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Ann Card Anaesth. 2019 Oct-Dec;22(4):379-382. doi: 10.4103/aca.ACA_124_18.

Proximal penholding method - A variant to enhance safety of ultrasoundguided central venous cannulation: A prospective pilot study.

Author information

Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.



A significant incidence of Posterior Vessel Wall Puncture (PVWP) was reported during ultrasound guidance (USG) for internal jugular vein (IJV) catheterization. We studied a new technique of USGIJV cannulation to minimize or avoid PVWP, thereby decreasing overall complication rate, irrespective of the operators' experience level.

Materials and Methods:

After ethical approval, a prospective study was conducted on adult patients of either gender between 18-65 years of age, belonging to the American Society of Anesthesiologists Physical Status I-III, undergoing general anesthesia and requiring USG-guided IJV cannulation. After induction of general anesthesia and intubation, USG-guided IJV cannulation was done using technique of "proximal pen-holding method" in patients placed in supine position with neck rotated in 15° rotation to the opposite side. The primary outcome was defined as success rate of USG-guided IJV cannulation and incidence of PVWP. The secondary outcome was the incidences of complications such as arterial puncture, adjacent tissue damage, and performer's ease of the procedure (0-10 scale; 0 denoting no ease and extreme difficulty and 10 denoting extreme ease and no difficulty).


In 135 patients, right IJV puncture, guidewire, and central line insertion were achieved in single attempt without any PVWP by nine operators which included two anesthesia consultants and seven senior registrars. No complications were reported and ease of procedure were rated as median (interquartile range) of 10 (10).


The "proximal pen-holding method" for real-time USG-IJV cannulation helped in avoiding PVWP with lesser complication rate and greater performer's ease.


Central venous catheters; internal carotid artery; internal jugular vein

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