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Unexpected Detection of Internal Jugular Vein Thrombus During Ultrasound-Guided Central Venous Cannulation
e36
LETTERS TO THE EDITOR
Unexpected Detection of Internal Jugular Vein Thrombus During Ultrasound-Guided Central Venous Cannulation To the Editor: The use of 2-dimensional ultrasound (US) to facilitate central venous catheter (CVC) placement in the internal jugular vein (IJV) improves patient safety and reduces complications. Even after the recommendations by the National institute for Clinical Excellence (NICE) guidelines1 in 2002, US guidance is still not routinely used by all physicians when obtaining central venous access. A common cause of this could be lack of the US machine, the probe, and the experience with US. A case in which thrombus in the right jugular vein was found during US-guided CVC placement is presented. A 78-year-old patient was admitted with chronic renal failure to the department of nephrology for the initiation of hemodialysis. His past medical history included hypertension, type I diabetes mellitus, and chronic renal failure not requiring hemodialysis. He was admitted 1 month previously with a history of urinary tract infections and was treated with antibiotics. He was discharged in stable condition. The patient was referred to the department of cardiac anesthesiology for the insertion of a hemodialysis catheter. The physical examination showed that the patient had a short, fat neck; therefore, anatomic landmarks for the CVC placement were not clear. CVC placement appeared to be difficult, so it was decided to perform US-guided cannulation. The procedure was explained to the patient, and informed consent was obtained. Because of the nonavailability of a dedicated bedside US machine with linear probe, the patient was transferred to the operating room. In the operating room, after positioning the patient properly, an S12 probe was used to visualize and locate the right IJV. As the probe was moved upside down over the vein, a thrombus was found attached over the anterior wall of the right IJV (Fig 1). The
Fig 1. An ultrasound image of the right IJV in the cross-sectional plane (A) showing the thrombus (B) on the anterior wall. (C) is the right carotid artery.
Fig 2. An ultrasound image of the right IJV in the longitudinal plane showing intraluminal narrowing caused by the thrombus. A, right IJV; B, thrombus; C, right carotid artery.
thrombus was big enough to reduce the lumen of the IJV. The longitudinal view of the IJV (Fig 2) also revealed narrowing of the lumen at the site of the thrombus. Because of the thrombus, the procedure on the right IJV was abandoned, and the left IJV was examined. Fortunately, the lumen of the left IJV was clear (Fig 3), and the hemodialysis catheter was placed uneventfully. The patient was questioned about a history of CVC placement in the right IJV, any injury, or neck infection in the past. However, the patient denied any such history. The concerned nephrologist was informed about the thrombus in the right IJV. The patient was transferred back to the dialysis room after a chest x-ray was performed. The British NICE recommended US guidance as the preferred method for CVC placement in 2002.1 Since then, there has been a lot of debate on US-guided CVC placement. Unfortunately, the incorporation of these recommendations into clinical practice has been met with resistance. A survey of 250 anesthesiologists in the United Kingdom found that 41% disagreed or strongly disagreed with the recommendation that US imaging should be the preferred method for the insertion of a CVC into the IJV.2 Although 84% of respondents believed that those using ultrasound imaging should have appropriate training, 67% of respondents believed the level of training provided for US-guided CVC placement was inadequate. Likewise, a study in the United States also found that only 15% of surgery, anesthesia, emergency medicine, internal medicine, and family medicine housestaff used ultrasound guidance for most CVC placements.3 In a recent survey of Fellows of the Australasian College for Emergency Medicine (FACEMs) to describe current US usage during CVC placement, only 37% of FACEM respondents routinely used US to guide the placement of CVCs. Also, 85% of FACEMs agreed that there should be access to US and US training, but only 34% thought its use should be mandatory.4 Thrombosis of the IJV is an underdiagnosed condition that may occur as a complication of central venous or pulmonary artery catheters in the IJV5; in individuals who abuse intravenous drugs using the IJV vein for access6; in patients with Lemierre syndrome,7 deep neck infections,8 neck dissection surgery com-
LETTERS TO THE EDITOR
e37
REFERENCES
Fig 3. An ultrasound image of the left IJV in the cross-sectional plane showing a normal-looking vein. A, left IJV; B, left carotid artery.
plication,9 head and neck malignancy,10 hypercoagulable state secondary to factor V Leiden, protein C, protein S, or antithrombin III deficiency,11 jugular bulb catheters,12 trauma,13 ovarian hyperstimulation syndrome,14 and hyperhomocysteinemia15; and even in individuals after neck massage.16 It also is reported to occur spontaneously.17 IJV thrombosis itself can have serious potentially life-threatening complications that include systemic sepsis, chylothorax, papilledema, airway edema, and pulmonary embolism.14 The diagnosis often is very challenging and requires, first and foremost, a high degree of clinical suspicion. The cause of IJV thrombus in this case remains speculative; it could be spontaneous in nature. If one is not aware about the presence of IJV thrombosis, insertion of a CVC on the same side can dislodge the thrombus. This can lead to fatal consequences. Such problems can only be detected if US guidance is used in all patients undergoing CVC placement. At the authors’ institution, US guidance is being used for all CVC placements in pediatric patients, whereas in adult patients it is being used only if there is difficulty in obtaining central venous access. A survey by Schummer et al18 in Germany revealed that only 40% of the responders used US guidance for CVC placement. Of these, only 24 (12.7%) used US routinely, and 114 (60.6%) used it when faced with a difficult cannulation. In addition, 41.1% of all departments did not possess the equipment, and 33.2% did not consider US necessary. In a study by Cavanna et al19 on cancer patients, the use of US guidance allowed the insertion of CVCs in 1,930 of 1,978 (97.6%) patients without any pneumothorax and major complications. Thus, this report emphasizes the fact that even if practitioners do not use US in all cases, at least it should be used in certain groups of patients who are at high risk because of distorted anatomy and patients at risk of IJV thrombus. The availability of dedicated equipment for this purpose would perhaps encourage physicians to use US when obtaining central venous access. Sanjay Goel, MD Sanjoy Majhi, MD Bishnu Panigrahi, MD Department of Cardiac Anesthesia Max Heart and Vascular Institute New Delhi, India
1. Calvert N, Hind D, McWilliams RG, et al: The effectiveness and cost-effectiveness of ultrasound locating devices for central venous access: A systematic review and economic evaluation. Health Technol Assess 7:1-84, 2003 2. Howard S: A survey measuring the impact of NICE guidance 49: The use of ultrasound locating devices for placing central venous catheters. 2004. Available at: http://www.nice.org.uk/pdf/ final_CVC_ placement_survey_report.pdf. Accessed 3. Girard TD, Schectman JM: Ultrasound guidance during central venous catheterization: A survey of use by house staff physicians. J Crit Care 20:224-229, 2005 4. Matera JT, Egerton-Warburton D, Meek R: Ultrasound guidance for central venous catheter placement in Australasian emergency departments: Potential barriers to more widespread use. Emerg Med Australas 22:514-523, 2010 5. Chastre J, Cornud F, Bouchama A, et al: Thrombosis as a complication of pulmonary-artery catheterization via the internal jugular vein: Prospective evaluation by phlebography. N Engl J Med 306:278-281, 1982 6. Myers EM, Kirkland LS Jr, Mickey R: The head and neck sequelae of cervical intravenous drug abuse. Laryngoscope 98:213-218, 1988 7. Peer Mohamed B, Carr L: Neurological complications in two children with Lemierre syndrome. Dev Med Child Neurol 52:779-781, 2010 8. Gurley MB, King TS, Tsai FY: Sigmoid sinus thrombosis associated with internal jugular venous occlusion: Direct thrombolytic treatment. J Endovasc Surg 3:306-314, 1996 9. Leontsinis TG, Currie AR, Mannell A: Internal jugular vein thrombosis following functional neck dissection. Laryngoscope 105: 169-174, 1995 10. Felstead AM, Perkins CS: Thrombosis of the internal jugular vein: A rare but important operative finding. Br J Oral Maxillofac Surg 48:195-196, 2010 11. Gunasekaran S, Anthony R, Woodhead CJ: Bilateral internal jugular vein thrombosis in a child with protein S deficiency. J Laryngol Otol 119:661-664, 2005 12. Coplin WM, O’Keefe GE, Grady MS, et al: Thrombotic, infectious, and procedural complications of the jugular bulb catheter in the intensive care unit. Neurosurgery 41:101-107, 1997 13. Al-Qahtani YA, Al-Qahtani KA: Thrombosis of the internal jugular vein resulting from migration of a sharp esophageal foreign body. Saudi Med J 32:77-79, 2011 14. Gbaguidi X, Janvresse A, Benichou J, et al: Internal jugular vein thrombosis: Outcome and risk factors. Q J Med 104:209-219, 2011 15. Scaramella JG: Hyperhomocysteinemia and left internal jugular vein thrombosis with Ménière’s symptom complex. Ear Nose Throat J 82:856, 2003 16. Wada Y, Yanagihara C, Nishimura Y: Internal jugular vein thrombosis associated with shiatsu massage of the neck. J Neurol Neurosurg Psychiatry 76:142-143, 2005 17. Serinken M, Karcioglu O, Korkmaz A: Spontaneous internal jugular vein thrombosis: A case report. Kaohsiung J Med Sci 26:679-681, 2010 18. Schummer W, Sakka SG, Hüttemann E, et al: [Ultrasound guidance for placement control of central venous catheterization. Survey of 802 anesthesia departments for 2007 in Germany]. Anaesthesist 58:677-685, 2009 19. Cavanna L, Civardi G, Vallisa D, et al: Ultrasound-guided central venous catheterization in cancer patients improves the success rate of cannulation and reduces mechanical complications: A prospective observational study of 1,978 consecutive catheterizations. World J Surg Oncol 8:91, 2010 doi:10.1053/j.jvca.2011.03.177
LETTERS TO THE EDITOR
Unexpected Detection of Internal Jugular Vein Thrombus During Ultrasound-Guided Central Venous Cannulation To the Editor: The use of 2-dimensional ultrasound (US) to facilitate central venous catheter (CVC) placement in the internal jugular vein (IJV) improves patient safety and reduces complications. Even after the recommendations by the National institute for Clinical Excellence (NICE) guidelines1 in 2002, US guidance is still not routinely used by all physicians when obtaining central venous access. A common cause of this could be lack of the US machine, the probe, and the experience with US. A case in which thrombus in the right jugular vein was found during US-guided CVC placement is presented. A 78-year-old patient was admitted with chronic renal failure to the department of nephrology for the initiation of hemodialysis. His past medical history included hypertension, type I diabetes mellitus, and chronic renal failure not requiring hemodialysis. He was admitted 1 month previously with a history of urinary tract infections and was treated with antibiotics. He was discharged in stable condition. The patient was referred to the department of cardiac anesthesiology for the insertion of a hemodialysis catheter. The physical examination showed that the patient had a short, fat neck; therefore, anatomic landmarks for the CVC placement were not clear. CVC placement appeared to be difficult, so it was decided to perform US-guided cannulation. The procedure was explained to the patient, and informed consent was obtained. Because of the nonavailability of a dedicated bedside US machine with linear probe, the patient was transferred to the operating room. In the operating room, after positioning the patient properly, an S12 probe was used to visualize and locate the right IJV. As the probe was moved upside down over the vein, a thrombus was found attached over the anterior wall of the right IJV (Fig 1). The
Fig 1. An ultrasound image of the right IJV in the cross-sectional plane (A) showing the thrombus (B) on the anterior wall. (C) is the right carotid artery.
Fig 2. An ultrasound image of the right IJV in the longitudinal plane showing intraluminal narrowing caused by the thrombus. A, right IJV; B, thrombus; C, right carotid artery.
thrombus was big enough to reduce the lumen of the IJV. The longitudinal view of the IJV (Fig 2) also revealed narrowing of the lumen at the site of the thrombus. Because of the thrombus, the procedure on the right IJV was abandoned, and the left IJV was examined. Fortunately, the lumen of the left IJV was clear (Fig 3), and the hemodialysis catheter was placed uneventfully. The patient was questioned about a history of CVC placement in the right IJV, any injury, or neck infection in the past. However, the patient denied any such history. The concerned nephrologist was informed about the thrombus in the right IJV. The patient was transferred back to the dialysis room after a chest x-ray was performed. The British NICE recommended US guidance as the preferred method for CVC placement in 2002.1 Since then, there has been a lot of debate on US-guided CVC placement. Unfortunately, the incorporation of these recommendations into clinical practice has been met with resistance. A survey of 250 anesthesiologists in the United Kingdom found that 41% disagreed or strongly disagreed with the recommendation that US imaging should be the preferred method for the insertion of a CVC into the IJV.2 Although 84% of respondents believed that those using ultrasound imaging should have appropriate training, 67% of respondents believed the level of training provided for US-guided CVC placement was inadequate. Likewise, a study in the United States also found that only 15% of surgery, anesthesia, emergency medicine, internal medicine, and family medicine housestaff used ultrasound guidance for most CVC placements.3 In a recent survey of Fellows of the Australasian College for Emergency Medicine (FACEMs) to describe current US usage during CVC placement, only 37% of FACEM respondents routinely used US to guide the placement of CVCs. Also, 85% of FACEMs agreed that there should be access to US and US training, but only 34% thought its use should be mandatory.4 Thrombosis of the IJV is an underdiagnosed condition that may occur as a complication of central venous or pulmonary artery catheters in the IJV5; in individuals who abuse intravenous drugs using the IJV vein for access6; in patients with Lemierre syndrome,7 deep neck infections,8 neck dissection surgery com-
LETTERS TO THE EDITOR
e37
REFERENCES
Fig 3. An ultrasound image of the left IJV in the cross-sectional plane showing a normal-looking vein. A, left IJV; B, left carotid artery.
plication,9 head and neck malignancy,10 hypercoagulable state secondary to factor V Leiden, protein C, protein S, or antithrombin III deficiency,11 jugular bulb catheters,12 trauma,13 ovarian hyperstimulation syndrome,14 and hyperhomocysteinemia15; and even in individuals after neck massage.16 It also is reported to occur spontaneously.17 IJV thrombosis itself can have serious potentially life-threatening complications that include systemic sepsis, chylothorax, papilledema, airway edema, and pulmonary embolism.14 The diagnosis often is very challenging and requires, first and foremost, a high degree of clinical suspicion. The cause of IJV thrombus in this case remains speculative; it could be spontaneous in nature. If one is not aware about the presence of IJV thrombosis, insertion of a CVC on the same side can dislodge the thrombus. This can lead to fatal consequences. Such problems can only be detected if US guidance is used in all patients undergoing CVC placement. At the authors’ institution, US guidance is being used for all CVC placements in pediatric patients, whereas in adult patients it is being used only if there is difficulty in obtaining central venous access. A survey by Schummer et al18 in Germany revealed that only 40% of the responders used US guidance for CVC placement. Of these, only 24 (12.7%) used US routinely, and 114 (60.6%) used it when faced with a difficult cannulation. In addition, 41.1% of all departments did not possess the equipment, and 33.2% did not consider US necessary. In a study by Cavanna et al19 on cancer patients, the use of US guidance allowed the insertion of CVCs in 1,930 of 1,978 (97.6%) patients without any pneumothorax and major complications. Thus, this report emphasizes the fact that even if practitioners do not use US in all cases, at least it should be used in certain groups of patients who are at high risk because of distorted anatomy and patients at risk of IJV thrombus. The availability of dedicated equipment for this purpose would perhaps encourage physicians to use US when obtaining central venous access. Sanjay Goel, MD Sanjoy Majhi, MD Bishnu Panigrahi, MD Department of Cardiac Anesthesia Max Heart and Vascular Institute New Delhi, India
1. Calvert N, Hind D, McWilliams RG, et al: The effectiveness and cost-effectiveness of ultrasound locating devices for central venous access: A systematic review and economic evaluation. Health Technol Assess 7:1-84, 2003 2. Howard S: A survey measuring the impact of NICE guidance 49: The use of ultrasound locating devices for placing central venous catheters. 2004. Available at: http://www.nice.org.uk/pdf/ final_CVC_ placement_survey_report.pdf. Accessed 3. Girard TD, Schectman JM: Ultrasound guidance during central venous catheterization: A survey of use by house staff physicians. J Crit Care 20:224-229, 2005 4. Matera JT, Egerton-Warburton D, Meek R: Ultrasound guidance for central venous catheter placement in Australasian emergency departments: Potential barriers to more widespread use. Emerg Med Australas 22:514-523, 2010 5. Chastre J, Cornud F, Bouchama A, et al: Thrombosis as a complication of pulmonary-artery catheterization via the internal jugular vein: Prospective evaluation by phlebography. N Engl J Med 306:278-281, 1982 6. Myers EM, Kirkland LS Jr, Mickey R: The head and neck sequelae of cervical intravenous drug abuse. Laryngoscope 98:213-218, 1988 7. Peer Mohamed B, Carr L: Neurological complications in two children with Lemierre syndrome. Dev Med Child Neurol 52:779-781, 2010 8. Gurley MB, King TS, Tsai FY: Sigmoid sinus thrombosis associated with internal jugular venous occlusion: Direct thrombolytic treatment. J Endovasc Surg 3:306-314, 1996 9. Leontsinis TG, Currie AR, Mannell A: Internal jugular vein thrombosis following functional neck dissection. Laryngoscope 105: 169-174, 1995 10. Felstead AM, Perkins CS: Thrombosis of the internal jugular vein: A rare but important operative finding. Br J Oral Maxillofac Surg 48:195-196, 2010 11. Gunasekaran S, Anthony R, Woodhead CJ: Bilateral internal jugular vein thrombosis in a child with protein S deficiency. J Laryngol Otol 119:661-664, 2005 12. Coplin WM, O’Keefe GE, Grady MS, et al: Thrombotic, infectious, and procedural complications of the jugular bulb catheter in the intensive care unit. Neurosurgery 41:101-107, 1997 13. Al-Qahtani YA, Al-Qahtani KA: Thrombosis of the internal jugular vein resulting from migration of a sharp esophageal foreign body. Saudi Med J 32:77-79, 2011 14. Gbaguidi X, Janvresse A, Benichou J, et al: Internal jugular vein thrombosis: Outcome and risk factors. Q J Med 104:209-219, 2011 15. Scaramella JG: Hyperhomocysteinemia and left internal jugular vein thrombosis with Ménière’s symptom complex. Ear Nose Throat J 82:856, 2003 16. Wada Y, Yanagihara C, Nishimura Y: Internal jugular vein thrombosis associated with shiatsu massage of the neck. J Neurol Neurosurg Psychiatry 76:142-143, 2005 17. Serinken M, Karcioglu O, Korkmaz A: Spontaneous internal jugular vein thrombosis: A case report. Kaohsiung J Med Sci 26:679-681, 2010 18. Schummer W, Sakka SG, Hüttemann E, et al: [Ultrasound guidance for placement control of central venous catheterization. Survey of 802 anesthesia departments for 2007 in Germany]. Anaesthesist 58:677-685, 2009 19. Cavanna L, Civardi G, Vallisa D, et al: Ultrasound-guided central venous catheterization in cancer patients improves the success rate of cannulation and reduces mechanical complications: A prospective observational study of 1,978 consecutive catheterizations. World J Surg Oncol 8:91, 2010 doi:10.1053/j.jvca.2011.03.177