Incidental Vascular Flaps on Neck Ultrasound

Incidental Vascular Flaps on Neck Ultrasound Yashar Ettekal, MD, David Langdon, MD, Kody El-Mohtar, MD, Asim Raja, MD, Marcela Hanakova, MD, Saroj Pani, MD, and Farhan Shiekh, MD

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39-YEAR-OLD WOMAN presented for her third mitral valve repair. She had been hospitalized for increasing episodes of decompensated heart failure despite multiple attempts at medical amelioration of her symptoms. She had a large perivalvular leak contributing to her failure symptoms in addition to dilated cardiomyopathy, severe pulmonary hypertension, and severe tricuspid regurgitation (TR). After anesthetic induction with etomidate, pancuronium, and sufentanil, the right internal jugular vein was visualized for the placement of a catheter. On imaging of the right neck, hyperechoic flaps were observed within the vessel lumen. An audible murmur was heard during auscultation, and a

Fig 1. The short-axis view of the right internal jugular vein with hyperechoic flaps. The image was obtained by ultrasound of the neck supraclavicularly in between the 2 heads of the sternocleidomastoid.

thrill was palpable in this area of the neck. What is the diagnosis? (Figs 1 and 2)

From the Department of Anesthesiology, Albany Medical College, Albany, NY. Address reprint requests to Yashar Ettekal, MD, Department of Anesthesiology, Mail Code 131, 47 New Scotland Avenue, Albany, NY 12208. E-mail: [email protected] © 2012 Elsevier Inc. All rights reserved. 1053-0770/2701-0001$36.00/0 doi:10.1053/j.jvca.2011.12.008 Key words: jugular vein, venous valve, ultrasound

Fig 2. The long-axis view of the right internal jugular vein with hyperechoic flaps.

Journal of Cardiothoracic and Vascular Anesthesia, Vol 27, No 1 (February), 2013: pp 199-200

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ETTEKAL ET AL

DIAGNOSIS: INTERNAL JUGULAR VEIN VALVES

The images depict internal jugular venous valves. As seen in Figure 1, the short-axis view shows what appears to be true and false lumens associated with arterial dissection in a pulsatile vessel, but in fact are 2 juxtaposed valves of the internal jugular vein. In Figure 2, the long-axis view depicts 2 hyperechoic, flapping structures, again in a pulsatile vessel. The motion of the valves coupled with turbulent or regurgitant flow seen on color Doppler ultrasound can appear as an arterial dissection with flow into a false lumen (Fig 3). As visualized here, increased jugular venous pressure related to heart failure or severe TR causes neck veins to display systolic pulsatility similar to that of the arteries on pressure transduction and ultrasonography. Severe TR may even accentuate flow reversal alongside pulsatile flow patterns. In the images of the patient, flow patterns in the jugular vein reflected her high degree of tricuspid insufficiency; a degree of venous valvular insufficiency also may have accentuated these flow patterns. The presence of jugular venous valves has been known since early cadaveric dissection and been cited as a frequent finding.1 They generally are located at the junction of the innominate and jugular veins, acting to attenuate the transmission of increased intrathoracic pressure. This role serves to prevent reflux and maintains forward cerebral blood flow and normal intracranial pressure.2 However, many anatomic textbooks and descriptions omit discussion of these valves because they are presumed to be evolutionary or embryologic remnants. There are also known morphologic variations of valves. The bicuspid morphology presented here is the most prevalent type. Single- and triple-cusp variations also are reported.3 The presence of unilateral right-sided valves is the second most common finding.4 Valve incompetence is a phenomenon seen with anatomic variations and in the setting of pathologies can result in acquired valvular insufficiency. Venous congestion secondary to valve incompetence has an association with cough-induced headache, transient global amnesia, exertional headache, transient monocular blindness, and idiopathic intracranial

Fig 3. The long-axis view of the right internal jugular vein with color Doppler flow into what appears to be a false lumen.

hypertension.2 Similarly, chronic obstructive pulmonary disease and primary pulmonary hypertension have been implicated as causative mechanisms of valvular incompetence because of persistently elevated intrathoracic pressures.5 Another cause of acquired venous incompetence is central venous cannulation as presented by Wu et al6 in their case series. Pulsatile neck veins and thrill as signs of valve incompetence in the setting of TR also have been described.7 Despite their ubiquitous presence and response to pathologic flow, jugular venous valves are seldom discussed or visualized on a routine ultrasound.

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5. Doepp F, Bähr D, John M, et al: Internal jugular vein valve incompetence in COPD and primary pulmonary hypertension. J Clin Ultrasound 36:480-484, 2008 6. Wu X, Studer W, Erb T, et al: Competence of the internal jugular vein valve is damaged by cannulation and catheterization of the internal jugular vein. Anesthesiology 93:319-324, 2000 7. Amidi M, Irwin JM, Salerni R, et al: Venous systolic thrill and murmur in the neck: A consequence of severe tricuspid insufficiency. J Am Coll Cardiol 7:942-945, 1986