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Percutaneous right internal jugular venous cannulation in minimally invasive cardiac surgery/Minimal invaziv kalp cerrahisinde perkutan sag internal juguler venoz kanulasyon.


The applications of cardiac surgery (CS) have progressed most notably with the development of minimally invasive techniques. The usage of smaller diameter venous cannulas and vacuum-assisted venous return (VAVR), greatly provided the opportunity to perform minimally invasive procedures (MIP)(1). This has increasingly led surgeons perform cardiac procedures through smaller than traditional incisions which was suggested by Doty et al. in 1998 (2, 3). Nonetheless, the reduced incision size has been matched by a corresponding increase in technical difficulty and operative time due to the limited cardiac exposure (2). With this regard, taking as much the cannulas off the operation field was a concern in order to ease the manipulation and exposure (4). Moreover, the success and relative ease of peripheral cannulation along with the use of VAVR has permitted the application of cardiopulmonary bypass (CPB) feasible for MIPs (1, 5-7).

The aim of this article is to inform in regard to the advantages and the ease of the application of percutaneous right internal jugular venous cannulation (PRIJVC) in MIPs.

Case Report

In 2011, we performed two minimally invasive secundum atrial septal defect (ASD) closure with PRIJVC. The ASDs were inappropriate for percutaneous device closure due to inadequate antero-superior septal rim. The demographic and operative characteristics of the cases' are summarized in Table 1.

The jugular cannulation in both cases was performed as the first step before sternotomy percutaneously under 1 mg/kg intravenous hepatization with a 20 Fr femoral artery cannula (Edwards Lifesciences, FemFlex II, Irvine, CA, USA). The cannulation was performed with Seldinger technique through anterior approach in Trendelenburg's position (Fig. 1). The cannula was secured on the understanding that the final positioning of the tip of the cannula will be adjusted just before the superior caval tourniquet with inspection and palpation during cardiac exposure. The remaining 2 mg/kg intravenous heparin was administered after sternotomy in case 1 and before the femoral arterial cannulation in case 2.

Both operations were performed through 6 cm skin incision with distal partial 'T' sternotomy (Fig. 2) along with the application of -20 to -40 mmHg VAVR (Baxter, Las Vegas, Nevada, USA). In both cases, the ASDs were closed with ePTFE patch and the termination of CPB was performed in standard fashion. None of the cases experienced neurologic or access site related complication.

In Fig. 3, the setting of CPB along with the inferior vena cava cannula initiated through the skin incision of the pericardial drain is presented. The ASD can easily be explored in Fig. 4. The setting of CPB together with femoral vein cannulation in case 2 is demonstrated in Fig. 5.

During decannulation, after neutralization with protamine, the jugular venous cannula was pulled away and hemostasis was achieved by manual compression for 10-15 minutes (Fig. 6a). After surgical hemostasis was achieved, the chest was closed in standard fashion (Fig. 6b, c).


The advancements have been explosive sweeping aside the old standards in CS. The RIJV represents one of the most commonly used central venous access site for CS patients (8-10). Minimally invasive cardiac surgery (MICS) patients are increasingly becoming the greater part of the CS population. MICS is an important frontier facing the profession with a huge oasis of opportunity for both the cardiac surgeons and the patients. From another point of view, while this approach provides adequate exposure, only one operator could see well thus, it makes difficulties for assistants to help and moreover, it is hard to train residents how to perform these procedures via this incision (2). In our opinion, taking off the most cannulas out of operation field helps trainees to rule over the operation more efficiently. Use of a head video camera is thought to be an attractive way to take attention of the residents for the procedure.

It is apparent that the method of PRIJVC provides a less cluttered operative field, particularly when the arterial cannulation is made other than the site of ascending aorta.


PRIJVC in MIPs can readily be accomplished in most cases with relative ease and safety in experienced hands. As cardiovascular surgeons in this era of minimally invasiveness, we are responsible to embrace the future of the profession and the management of these patients that we will be expected to be facile with the commencement of CPB through RIJV.

Conflict of interest and funding

The authors declared no conflicts of interest with respect to the authorship and/or publication of this article. The authors received no financial support for the research and/or authorship of this article.


(1.) Colangelo N, Torracca L, Lapenna E, Moriggia S, Crescenzi G, Alfieri O. Vacuum-assisted venous drainage in extrathoracic cardiopulmonary bypass management during minimally invasive cardiac surgery. Perfusion 2006; 21: 361-5. [CrossRef]

(2.) Chitwood WR, Rodriguez E. Minimally invasive and robotic valve surgery. In: Cohn LH, ed. Cardiac Surgery in the Adult. 3 ed. New York: McGraw-Hill; 2008. p. 1079-100.

(3.) Doty DB, DiRusso GB, Doty JR. Full-spectrum cardiac surgery through a minimal incision: mini-sternotomy (lower half) technique. Ann Thorac Surg 1998; 65: 573-7. [CrossRef]

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(8.) Bartal J, Graber R, Markowitz AH, Capdeville M, Hartman GS, Shernan SK. Case 6-2006. Percutaneous superior vena cava cannulation for repeat sternotomy in cardiac operations. J Cardiothorac Vasc Anesth 2006; 20: 881-7. [CrossRef]

(9.) Ohuchi H, Kyo S, Asano H, Tanabe H, Yokote Y, Omoto R. Development and clinical application of minimally invasive cardiac surgery using percutaneous cardiopulmonary support. Jpn J Thorac Cardiovasc Surg 2000; 48: 562-7. [CrossRef]

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Emrah Sisli, Ali Aycan Kavala [1], Gokcen Ozserim [2], Oztekin Oto [2]

Clinic of Cardiovascular Surgery, Antakya State Hospital, Hatay-Turkey

[1] Clinic of Cardiovascular Surgery, Bakirkoy Sadi Konuk Education and Research Hospital, Istanbul-Turkey

[2] Department of Cardiovascular Surgery, Faculty of Medicine, Dokuz Eylul University, Izmir-Turkey

Address for Correspondence/Yazisma Adresi: Dr. Emrah Sisli Antakya Devlet Hastanesi, Kalp ve Damar Cerrahisi Klinigi Altincay mah. Mehmet Kafadar sok. 31040, Antakya, Hatay-Turkiye Phone: +90 505 598 52 33 E-mail:

Available Online Date/Cevrimici Yayin Tarihi: 22.04.2013

doi: 10.5152/akd.2013.115

Table 1. The demographic and operative characteristics of the cases'

Characteristics                           Case 1           Case 2

Age, years / Gender                     17/Female          35/Male
Body surface area, [m.sup.2]               1.6               2.1
Venous cannulation sites               IVC and RIJV     RFV and RIJV
Arterial cannulation site            Ascending aorta      Right CFA
Volume of prime solution, cc               1200             1450
Flow rate, L/min                           3.75             5.16
Duration of CPB                             40               45
Duration of ACC, min                        14               12
Duration of operation, min                 175               140
Duration of ICU stay, hours                 20               18
Duration of hospitalization, days           3                 4

ACC--aortic cross clamp, CFA--common femoral artery,
CPB--cardiopulmonary bypass, ICU--intensive care unit, IVC--inferior
vena cava, RFV--right femoral vein, RIJV--right internal jugular vein
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Title Annotation:Case Report/Olgu Sunumlari
Author:Sisli, Emrah; Kavala, Ali Aycan; Ozserim, Gokcen; Oto, Oztekin
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Date:Jun 1, 2013
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