Incidental finding of internal jugular vein clot during the perioperative period: An anesthesiologist’s nightmare

Unprovoked idiopathic internal jugular vein (IJV) thrombosis accounts for 17% of all IJV thrombosis cases.[1,2] It may result in life-threatening pulmonary embolism (10.3%), post-thrombotic syndrome (41.4), and death.[2,3]

We report a case of right IJV thrombus that was detected incidentally by ultrasound at the time of right IJV cannulation. A 19-year-old female patient having large atrial septal defect (27 mm) with severe tricuspid regurgitation had been scheduled for atrial septal defect closure and tricuspid valve repair. Preoperative blood coagulation profiles (prothrombin time/international normalized ratio and activated partial thromboplastin time) were within normal limits. Anesthesia was induced with fentanyl (2 μg/kg), thiopentone sodium (4 mg/kg), and vecuronium (0.1 mg/kg). Trachea was intubated with a 7.5-mm endotracheal tube. Central venous access into the right IJV was attempted using landmark technique but failed even after three attempts. Ultrasound assessment revealed a large clot within the lumen of the right IJV and color Doppler ultrasound revealed no flow within the IJV [Figure 1]. The clot was extending from the jugular foramen down to the clavicular base and was confirmed by sliding the ultrasound probe cranially to the skull base and caudally to the sternal end of the clavicle. Compression ultrasound (CUS) manoeuvre suggested that the vein was incompressible. Transesophageal echocardiography showed a 27-mm interatrial defect with left-to-right flow and no clot within the right atrium. Ultrasound-guided central venous catheter was placed successfully in the left IJV. After median sternotomy, heparinization (heparin 300 U/kg) was done and ascending aorta was cannulated with a 22-mm straight-tipped cannula while the superior vena cava and inferior vena cava were cannulated with a 28-mm and 32-mm angle-tipped venous cannula, respectively. Aortic cross-clamping, cardioplegia, and cardiopulmonary bypass (CPB) were initiated and the right atrium was opened. The clot was not visible within the right atrium. A pericardial patch was placed and the tricuspid valve was repaired. The patient came off the CPB uneventfully on ionotropic support. The patient was extubated after four hours without any thrombo-embolic event. Anticoagulation was initiated with enoxaparin 1 mg/kg twice a day, and serial ultrasonography was performed to assess the size and extent of the clot. Enoxaparin was switched to oral warfarin (2.5 mg) on the fifth postoperative day and the patient was discharged.

Figure 1.

Ultrasound image showing the thrombus within the right internal jugular vein. IJV = Internal jugular vein, IC = Internal carotid, SCM = Sternocleidomastoid

Preoperatively, this patient was asymptomatic and did not show any signs of neck vein thrombosis. Intraoperative heparinization was helpful in reducing the clot size, which was visualized after the patient was weaned from the cardiopulmonary bypass. De Oliveira Leite et al.[4] effectively used a superior vena cava filter for the prevention of symptomatic pulmonary embolism in patients in whom anticoagulation was contraindicated. The sensitivity and specificity of both CUS (96% and 93.5%) and color Doppler ultrasound (100% and 93%) aided in the diagnosis of idiopathic IJV thrombosis.[5] We suggest postoperative serial monitoring of IJV clot, anticoagulant therapy, and constant vigilance for pulmonary embolism in patients having IJV clot in situ. This will reduce the postoperative mortality. Our patient was not evaluated for thrombophilia in the postoperative period: this could be a limitation of our case.

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