eMedicine Specialties > Vascular Surgery > Medical Topics

Internal Jugular Vein Thrombosis: Treatment

Author: Dale K Mueller, MD, Clinical Associate Professor of Surgery, Section Chief, Department of Surgery, University of Illinois College of Medicine; Co-Medical Director, Thoracic Center of Excellence, Vice-Chair, Department of Cardiovascular Medicine and Surgery, OSF St Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, SC
Coauthor(s): Michael J Dacey, MD, Consulting Staff, Department of Internal Medicine, Division of Critical Care, Kent County Hospital
Contributor Information and Disclosures

Updated: Sep 21, 2009

Treatment

Medical Therapy

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.

Surgical Therapy

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.

Preoperative Details

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

Intraoperative Details

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.

Postoperative Details

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

Follow-up

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.

Complications

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

More on Internal Jugular Vein Thrombosis

Overview: Internal Jugular Vein Thrombosis
Workup: Internal Jugular Vein Thrombosis
Treatment: Internal Jugular Vein Thrombosis
Follow-up: Internal Jugular Vein Thrombosis
References
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References

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Further Reading

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Keywords

internal jugular vein thrombosis, IJ vein thrombosis, thrombosis of the internal jugular vein, thrombosis of the IJ, sepsis, pulmonary embolism, acute oropharyngeal infection, septic thrombophlebitis of the IJ vein, septic thrombophlebitis of the internal jugular vein, central venous catheters, Lemierre syndrome, necrobacillosis, postanginal septicemia

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Contributor Information and Disclosures

Author

Dale K Mueller, MD, Clinical Associate Professor of Surgery, Section Chief, Department of Surgery, University of Illinois College of Medicine; Co-Medical Director, Thoracic Center of Excellence, Vice-Chair, Department of Cardiovascular Medicine and Surgery, OSF St Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, SC
Dale K Mueller, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, American Medical Writers Association, Chicago Medical Society, Illinois State Medical Society, and Society of Thoracic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Michael J Dacey, MD, Consulting Staff, Department of Internal Medicine, Division of Critical Care, Kent County Hospital
Disclosure: Nothing to disclose.

Medical Editor

Richard M Stillman, MD, FACS, Honorary Medical Staff, Northwest Medical Center; Former Chief of Staff and Medical Director, Wound Healing Center, Department of Surgery, Northwest Medical Center
Richard M Stillman, MD, FACS is a member of the following medical societies: American College of Angiology, American College of Surgeons, Association for Academic Surgery, and Society of University Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Vincent Lopez Rowe, MD, Assistant Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center
Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, Association for Academic Surgery, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, and Society for Vascular Surgery
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

 
 
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