Internal jugular vein thrombosis: a complication of temporary hemodialysis catheter.

To the Editor,

Central venous catheter (CVC) — related thrombosis is common. The incidence of thrombosis varies from 1.9% in subclavian CVCs to 21.5% in femoral catheters.[1] Hemodialysis patients have to undergo multiple catheter placements and vascular access interventions. This along with their co-morbid conditions, increases the risk of thrombosis.[2]

A 23-year-old female patient with end stage renal disease was admitted to our hospital for renal transplant and she was on maintenance dialysis since 2 months. First double lumen catheter (DLC) was inserted percutaneously via right internal jugular vein (IJV) for hemodialysis. After that arterio-venous fistula was made at wrist and DLC removed on 18th day. A week later, DLC was inserted again in right IJV as fistula was thrombosed. After creation of another fistula, DLC was removed. For renal transplant, balanced general anesthesia with epidural anesthesia was given. After induction, IJV cannulation was attempted, but guide wire could not be negotiated. Hence, external jugular vein was punctured for catheter insertion, but guide wire could not be negotiated after 9 cm. We attempted catheter insertion and it passed easily. Fluid was going easily, but water column was not moving on central venous pressure manometer. Postoperatively in intensive care unit, X-ray chest with neck [Figure 1] revealed catheter going in upward direction. Ultrasonography (USG) neck revealed [Figure 2] a partial thrombus with partial flow in right IJV extending from angle of mandible up to the lower neck (10 cm × 8 cm in size). Lower part of IJV in its 1 cm area showed a partial dissection of IJV [Figures 3 and 4]. Intravenous low molecular weight heparin 3200 units subcutaneously was started for 8 days and then oral warfarin for 10 days was continued. Serial neck vessel Doppler showed gradual decrease in the size of thrombus to 3 mm × 3 mm.

Figure 1

Chest radiograph showing malposition of catheter

Figure 2

Ultrasonography color Doppler of neck showing partial thrombus in internal jugular vein

Figure 3

Ultrasonography neck showing flap in internal jugular vein

Figure 4

Ultrasonography Doppler neck showing flap with thrombus in internal jugular vein

Late complications of central vein cannulation are intracatheter blood clot, thrombosis and cannulated vein stricture. In the case of central venous lines, the catheter itself acts as the nidus for clot formation. Studies have suggested that catheter material, tip position, infection, previous catheterization and other factors may influence the risk of catheter related thrombosis.[3] Clinical incidence of catheter related central line thrombosis is as low as 0-4%.[2] Internal jugular thrombosis is often clinically occult. This is owing to the development of extensive venous collaterals of upper extremity, which minimizes the hemodynamic effects of thrombosis and isolates internal jugular thrombosis from the high outflow drainage from the upper extremities.[3] The generally recommended time interval for catheters to remain in situ is 1-2 weeks.[4] The rate of thrombosis was correlated with the number of catheter insertions. These rates were 14%, 15% and 47% in those undergoing catheter insertion once, twice and three times respectively in study of Yardim et al.[5]

In our case, patient was asymptomatic so we did not suspect IJV thrombosis. Right IJV was cannulated twice and catheter remained for more than 5 weeks. Cho et al. studied 23 patients and suggested that the right EJV is an acceptable and preferred access site when the right IJV is not available for central venous catheterization, as was done in our case.[6] USG and color Doppler flow USG are reliable and accurate for the diagnosis of IJV thrombosis. The usual treatment for IJV thrombosis involves anticoagulation and antibiotics. Our patient responded to anticoagulation therapy. After this event, we recommend USG Doppler of neck vessels preoperatively in whom, there is history of long-term catheter in situ for hemodialysis and multiple attempts.