What are the guidelines for external jugular vein (EJV) access?

External Jugular Vein Access Guidelines

Primary Recommendation

The external jugular vein (EJV) is an acceptable alternative access site for central venous catheterization when the internal jugular vein is unavailable, though central catheter positioning can be technically more difficult through this route. 1

When to Use EJV Access

Indications for EJV Selection

• Use the EJV when the right internal jugular vein (IJV) is not available due to occlusion, existing catheter placement, or local infection at the IJV site 2
• Consider EJV access when there is concern for catheter-related infection risk from IJV catheterization in patients with adjacent tracheostomy devices 2
• The EJV provides an alternative to avoid subclavian vein puncture, which carries risks of pneumothorax and hemothorax 3
• For patients with breast cancer or contraindications to contralateral access, the EJV cutdown approach offers a viable alternative 3

Clinical Context

• The right EJV is preferred over the left EJV when IJV access is not feasible, as it provides a more direct anatomical course to central veins 1, 4
• The EJV is visible and accessible, making it suitable for emergency peripheral IV access in patients with difficult venous access 5

Technical Considerations

Catheter Positioning Challenges

• Central catheter positioning through the EJV can be difficult due to the anatomical course and valve structures 1
• The catheter tip should be positioned in the lower superior vena cava (SVC) or upper right atrium, parallel to the vessel wall 1
• Post-insertion chest X-ray is mandatory to verify proper catheter tip position 1

Success Rates and Outcomes

• Technical success for central venous catheterization via the right EJV is 96% when the right IJV is unavailable 2
• Mean catheter dwell time through the EJV is approximately 63 days (range 2-182 days) 2
• The EJV approach for totally implantable access ports has comparable complication rates to other approaches 3

Complications and Safety Profile

Early Complications

• Port hematoma occurs in approximately 2% of cases 3
• Catheter migration occurs in approximately 2% of cases 3
• No procedural complications (pneumothorax, hemothorax) were reported in EJV access studies 2, 3

Late Complications

• Catheter-related infection rate: 0.22 per 100 catheter-days (approximately 3% overall) 2, 3
• Catheter occlusion: 2.5% 3
• Venous thrombosis: 2% 3
• Catheter malfunction: 0.07 per 100 catheter-days 2
• No symptomatic venous thrombosis was observed in one series 2

Comparison with Other Access Sites

EJV vs. Internal Jugular Vein

• The right IJV remains the preferred first-line access site due to its straighter course to the SVC and easier catheter positioning 1, 4
• The right IJV requires a 15 cm catheter length, while the left IJV requires 20 cm 1
• Use the EJV only when the IJV is not available or contraindicated 2

EJV vs. Subclavian Vein

• The EJV approach avoids the life-threatening complications of subclavian puncture (pneumothorax, hemothorax) 3
• Subclavian access should be avoided in patients who may need future permanent vascular access due to high risk of central venous stenosis 1, 6
• Subclavian access should only be used when no other upper-extremity or chest-wall options are available 1

EJV vs. Femoral Vein

• Femoral catheters should not remain in place longer than 5 days and should only be used in bed-bound patients 6
• Femoral access has higher infection rates and thrombotic complications compared to upper body sites 1, 6
• Upper body insertion sites (including EJV) are preferred to minimize infection and thrombotic risks 1

Specific Clinical Applications

Emergency Peripheral IV Access

• For emergency peripheral IV access in difficult-access patients, ultrasound-guided peripheral IV has 84% initial success compared to 50% for EJ approach 7
• However, when the EJ is visible, success rates are comparable (84% vs. 66%, not statistically significant) 7
• Using both techniques together achieves peripheral vascular access in 98% of difficult-access patients 7

Central Venous Catheters

• The EJV achieved 96% technical success for central venous catheter placement when the right IJV was unavailable 2
• Fluoroscopy should be used for tunneled catheter placement to ensure optimal tip position 1, 6
• Ultrasound guidance is recommended to reduce insertion-related complications 1, 6

Totally Implantable Access Ports

• The EJV cutdown approach for port placement has a mean operating time of 54.5 minutes 3
• This approach provides comfortable results with rare complications 3

Specialized Procedures

• The EJV is feasible and safe for retrieval of inferior vena cava filters designed for jugular approaches 8
• No significant difference in technical success rates between IJV and EJV for IVC filter retrieval 8

Key Pitfalls to Avoid

• Do not assume the EJV will provide easy central catheter positioning—the anatomical course makes tip placement more challenging than IJV 1
• Always verify catheter tip position with chest X-ray after insertion 1
• Do not use the EJV as first-line access when the right IJV is available and patent 1, 4
• Avoid leaving non-cuffed catheters in place beyond 1 week due to exponentially increasing infection risk 6
• Do not discharge patients with non-cuffed EJV catheters due to risks of infection, inadvertent removal, and hemorrhage 6