Internal Jugular Vein Thrombosis Treatment & Management

Once a diagnosis of internal jugular (IJ) thrombosis is made, consider the use of anticoagulant therapy. Unfortunately, no studies of sufficient size are currently available to guide physicians in this area. Clearly, many patients do well without serious effects, as evidenced by the fact that the condition is often underdiagnosed.

The risk of pulmonary embolism is truly unknown. The most commonly quoted rate of pulmonary embolism occurring in the setting of IJ thrombosis is 5%. However, this statistic is taken from a relatively small retrospective study performed more than 25 years ago. A recent retrospective study demonstrated pulmonary embolism rates of 0.5% and 2.4% for isolated IJ thrombosis and combined subclavian/axillary vein and IJ thrombosis, respectively.

Isolated case series discuss the use of thrombolytic therapy, usually via catheters inserted directly adjacent to the thrombus. Most reports involved patients with extensive thrombus extending into the sigmoid sinus, with treatment resulting in few complications. However, neither the indications for nor the safety of thrombolytic treatment has been defined.

If an indwelling catheter is present, remove it. Exceptions to this are rare but do include situations where no other options for venous access exist in a patient who would experience a life-threatening situation without it.

In the setting of infection, many patients do well with antibiotics alone, without anticoagulant therapy. However, in the presence of septic emboli or with clear evidence of clot propagation, many physicians choose to add systemic anticoagulation. The major risk involves further bleeding and even airway compromise from the expanding hematoma, especially when associated with central venous catheters.

In the setting of thrombophlebitis associated with central venous catheters, promptly institute antibiotic therapy directed at gram-positive organisms. Vancomycin is a good initial choice and can be changed to nafcillin if culture data subsequently indicate sensitivity to methicillin. Daptomycin has also recently been approved for use in this setting.

In all other cases of infected IJ thrombus, promptly institute prolonged antibiotic therapy specifically directed against anaerobic organisms as soon as blood cultures are obtained. Recommended antibiotics include ticarcillin-clavulanate or ampicillin-sulbactam. In patients with true anaphylaxis to penicillin, clindamycin, metronidazole, or chloramphenicol could be used as alternatives. Duration of therapy for all cases of thrombophlebitis is 4-6 weeks.

Uncomplicated cases of IJ thrombosis seldom require surgical intervention. However, cases associated with deep neck infections require drainage of any fluid collections and debridement of all infected tissue. Likewise, cervical necrotizing fasciitis requires extensive and complete debridement.

Cases of intraluminal abscesses may require excision of the IJ vein in order to prevent subsequent serious complications. However, most cases of postanginal sepsis can be managed medically, without the need for resection of the infected vein. Cases that do not respond to antibiotic therapy are unusual, and, importantly, remember that fever may persist for some time, especially in cases of metastatic infection.

The carotid sheath often protects the carotid artery. However, if it becomes involved, early and prompt surgical intervention is required to prevent devastating neurologic or airway complications.

Indications for a superior vena cava (SVC) Greenfield filter are rare. No reports demonstrate the use of a SVC filter for an isolated IJ thrombosis. Indications for a superior vena caval filter with axillary/subclavian vein thrombosis are similar to those of deep venous thrombosis in the lower extremity. These include upper extremity deep vein thrombosis that extended to the IJ. Therefore, in the clinical setting of an axillary/subclavian vein thrombosis alone or combined with an IJ thrombus with a pulmonary embolism in which therapeutic anticoagulation has failed or is contraindicated, a SVC filter should be inserted.

Superior vena cavograms are obtained in all patients prior to filter placement to determine caval size and to exclude venous abnormalities and SVC thrombus.^[4]

Whenever possible, the filters are placed via the right common femoral vein. Filter placement in the SVC is more difficult than in the inferior vena cava (IVC) secondary to the relatively small area for appropriate filter placement. For femoral insertion of the SVC filter, a jugular insertion kit is used for correct filter orientation. For jugular vein insertion, a femoral insertion kit is used.

A chest radiography should be obtained to access for filter migration, dislodgement, or fracture.

For excellent patient education resources, visit eMedicine's Lung and Airway Center and Circulatory Problems Center. Also, see eMedicine's patient education articles Pulmonary Embolism, Venous Access Devices, Phlebitis, and Blood Clot in the Legs.

Once a diagnosis of internal jugular (IJ) thrombosis is made, be vigilant for the following complications:

• Pulmonary embolism
• Subclavian vein thrombosis
• Superior sagittal sinus thrombosis
• Superior vena cava syndrome
• Pseudotumor cerebri
• Laryngeal and lower airway edema
• Infected thrombophlebitis, which has the following complications:

  • Systemic sepsis syndrome
  • Septic emboli to lungs, liver, spleen, brain, skin, muscle, and bone marrow
  • Empyema
  • Septic arthritis
  • Renal failure
  • Hepatic dysfunction
  • Cerebral edema

Outcome is generally good but has similar morbidity and mortality to subclavian and axillary vein thrombosis. Pulmonary embolism can occur but is uncommon when full-strength systemic anticoagulation is in place. Rates of pulmonary embolism are 0.5% for isolated internal jugular (IJ) thrombosis and 2.4% for combined IJ and subclavian/axillary thrombosis. Mortality rates at 1, 3, and 12 months have been reported to be 14%, 33%, and 42%, respectively.^[5]

Lemierre syndrome was associated with a mortality rate of higher than 50% prior to antibiotic use. However, when recognized early and treated with appropriate aggressive medical and surgical therapy, death is uncommon today. In one series of patients with septic thrombophlebitis occurring over a 9-year period, death occurred in 17% of patients.

Many patients have ongoing critical illness, often with multisystem involvement. This makes the contribution to mortality by the thrombus itself difficult to determine. The advantage of being aware of the diagnosis is that the physician can be more vigilant for potential complications and perhaps treat them earlier.

Studies have demonstrated similar morbidity and mortality compared with those of upper extremity deep vein thrombosis; therefore, consideration should be given to treat these 2 entities in a similar fashion. Randomized clinical trials should investigate anticoagulation as primary treatment and superior vena cava filter placement as secondary treatment in the setting of therapeutic anticoagulation that has failed or is contraindicated. Currently, no well-designed clinical trials are available to assess this. If, in fact, the incidence is as high as is suspected now, the question would lend itself well to a randomized controlled clinical trial.

Thrombolytic treatment has rarely been used. Consideration should be given for treatment of IJ thrombosis in the setting of pulmonary embolism with thrombolytics in a randomized clinical trial.

The best method for making the diagnosis once suspicion is raised should also be assessed. A study assessing the merits of CT scanning, MRI, and ultrasonography would not be difficult to perform.