CLINICS 2009;64(10):989-92
CLINICAL SCIENCE
INTERNAL JUGULAR VEIN CANNULATION: AN 
ULTRASOUND-GUIDED TECHNIQUE VERSUS A 
LANDMARK-GUIDED TECHNIQUE
Gurkan Turker,I Fatma Nur Kaya,I Alp Gurbet,I Hale Aksu,I Cuneyt Erdogan,II 
Ahmet AtlasI 
 
doi: 10.1590/S1807-59322009001000009
Turker G, Kaya FN, Gurbet A, Aksu H, Erdogan C, Atlas A. Internal jugular vein cannulation: an ultrasound-guided technique 
versus a landmark-guided technique. Clinics. 2009;64(10):989-92.
OBJECTIVES: To compare the landmark-guided technique versus the ultrasound-guided technique for internal jugular vein can-
nulation in spontaneously breathing patients.
METHODS: A total of 380 patients who required internal jugular vein cannulation were randomly assigned to receive internal 
jugular vein cannulation using either the landmark- or ultrasound-guided technique in Bursa, Uludag University Faculty of Medi-
cine, between April and November, 2008. Failed catheter placement, risk of complications from placement, risk of failure on first 
attempt at placement, number of attempts until successful catheterization, time to successful catheterization and the demographics 
of each patient were recorded.
RESULTS: The overall complication rate was higher in the landmark group than in the ultrasound-guided group (p < 0.01). Carotid 
puncture rate and hematoma were more frequent in the landmark group than in the ultrasound-guided group (p < 0.05). The number 
of attempts for successful placement was significantly higher in the landmark group than in the ultrasound-guided group, which 
was accompanied by a significantly increased access time observed in the landmark group (p < 0.05 and p < 0.01, respectively). 
Although there were a higher number of attempts, longer access time, and a more frequent complication rate in the landmark group, 
the success rate was found to be comparable between the two groups.
CONCLUSION: The findings of this study indicate that internal jugular vein catheterization guided by real-time ultrasound results 
in a lower access time and a lower rate of immediate complications. 
KEYWORDS: Central venous cannulation; Jugular vein; Ultrasonography; Landmark; Complication.
INTRODUCTION puncture have been described.1,2 Complications, including 
death, are influenced by patient factors such as Body 
Internal jugular vein (IJV) catheterization is commonly Mass Index (BMI), site of attempted access, and operator 
attempted to obtain central venous access for hemodynamic experience.3 It has been suggested that ultrasound (US) 
monitoring (such as central venous pressure), long-term guidance could improve the success rate, reduce the 
administration of fluids, antibiotics, total parenteral number of needle passes, and decrease complications.4,5 
nutrition, kemoterapics, and hemodialysis. Many Although the ultrasound method has been favorably 
anatomical landmark (LM)-guided techniques for IJV compared to the landmark technique, its widespread use 
has been hampered by the unavailability of equipment, 
I Departments of Anesthesiology and Reanimation, Uludag University Medi- such as the specially designed ultrasound device, and the 
cal Faculty - Bursa/Turkey.
II Departments of Radiology, Uludag University Medical Faculty - Bursa/ lack of trained personnel. 
Turkey. Cannulation of the IJV is usually preferred because of its 
Email: agurbet@uludag.edu.tr anatomical position and large diameter in the Trendelenburg 
Tel.: 90.224.4428958
Received for publicaiton on June 19, 2009 position. Moreover, the minimal likelihood of obstructions 
Accepted for publication on July 23, 2009 along its route to the right atrium facilitates the introduction 
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Turker G et al.
of various sizes of catheters using the external anatomical vessel, evidenced by the ultrasound and the return of venous 
landmark method. blood into the syringe, a guide-wire was placed through 
The purpose of this study was to determine whether the needle into the vein and the needle was removed. A 
ultrasound guidance could improve the success rate and central venous catheter (Certofix® B. Braun Melsungen 
decrease the complication rate of IJV catheterization AG, Germany) was placed over the wire and advanced into 
compared to the landmark technique. the IJV. 
Demographic characteristics, such as age, gender, 
METHODS physiological score (ASA), coagulation parameters (such 
as platelet numbers), and clinical parameters were recorded 
This prospective study was approved by the Uludag for all patients. 
University Medical Faculty, Bursa-Turkey ethics committee The measured outcomes were the access time, the 
(15 April 2008, 2008-8/28), and written consent was number of attempts for successful placement, and catheter 
obtained from all participants. A total of 380 patients were complications, such as carotid artery puncture, skin 
enrolled in between April and November, 2008. Patients with hematoma, brachial plexus injury, pneumothorax, and 
local or systemic infection, known vascular abnormalities, hemothorax. 
untreated coagulopathy (international normalization ratio Access time was defined as the time between the first 
> 1.5 and platelets < 50000/mm3) were excluded from the skin puncture and the aspiration of venous blood into the 
study. Patients were randomly assigned to one of two groups: syringe. Successful placement was defined as the observation 
the LM group, in which cannulation was attempted via the of the catheters in the proper position by X-ray and 
landmark technique, and the US group, in which cannulation functional determinants (i.e., no difficulty in the infusion or 
was attempted using ultrasound guidance. aspiration of venous blood). 
The landmark technique Statistical Analysis
Patients were placed in a supine position with the head We estimated a 0.90 probability [standard deviation 
rotated at a 300 angle in the Trendelenburg position. The (SD)] that a patient who received IJV catheterization using 
operator, who was a senior medical student in their final the US-guided technique would have lower attempt numbers 
year, wore gown, cap, mask, and sterile gloves. The skin was and complications. Assuming that the number of attempts 
cleaned with povidone-iodine before the placement of sterile would be compared using the Wilcoxon’s rank sum test with 
drapes. After infiltration with 1% lidocaine, the IJV was a two-sided, 10% level of statistical significance and 90% 
located with a ‘finder’ needle connected to a 2-ml syringe. power, we calculated that at least 167 patients for per group 
The needle was advanced through the skin at a 450 angle were required. Data are presented as mean ± SD or as the 
in the direction of the right nipple. The return of venous number of patients per category. A chi-square test was used 
blood into the syringe confirmed entry into the vessel, and to compare categorical variables, and a Student’s t-test was 
the finder needle was then used to guide a 16-gauge, 10 cm used to compare independent means. P-values < 0.05 were 
needle connected to a 10-ml syringe. A guide-wire was then considered statistically significant.
placed through the needle into the vein, and the needle was 
removed. A central venous catheter (Certofix® B. Braun RESULTS
Melsungen AG, Germany) was placed over the wire and 
advanced into the IJV. The characteristics of the 380 patients studied are 
summarized in table 1. 
The ultrasound technique 
Table 1 - Characteristics of the patients
The area was prepared as described in the landmark 
technique section above. Before the procedure, the position The LM group The US group 
of the IJV was determined using a 7.5 MHz linear ultrasound (n = 190) (n = 190)
probe (PLT 704 AT Toshiba Tokyo, Japan) and ultrasound Age (years) 45.9 ± 13.5 49 ± 15.9
(Aplio, Toshiba Tokyo Japan). After choosing the proper Gender (% male) 62.63% 64.21%
position, the skin was infiltrated with %1 lidocaine, and BMI (kg.m-2) 24.2 ± 5.2 23.7 ± 5.8
the IJV was located with an 18-gauge needle guided by the Side of catheterization (% right) 94.73% 90.52%
ultrasound probe. When the needle appeared to be in the Data are presented as mean ± SD or %.
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Turker G et al.
There were no significant differences between the two US group, which explains the significant increase in access 
groups for age, BMI, gender, the side of catheterization, time in the LM group (p < 0.05 and p < 0.01, respectively). 
or the risk factors for difficult venous cannulation (such as Although the LM group had a higher number of attempts, a 
prior catheterization, limited sites for access attempts, known longer access time, and a more frequent complication rate, 
vascular abnormalities, untreated coagulopathy, and skeletal the success rate was comparable between the two groups 
deformity). (Table 2). 
In all except 189 patients in the US group, the IJV 
was visualized and cannulated. One of the patients in the DISCUSSION
ultrasound group had an abnormality of the vascular track 
(thrombus visualized in the vena cava superior behind the This prospective study demonstrated the superiority of 
azygos vein), which resulted in an unsuccessful attempt. US-assisted cannulation of the IJV compared to the external 
During the US-guided procedure, the IJV can be visualized landmark technique. 
before the vessel is actually penetrated. Using this approach, Most studies in the literature have used only US guidance 
a single-wall puncture can be made by the needle to the in placing central venous catheters.6 These studies, however, 
anterior wall. A short stabbing motion of the needle at were conducted on critically ill or mechanically ventilated 
this point will tend to puncture the anterior wall without patients.7 We studied 380 patients, all of whom had 
opposing it to the posterior wall, thereby avoiding a double spontaneous breathing. All catheters were inserted to give 
wall puncture. Single wall punctures were achieved in all total parenteral nutrition solution and chemotherapeutics 
cases in the US group. or to measure the central venous pressure for i.v. fluid 
Bleeding through the insertion site developed in two management. Some authors have recommended the US-
patients in the US group as an immediate complication guided technique in order to identify the location of the IJV 
of catheter placement. None of the patients developed a before insertion of the needle.6 In addition, the superiority 
pneumothorax, hemothorax, or inappropriate position of the of the real-time US guidance over the traditional landmark 
catheter in the US group. technique has already been shown by Nadig et al.8 
The overall complication rate was higher in the The skill of the individual placing the central venous 
LM group compared to the US group (p < 0.01). catheter plays an important role in the success rate. 
Carotid puncture and hematoma were the most frequent According to previous reports, the US-guided technique 
complications in the LM group compared to the US group allowed a marked reduction of the access time.9-11 Central 
(p < 0.05). None of the minor complications required any venous catheters were placed within 3 minutes for all 
specific intervention other than compression of the puncture patients with US guidance.10 In our study, the access times 
site (Table 2). of the groups were statistically different, which is consistent 
Finally, the number of attempts for successful placement with previous studies.
was significantly higher in the LM group compared to the As previously described, the complication rate varied 
with the experience of the physician. The rate of 14.3% was 
Table 2 - Comparison of ultrasound and landmark techniques determined in an inexperienced group in a study by Sznajder 
12
in internal jugular vein cannulation et al.  
The use of real-time US guidance prevents the insertion 
of the catheter into a vein complicated by thromboses or 
LM group US group 13
(n = 190) (n = 190) into a small vein.  In our study, catheterization was not 
successful in one patient in the ultrasound group due to an 
Average number of attempts 1.42 ± 0.92 1.08 ± 0.33*
abnormality of the vascular track (thromboses visualized in 
Complications 8.42 ± 0.44 1.57 ± 0.14† the vena cava superior behind the azygos vein). Using the 
Carotid puncture  9 (4.73%) 1 (0.5%)*
Hematoma 7 (3.68%) 2 (1%)* landmark technique, we found that the success rate of IJV 
Hemothorax 0% 0% catheterization was 97.3%, which is consistent with previous 
Pneumothorax 0% 0% reports (ranging from 85% to 99%).14-16
Access time (seconds) 236 ± 110 95 ± 136† Arterial puncture of the carotid artery is the most 
Success rate 185 (97.36%) 189 (99.47%) frequent complication of IJV catheterization because of 
Access time and the average number of attempts are shown as mean ± SD. its close anatomical proximity to the IJV. The number 
Success rate, carotid puncture, hematoma, hemothorax, pneumothorax, and of attempts for finding the IJV was strongly associated 
side of catheterization are shown as both the absolute number of the patients with the overall rate of complications.17 Mansfield et al.18 
and their percentage in their group. 
*p < 0.05 versus the LM group; †p < 0.01 versus the LM group reported that the complication rate was 4.6% if the catheter 
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Turker G et al.
insertion was successful on the first attempt. The rate, that the carotid artery remained intact, but the introducer 
however, increased to 63.8% for two or more attempts. sheath had passed the posterior wall of the right IJV and then 
Yeum et al.19 retrospectively analyzed 150 patients who entered the inferior thyroid artery.20 
required IJV catheterization, showing that arterial puncture The procedural complexity of transducer sterility and the 
of the common carotid artery occurred in 11.3% of the requirement for an experienced staff are drawbacks of using 
cases. In our study, the rate of carotid artery punctures the US-guided technique for IJV catheterization.
was 5% with the landmark technique and 0.5% with the The findings of this  study indicate that  IJV 
US-guided technique. Schummer et al.20 recently reported catheterization with the guidance of real-time ultrasound 
an intra-arterial catheter misplacement case during IJV results in better success rates and lower immediate 
catheterization. Surgical exploration of the neck showed complications. 
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