo-nary valve could not be crossed from the femoral vein,has only been reported twice in the literature [6,7] andrequires further study.Reluctance of operators to use thisapproach may be related to unfamiliarity with the technique,potential complications, paucity of reports describing resultsof transjugular cardiac interventional procedures, and disincli-nation to introduce large balloon catheters and sheaths into theright internal jugular vein. The situation haschanged re-cently with the reported safe and effective use of thetransjugular approach for balloon angioplasty of periph-eral pulmonary artery stenosis in children [8] and balloonmitral valvuloplasty in adults [9]. We report five caseswherein a transjugular approach to BPV was used, because ofdifficulty in crossing the pulmonary valvefrom the femoralvein in two cases, and electively in three cases.

CASE REPORTS

Case 1

A 30-year-old female presented with features of severeright heart failure. Plain chest radiography showed gross

cardiomegaly (Fig. 1A). Echocardiography revealedmarked right atrial enlargement, severe tricuspid regurgi-tation, and valvar pulmonary stenosis. The atrial septumand ventricular septum were intact. A BPV procedure wasplanned. After informed consent and mild sedation,percutaneous femoral venous access was obtained andright ventriculography was performed. This confirmedthe presence of valvar pulmonary stenosis, severe tricus-pid regurgitation, and huge right atrium (Fig. 1B).Attempts to cross the pulmonary valve using end-holecatheters and balloon floatation catheters were unsuccess-ful. With two large loops of catheter in the right atrium,the tip of a guidewire could be passed across the valve(Fig. 1C), but it was not possible to straighten out thecatheter loops without losing wire position. Hence theright internal jugular vein was cannulated percutaneouslyusing standard technique [10], and a 9 Fr sheath withhemostatic valve was inserted. The pulmonary valvecould now be crossed quickly and easily using a balloon-tipped wedge-pressure catheter (Arrow, Reading, PA) anda standard 0.035’’ guidewire. Peak systolic pressuregradient of 74 mm Hg across the pulmonary valve wasestablished (Table I). A 0.035’’ Amplatz supersiffguidewire (Meditech, Boston Scientific, Watertown, MA)was introduced through the wedge pressure catheter intothe distal right pulmonary artery. The 9 Fr sheath wasreplaced with a short 14 Fr sheath (Cook, Bloomington,

Department of Cardiology, Christian Medical College Hospital,Vellore, India

*Correspondence to: Dr. George Joseph, Department of Cardiology,Christian Medical College Hospital, Vellore 632 004, South India.E-mail: gjoseph59@hotmail.com

Received 8 July 1998; Revision accepted 14 October 1998

Catheterization and Cardiovascular Interventions 46:425–429 (1999)

r 1999 Wiley-Liss, Inc.

IN). The pulmonary valve was dilated twice using a 9 FrNucleus balloon catheter (Numed, Ontario, Canada) with26-mm-diameter, 4-cm-length balloon (Fig. 2), which iscapable of rapid inflation and deflation. The stiff guidewirehelped to stabilize the balloon at the pulmonary valve.The final gradient across the pulmonary valve was 8 mmHg. Five thousand units of heparin were administeredduring the procedure. There were no complicationsduring or after the procedure. Sheaths were removedimmediately and the patient was discharged from thehospital 24 hr later. At 7-month follow-up, the patient wasasymptomatic, and the peak pulmonary valve gradientdetermined by Doppler echocardiography was 10 mm Hg.

Case 2

An 8-year-old boy presented with features of severepulmonary stenosis, right ventricular failure, and proteinenergy malnutrition. Angiography revealed severe valvarpulmonary stenosis, gross tricuspid regurgitation, andlarge right atrium. Crossing the pulmonary valve usingthe right femoral vein approach was achieved afterconsiderable difficulty. Transfemoral BPV was performedusing an 18-mm-diameter balloon and resulted in fall inpeak systolic gradient across the pulmonary valve from103 to 41 mm Hg and right ventricular peak systolicpressure from 135 to 75 mm Hg. At follow-up 5 monthslater, features of right heart failure had decreased, andnutritional status had improved significantly. Echocardi-ography revealed a peak systolic pressure gradient of 50mm Hg across the pulmonary valve. Further reduction ofthis gradient was considered desirable, and a second BPVprocedure using a larger balloon was performed. Thistime the right internal jugular vein approach was used inview of the difficulty encountered in crossing the pulmo-nary valve from the femoral vein during the first BPVprocedure. The technique used was identical to that incase 1, except that a 12 Fr jugular sheath and a 22-mm-diameter balloon (Numed) were used. The peak pulmo-nary valve pressure gradient was reduced from 50 to 21mm Hg. There were no complications during or after theprocedure. At follow-up 6 months later, the patient wasasymptomatic, and features of right heart failure hadcompletely resolved. The peak pulmonary valve gradientdetermined by Doppler echocardiography was 14 mm Hg.

Case 3

BPV using the right internal jugular vein approach wasperformed electively in a 21-year-old female. The tech-

Fig. 1. Case 1. A: Plain chest radiograph (posteroanterior view)showing marked cardiomegaly. B: Right ventriculogram show-ing valvar pulmonary stenosis, severe tricuspid regurgitation,and huge right atrium. C: Unsuccessful attempt to cross thepulmonary valve from the femoral vein.

426 Joseph et al.

nique used was identical to that in case 1 except that a25-mm-diameter, 4-cm-length Triad-AT balloon (Mans-field, Boston Scientific) was used. This balloon inflatesrelatively slowly and tended to slip distally into thepulmonary artery before full inflation was achieved.Traction on the balloon catheter during inflation resultedin shortening of the loop of catheter in the right atriumand ventricle, rather than stabilization of the balloon.Advancing the 14 Fr jugular sheath tip to the level of thetricuspid valve helped to reduce shortening of the catheterloop. A successful, complication-free result was obtained.

Case 4

Elective transjugular BPV using a 24-mm-diameterInoue balloon (Toray, Tokyo, Japan) was performed in a13-year-old boy. The balloon was introduced through a 14Fr sheath, over a 0.025’’ Amplatz extrastiff wire (Cook)placed in the distal right pulmonary artery. Although theoutcome was successful and complication-free, stableballoon position during inflation was difficult to obtain.Traction on the catheter, especially during the firstballoon dilatation to 22 mm, resulted in a markedtendency of the catheter loop in the right atrium andventricle to shorten and pull upward at the tricuspid valve(Fig. 3). The balloon tended to slip proximal or distal to thepulmonary valve during subsequent balloon dilatation to 24mm, after partial relief of valvar stenosis had been obtained.

Case 5

Elective transjugular BPV was performed in a 33-year-old male with unusually large pulmonary annulus (diam-eter 28 mm). Use of 9 Fr balloon catheters (Mansfield andNumed) with balloon diameter$25 mm resulted in theballoon repeatedly slipping proximal or distal to thepulmonary valve during inflation. This problem wasovercome by using a 11 Fr Joseph mitral balloon catheter(Numed) with 26-mm-diameter, 4-cm-length balloon.The coaxial design and large diameter of the shaft of thiscatheter allow very rapid balloon inflation and deflation.A successful, complication-free result was obtained.

DISCUSSION

The feasibility of transjugular BPV was demonstratedby two case reports prior to this case series. Chaara et al.[6] used this alternative approach to BPV in a 6-year-oldwith severe right heart failure, after attempts to cross thepulmonary valve from the femoral vein failed. A subse-quent transfemoral BPV was necessary to obtain optimalresults. Shrivastava et al. [7], in their case series of BPVin patients with congestive heart failure, reported usingthe transjugular approach in one patient, but do notprovide procedural details. The present case series addssignificantly to the information provided by the earliertwo case reports on transjugular BPV, especially withregard to safety, efficacy, methodology, and equipment.

Meticulous attention needs to be paid to the internaljugular vein cannulation technique, because complica-tions, though rare, can be serious. In a review of literatureby Senzaki et al. [8], complications related to internaljugular vein cannulation that have been reported includepneumothorax, hydrothorax, injury to the vagus, phrenicand other nerves, superior sagittal sinus thrombosis,thoracic duct puncture, laryngeal edema, and vertebralartery pseudoaneurysm. These complications are almostalways caused by inexperienced operators and are usuallydue to unfamiliarity with or inaccurate identification ofthe anatomic landmarks [11]. Ultrasound-guided cannula-tion of the internal jugular vein significantly reducescomplication rates [12] and may be the preferred tech-nique early in an operator’s experience. Complicationsrelated to internal jugular vein cannulation were absent inthis case series and have been minimal or absent in twoother reports where this approach was used for cardiacinterventions [8,9]. Besides the common indications ofcentral venous line placement and right heart hemody-namic monitoring, right internal jugular vein access hasalso been used for conventional cardiac catheterization inchildren [13–15], cardiac biopsy [10,11], and liver biopsy[16], with low complication rates. Thus the rare occur-rence of significant complications should not discourage

TABLE I. Patient Characteristics and Results of Transjugular BPV a

Patientnumber

Age andsex

Weight(kg)

Rightven-

tricularfailure

Peak PVgradient(mm Hg)pre/post

RV systolicpressure(mm Hg)pre/post

Pulmonaryannulus(mm)

Balloonsize

(mm)Balloonmake

Jugularsheath size

(Fr)

Indication fortransjugular

approachCom-

plications

1 30F 35 Present 74 8 90 26 20 26 Numed 9 Fr 14 Failure to cross PVfrom femoral vein

None

2 8M 15 Present 50 21 80 51 16 22 Numed 9 Fr 12 Past difficulty in trans-femoral PV crossing

None

3 21F 48 Absent 57 10 82 32 19 25 Mansfield 9 Fr 14 Elective None4 13M 34 Absent 88 10 104 28 16 24 Toray 12 Fr 14 Elective None5 33M 74 Absent 60 20 87 47 28 26 Numed 11 Fr 14 Elective NoneaAbbreviations: BPV, balloon pulmonary valvuloplasty; PV, pulmonary valve; RV systolic pressure, right ventricular peak systolic pressure.

Transjugular Balloon Pulmonary Valvuloplasty 427

use of internal jugular venous access. Careful attention tolandmarks and technique, if necessary with ultrasoundguidance, will almost invariably result in a safe andsuccessful procedure.

Introduction of sheaths, appropriately large for valvulo-plasty balloons, into the right internal jugular veinappears to be well tolerated in all age groups. In this caseseries, a 12 Fr sheath used in an 8-year-old, and 14 Frsheaths used in an older child and three adults were notassociated with any complications. Senzaki et al. [8], whoused the right internal jugular vein approach to performballoon angioplasty of peripheral pulmonary artery steno-sis, used two 9 Fr sheaths side-by-side in the sameinternal jugular vein for double-balloon dilatation in

children 6 to 13 years old, and a single 7 Fr sheath in a4-month-old infant, without complications. Transjugularplacement of inferior vena caval Greenfield filters for-merly required dilatation of the venous insertion site to 24Fr and was associated with a local thrombosis rate of 14%[17]. Such an occurrence is usually asymptomatic and ofno clinical importance, and migration of jugular veinthrombi and consequent pulmonary embolization havenot been described [18]. However, it may rarely lead to

Fig. 2. Case 1. A: Transjugular pulmonary valve dilatation.Indentation produced by the stenotic valve is seen on theballoon. B: Fully inflated balloon.

Fig. 3. Case 4. Transjugular pulmonary valve dilatation usingthe Toray balloon. A: Inflation of the distal part of the balloon. B:Traction on the catheter results in shortening of the catheterloop and pulling up at the tricuspid valve.

428 Joseph et al.

sagittal sinus thrombosis and superior vena caval syn-drome [19]. The biggest (23- to 28-mm-diameter) valvu-loplasty balloons currently available (Numed, Mansfieldand Toray) do not require sheaths larger than 14 Fr, whilesmaller (15- to 22-mm-diameter) balloons require 12 Frsheaths or less. Jugular venous thrombosis is thereforeunlikely to occur. It is essential that catheters andballoons are introduced into the jugular vein only throughsheaths with hemostatic valves. Negative intrathoracicpressure can lead to air embolism when a sheath is notused and the skin puncture site is kept patent by anindwelling wire or catheter [9].

The only significant technical difficulty encountered inthis case series was balloon instability, which was seen inthree patients. Control of balloon position is more diffi-cult when using the transjugular approach, because of the180 degree loop of wire and catheter in the right heart.Backward traction on the balloon and wire results inshortening of this loop, rather than preventing the balloonfrom slipping distally. Balloon instability can be mini-mized by using a 0.035’’ extrastiff wire and the rapidlyinflating Numed balloon, especially one with a 11 Frshaft. Increasing the length of the balloon to.5 cm mayhelp reduce instability, but this advantage may be offsetby a longer balloon inflation time. Besides, if shorteningof the catheter loop occurs, long balloons may inadver-tently damage the tricuspid valve. The Toray balloon hassome limitations when used with this technique: first, it iscompatible with only a 0.025’’ wire, which provides lessstability than a 0.035’’ wire; second, it needs to be pulledback to engage the pulmonary valve, at which time thecatheter loop shortens markedly and pulls up at thetricuspid valve; third, the Toray balloon tends to slipproximal or distal to the pulmonary valve during infla-tion, especially after partial relief of stenosis has beenobtained. The slower inflating Mansfield balloon is alsonot optimal for this technique.

In conclusion, the right internal jugular vein approachto BPV is safe, effective, and reliable. In all five patientsin this case series, crossing the pulmonary valve with aballoon-floatation catheter was consistently quick andeasy, despite the presence of severe tricuspid regurgita-tion and marked enlargement of the right atrium in twopatients. The transjugular approach to BPV should beconsidered whenever crossing the pulmonary valve fromthe femoral vein is difficult, and may be utilized elec-tively in patients with severe right heart failure, markedlyenlarged right atrium, or gross tricuspid regurgitation.

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