Can a patient have both a right and left internal jugular (IJ) central line simultaneously?

Bilateral Internal Jugular Central Lines: Feasibility and Recommendations

Yes, a patient can technically have both right and left internal jugular central lines simultaneously, but this should be avoided whenever possible due to significantly increased risks of thrombosis, stenosis, and infection, particularly on the left side. 1

Primary Recommendation: Avoid Bilateral IJ Access

• The right internal jugular vein should always be the first choice for central venous catheterization due to its straighter anatomical course to the superior vena cava, lower thrombotic complications, and superior blood flow rates. 1, 2

• Left-sided IJ access is explicitly discouraged in guidelines due to poorer blood flow rates, higher rates of stenosis and thrombosis, and potential compromise of the left arm's vasculature for future permanent access. 1, 2, 3

When Bilateral Access Might Be Considered

If bilateral IJ lines are absolutely necessary (e.g., multiple incompatible infusions, high-volume resuscitation, extracorporeal support), consider this hierarchy:

1. First line: Right IJ - Place the primary/long-term catheter here 1
2. Second line alternatives (in order of preference):
   • Right subclavian vein (if patient will never need hemodialysis or permanent vascular access) 1
   • Femoral vein (only for short-term use ≤5 days in bed-bound patients) 1
   • Left IJ only as last resort 1, 2

Critical Risks of Left IJ Catheterization

• Thrombosis risk is significantly elevated compared to right-sided access, with one study showing diabetic patients developing severe arm swelling requiring access ligation after left IJ catheterization. 3

• Infection rates are nearly double - 20.8% removal rate for infection with left IJ versus 10.9% for right IJ, with infection incidence of 3.72 per 1000 catheter days (left) versus 1.57 (right). 3

• Anatomical disadvantages include smaller vessel diameter (1.13 cm vs 1.51 cm on right), deeper location from skin, and more tortuous path to the SVC. 4

• Risk of unrecognized persistent left superior vena cava (present in 0.3-0.5% of population) can lead to catheter malposition, coronary sinus irritation, arrhythmias, and hemodynamic instability. 5

Technical Considerations for Bilateral Placement

If bilateral IJ lines are unavoidable:

• Use ultrasound guidance for both insertions to minimize complications, particularly on the left side where anatomy is less favorable. 6

• Verify catheter tip position at the cavo-atrial junction (right atrial-SVC junction) with post-insertion chest X-ray for both catheters. 1

• Monitor closely for thrombotic complications, particularly in patients with diabetes, hypercoagulable states, or prior central venous catheterization. 3

• Plan for early removal of the left-sided catheter as soon as clinically feasible to minimize cumulative thrombotic risk. 1, 3

Common Pitfalls to Avoid

• Never place bilateral IJ lines for convenience alone - the increased morbidity from bilateral upper extremity venous thrombosis can be devastating. 1, 3

• Avoid left IJ in patients who may need future hemodialysis access or permanent vascular access, as it jeopardizes the left arm's vasculature. 1, 2

• Do not assume symmetric anatomy - always check for anatomical variants like persistent left SVC on prior imaging before left IJ catheterization. 5

• Recognize that subclavian access (either side) should be avoided in patients with potential future need for permanent vascular access due to high stenosis risk. 1, 2