UMEM Educational Pearls

Category: Critical Care

Title: Posterior Wall Penetration

Posted: 7/28/2009 by Mike Winters, MD (Updated: 9/22/2023)
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Internal Jugular CVC Placement and Posterior Wall Penetration

  • For a variety of reasons, many critically ill ED patients require central venous access.
  • Ultrasound guidance, especially with catheters placed in the internal jugular (IJ), has become standard practice in many EDs.
  • Ultrasound guidance is associated with higher success rates, reduced insertion attempts, and reduced placement failures.
  • Importantly, ultrasound allows you to visualize the carotid artery which often either partially overlies or even sits direclty under the IJ.
  • Recent literature, however, suggests that posterior wall penetration of the IJ, even with ultrasound guidance, may be much more common than previously thought.
  • Take Home Point: Even when using ultrasound, maintain strict visualization of the needle in the IJ lumen and recognize that posterior wall penetration (into the carotid) can easily occur.


Blaivas M, Adhikari S. An unseen danger: frequency of posterior vessel wall penetration by needles during attempts to place internal jugular vein central catheters using ultrasound guidance. Crit Care Med 2009;37:2345-9.