Ultrasound-Guided Retrograde Internal Jugular Venous Puncture in Neurointerventional Procedures

Article information

Neurointervention. 2026;21(1):29-34

Publication date (electronic) : 2025 December 1

doi : https://doi.org/10.5469/neuroint.2025.00745

Jan Mohd Suhail, MD, Santhosh Babu Kannan Bharathy, MD, Shikhar Garg, MD, Shoban Haridass, MD, Shyamkumar Nidugala Keshava, MD

Department of Interventional Radiology, Christian Medical College Vellore, Vellore, Tamil Nadu, India

Correspondence to: Shyamkumar Nidugala Keshava, MD Department of Interventional Radiology, Christian Medical College Vellore, Doctors housing, Ranipet 91-416-228207, Vellore, Tamil Nadu 632004, India E-mail: shyamkumar.n.keshava@gmail.com

Received 2025 August 29; Revised 2025 November 15; Accepted 2025 November 16.

Abstract

INTRODUCTION

In neurovascular pathologies, transvenous access may sometimes be necessary for diagnostic or interventional purposes. Transvenous access often requires simultaneous transarterial access to delineate the pathology, study the venous pathways, and obtain roadmaps during the procedure [1]. Common neurointerventions performed via venous access are thrombectomy in cerebral venous thrombosis (CVT), inferior petrosal sinus sampling (IPSS) in Cushing’s disease, diagnostic venous manometry, deployment of venous sinus stent in sinus stenosis and idiopathic intracranial hypertension, transvenous embolization of arteriovenous malformations, dural arteriovenous fistulae (dAVF), carotid-cavernous fistulae (CCF), and vein of Galen malformation [1-5]. The venous access in such situations is secured by retrograde puncture of the femoral vein, upper limb veins, jugular veins, superior ophthalmic veins, or by direct puncture of the venous sac or venous cut-down [1,5,6].

Antegrade puncture of the internal jugular vein (IJV) is commonly performed for various indications, such as gaining access for hemodynamic monitoring, parenteral nutrition, dialysis ports, chemoports, transjugular intrahepatic portosystemic shunts, and transvenous liver biopsies [7-9]. To gain such access ultrasound-guided and anatomical landmark-guided techniques have been described [10,11]. It has been shown that the ultrasound-guided technique is safer, with fewer complications (hematoma/carotid puncture), shorter time to access, and fewer attempts needed to gain access [12,13]. Since retrograde internal jugular access is a valuable but underutilized method to gain access to neurovascular territory, we retrospectively evaluated neurointerventions performed in our center over 20 years using ultrasound-guided retrograde IJV punctures to ascertain its utility, safety and efficacy. The key highlights of this study include its technical success, the broad range of clinical indications and the substantial number of retrograde jugular punctures performed under ultrasound guidance—underscoring the value of ultrasound- guided retrograde jugular access as a viable alternative in neurointervention.

This study was conducted to evaluate the safety, efficacy, and potential indications of ultrasound-guided retrograde IJV puncture in neurointerventional procedures.

MATERIALS AND METHODS

This is a retrospective observational study evaluating patients over 20 years (January 2000 to July 2024) who underwent ultrasound-guided retrograde IJV punctures for various neurovascular indications in our institute, in the department of interventional radiology. The source of our data was the institutional Picture Archiving and Communication System. We analyzed patient demographics, indications, technique of puncture, access size, complications, and the safety of punctures in our study population. We routinely used sonographic guidance in all our accesses as a standard of care. All retrograde punctures were performed under general anaesthesia by experienced interventional radiologists at our center. In addition, ultrasound-guided jugular vein puncture for body interventions is a routinely performed procedure in our institution. All patients received 70 U/kg of heparin at the beginning of the procedure, followed by 20 U/kg every hour. The patients had normal coagulation parameters (International Normalized Ratio [INR]<1.5, activated partial thromboplastin time [aPTT]<35 seconds, platelet count >50,000 /μL) before planned intervention; however, patients in the CVT group were invariably on heparin (adjusted to weight) as part of best medical management and their parameters need not be within range.

Technique of Ultrasound-Guided Puncture

We routinely evaluate the IJVs for patency and anatomical feasibility before the standard site preparation. In some peculiar situations such as in patients with a short neck, extension of the neck was ensured to augment the technical success of the procedure. Similarly, enlarged breasts in some females can limit the ease of access, and we routinely prefer to strap the breast tissue with elastic material. The patient’s entire body is draped to ensure the interventionist can operate at the patient’s groin level. While the site of puncture changes in comparison to femoral access, the principle of intervention remains the same.

Using a high-frequency ultrasound probe (Sonoscape P40, 3.0 -17 MHz linear probe), and after infiltration of the site with local anaesthetic (2% lignocaine), retrograde puncture of the jugular vein was performed using an 18G puncture needle or micropuncture introducer set (21G, 7 cm) system. We routinely puncture the jugular vein at its 12 o’clock position (in cross-section on ultrasound) in its lower one-third, accounting for the possible low confluence of the facial vein, occipital vein or petrosal sinus, so that the caveats in cannulating the vessels of interest are obviated. In some patients, bilateral jugular venous accesses were taken depending on the indication. This was followed by the passage of a 0.035” J-tip guidewire or 0.018” Mandril wire (40 cm; Cook Medical) and securing the access with (4 to 8F) sheaths. The cannulation of intracranial sinuses (sigmoid, transverse, and superior sagittal) was done with a 0.035” hydrophilic-coated guidewire (150 cm, Radiofocus^®; Terumo Vietnam) and angiographic catheter combination (Figs. 1, 2). When needed, the IPS and straight sinus were cannulated using a microcatheter-wire system. The subsequent steps would depend on the procedure’s indication. The procedures were most often performed with guiding catheters similar to the ones used with femoral venous accesses. For dural sinus thrombectomy, Fogarty balloon catheters (Edwards Lifesciences) were used as described by Alwan et al. [14]. At the end of the procedure, the sheaths were removed and hemostasis was achieved by manual compression.

Fig. 1.

Line diagram of retrograde jugular puncture of the right IJV in coronal and axial planes. 1: mastoid, 2: IJV, 3: carotid artery, 4: guidewire, *: needle. IJV, internal jugular venous.

Fig. 2.

Photographs depicting ultrasound-guided retrograde jugular puncture. (A) Ultrasound guided puncture of the IJV with the needle tip seen entering at 12 o’clock of vein. (B) Puncture needle with guidewire advanced across into the IJV. (C) Jugular access secured by 8F sheath. (D) Bilateral retrograde jugular access in a patient. IJV, internal jugular venous.

We used the SQUIRE (Standards for QUality Improvement Reporting Excellence) checklist when writing our report [15].

RESULTS

In this study, we analyzed 60 patients (males: n=38, 63%; females n=22, 37%). The study group ranged in age from 13 to 73 years with a median age of 33 years. The baseline characteristics of our study population are summarized in Table 1.

Table 1.

Demographics and anticoagulation protocols in our study population

A total of 74 retrograde jugular punctures were performed, out of which 34 (46%) were isolated right-sided, 18 (24%) were isolated left-sided, and 22 (30%) (in 11 patients) were bilateral. Isolated right-sided punctures were done in 31 patients (52%), isolated left-sided punctures in 18 (30%), and 11 patients (18%) underwent bilateral punctures. In the isolated right-sided puncture group, 3 patients underwent repeat punctures at 2 separate sessions due to the need for re-intervention for the primary pathology (thus 34 right-sided punctures were performed in 31 patients). Most bilateral punctures were performed in a single session; however, in 3 patients, cannulation of the alternate jugular sides was performed in 2 separate sessions at 2 different times.

All the punctures were ultrasound-guided and technically successful. Access was usually gained via an 18G vascular access needle; however, in some patients, micropuncture was used. The smallest short sheath used was 4F (n=3), and the largest was 8F (n=2), with 5F being the most commonly used (n=29, 48%). We did not encounter any inadvertent arterial punctures. One patient developed a small hematoma during the puncture on the right side; however, the access was successfully secured on the left side, the usual dose of heparin was administered and the procedure was completed uneventfully.

The most common indication for the retrograde jugular puncture in our study was mechanical thrombectomy for CVT (37 patients, 61.6% of patients; 46 punctures, 62% of all punctures). Other indications were transvenous embolization of CCF (10 patients, 16.6% of patients; 12 punctures, 16% of all punctures), embolization of cerebral dAVF (6 patients, 10.0% of patients; 6 punctures, 8% of all punctures), IPSS (3 patients, 5.0% of patients; 6 punctures, 8% of all punctures), and cerebral venous sinus angioplasty or stenting (4 patients, 6.6% of patients; 4 punctures, 6% of all punctures). All these procedures were performed under general anaesthesia, and the expected technical outcome was achieved.

In the CVT group, most patients had concomitant multiple sinus involvement, with the superior sagittal sinus being the most commonly involved in 31 patients (83%, n=37), followed by right transverse sinus involvement in 18 patients (48%). The left transverse sinus was involved in 14 patients (37%), the straight sinus in 11 (29%) and one patient (3%) had associated left IJV thrombosis. In all these cases balloon maceration was successfully performed.

DISCUSSION

IJV puncture for central venous access was first described in 1969 by English et al. [16] and has now evolved into a standard procedure in daily clinical practice, with the antegrade approach being the common mode of access. The retrograde jugular access is both clinically uncommon and technically demanding, given the limited expertise and available literature. However the retrograde approach is rewarding because it allows interventionists to use a shorter guiding system, which is close to the site of pathology, allowing sufficient working length for selective cannulations and potentially decreasing the hardware used for the procedure and, hence, the cost. It gives an option of establishing a less tortuous guiding system by avoiding the need to negotiate the angulated brachiocephalic vein-superior vena cava and brachiocephalic vein-IJV junctions. Thus, the manipulations at the site of intervention become less challenging, shortening the procedure time. Having shorter catheter assemblies within the patient may decrease the risk of thromboembolic events [6]. Besides these technical advantages, jugular access also reduces patient morbidity by allowing normal ambulation [17]. In addition, the cannulation of the jugular vein is relatively easy in patients with enlarged groin folds compared to the femoral vein. Since retrograde jugular access bypasses the central veins, it may allow neurovascular access in the setting of central venous occlusions.

Retrograde jugular access can be safely employed in the setting of CVT for balloon maceration. In our study, in all cases of CVT, retrograde jugular access was successful for cannulation across different thrombosed sinuses. Generally, patients with CVT who do not improve clinically despite optimal medical management, including anticoagulation, are selected for mechanical thrombectomy at our institution [14]. The retrograde jugular access in such cases allows us to use certain shorter catheters and other hardware that cannot be used with femoral access, such as a Fogarty balloon (4F, 80 cm) for maceration of thrombus. These patients may have a deranged coagulation profile at the time of intervention; however, considering the urgency of the procedure, anticoagulation being part of their medical management and no significant risk of life-threatening hematoma in our experience, we go ahead with thrombectomy.

Transvenous embolization of dAVFs and transvenous embolization of CCFs can be safely performed using retrograde jugular access. In our study, we encountered no access-related challenges during these procedures.

In the setting of Cushing’s disease, IPSS is of diagnostic value, with very high sensitivity (88% to 100%) and specificity (67% to 100%) [18]. We were able to cannulate petrosal sinuses in all the patients (n=3) and retrieve samples with precision. We used retrograde jugular access for transverse sinus cannulations in the setting of stenosis, with the intention of balloon angioplasty and/or stenting, and completed the procedures uneventfully. The complications of IJV puncture in the form of iatrogenic carotid artery injury are well known, albeit its low incidence in ultrasound-guided technique is as low as 0.5% [7]. The complications related to IJV puncture increase with the increase in number of attempts to cannulate [19,20]. The number of attempts required for successful cannulation decreases with ultrasound-guidance, thereby reducing procedure-related complications.

The severe complications, including stroke, arteriovenous fistulae, life-threatening haemorrhage and airway compromise have been described with IJV cannulation [21]; however, in our study, we did not encounter any clinically significant complication, thus making ultrasound-guided access a standard of care in our institution. The lone patient who developed a small self-limiting hematoma on the right side was on subcutaneous Enoxaparin 1 mg/kg, twice a day regimen for CVT with an INR of 1.4, aPTT of 39 and platelet count of 211,000. The contralateral side was cannulated successfully after effective manual compression of the hematoma, and we achieved the desired technical success.

The limitations of this study may be its retrospective design and lack of a control group. Comparing data with other venous accesses for the same set of indications may better help study the role of retrograde jugular puncture in neurointerventional procedures. In addition, details such as the number of attempts required to gain access, the time taken to secure the access, the operator radiation dose and difference in the hardware used may be studied.

CONCLUSION

Ultrasound-guided retrograde IJV puncture is a safe and effective method for gaining access to neurovascular pathologies that require a transvenous approach. Being closer to the site of pathology and bypassing anatomical limitations, jugular access reduces the need for some major hardware and thus the cost compared to the conventional femoral approach, while also reducing procedure time without compromising patient safety.

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