What vein is commonly injured during a tracheostomy?

The Anterior Jugular Vein is the Most Commonly Injured Vein During Tracheostomy

The anterior jugular vein is the most commonly injured vein during tracheostomy procedures due to its anatomical position directly anterior to the trachea. This vascular injury can lead to significant hemorrhage, which is one of the most serious complications of tracheostomy, associated with increased mortality rates.

Anatomical Considerations

The anterior jugular vein is particularly vulnerable during tracheostomy for several reasons:

• It runs vertically in the anterior neck, often directly in the surgical field
• Anatomical variants are common, including:
  • Midline position (median vein) overlying the trachea 1
  • Variable size and position between patients
  • Communicating branches that cross the midline

Hemorrhagic Complications

Tracheostomy-related hemorrhage is a significant complication:

• Hemorrhage is the second most common adverse event in adult tracheostomy patients (1.74 per 1000 tracheostomy bed days) 2
• Associated with 2-4 fold increase in mortality risk 2
• Can be immediate, early, or late in presentation 2

Sources of bleeding include:

1. Anterior jugular veins (most common)
2. Inferior thyroid veins
3. High brachiocephalic vein
4. Aberrant anterior jugular communicating veins 3
5. Tracheo-arterial fistulae (rare but often fatal) 2

Prevention Strategies

To minimize vascular injury during tracheostomy:

1. Preoperative ultrasound scanning:

   • Identifies vulnerable blood vessels in the neck 4
   • Locates the tracheal midline and thyroid isthmus
   • Particularly important for patients with difficult landmarks 4
   • Can detect anterior jugular vein variants that may be at risk 1

2. Surgical technique considerations:

   • Avoid fully extending the neck to reduce injury to vessels low in the neck 3
   • Site the stoma at upper tracheal rings (but above the 4th ring) 3
   • Consider surgical rather than percutaneous approach when vascular anomalies are identified 1
   • Use fiberoptic endoscopy to confirm correct tube placement 3

Management of Tracheostomy Bleeding

When bleeding occurs during or after tracheostomy:

• Minor bleeding: Conservative management with observation 2
• Moderate bleeding with suspected tracheo-arterial fistula:
  • Hyperinflate the tracheostomy tube cuff if present
  • Alternatively, intubate the stoma with a cuffed tracheal tube placed distal to the fistula
  • Apply pressure via hyperinflated cuff or digitally 2
• Severe bleeding:
  • Differentiate between suction trauma and arterial erosion
  • For suspected arterial erosion, immediate evaluation in the operating room by personnel capable of performing a sternotomy 2
  • For confirmed tracheo-arterial fistula, definitive surgical treatment (usually ligation of the innominate artery) 2

Clinical Implications

The risk of vascular injury during tracheostomy emphasizes the importance of:

• Thorough preoperative assessment
• Consideration of ultrasound guidance, particularly for percutaneous procedures
• Having appropriate equipment and experienced personnel available
• Vigilance for "sentinel bleeds" which may precede catastrophic hemorrhage in approximately 50% of tracheo-arterial fistula cases 2

Understanding the vascular anatomy of the anterior neck and taking appropriate precautions can significantly reduce the risk of this potentially life-threatening complication.