A27-YR-OLD male patient with a history of end-stage liver disease due to hepatitis C infection and a transjugular intrahepatic portosystemic shunt presented for ordiotopic liver transplantation. We attempted to place a central venous pressure catheter via the right internal jugular vein (IJV), initially without ultrasound. An 18-gauge catheter was easily passed into the IJV using anatomic landmarks, but the guide wire could not be advanced more than 8 cm because of resistance. We then performed an ultrasound examination using a SonoSite TITAN~R (SonoSite Inc., Bothell, WA) and detected a large venous valve protruding into the lumen of the IJV (fig. 1). To avoid damage, we then switched sides and placed a left IJV catheter instead, which was performed successfully under ultrasound guidance. After verifying catheter placement with a portable chest x-ray film, we proceeded to orthotopic liver transplantation without further complications.
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