Internal Jugular Vein Thrombosis Treatment & Management
- Author: Dale K Mueller, MD; Chief Editor: Vincent Lopez Rowe, MD more...
Uncomplicated cases of internal jugular (IJ) vein thrombosis seldom require surgical intervention. Pharmacologic therapy may involve anticoagulants, thrombolytics, or antibiotics as indicated.
Rare indications for a superior vena cava (SVC) filter are similar to those of deep vein thrombosis (DVT) in the lower extremity when upper-extremity DVT is associated with an IJ vein thrombosis. These include the clinical setting of pulmonary embolism (PE) in which therapeutic anticoagulation has failed or is contraindicated. The contraindications for surgery are few but would include uncorrected coagulopathy and cardiac risks for the procedure that are believed to outweigh the benefits.
Once a diagnosis of IJ vein thrombosis is made, consideration should be given to initiating anticoagulant therapy. To date, unfortunately, there have been no studies of sufficient size to guide physicians in this area. Clearly, many patients do well without serious effects, as evidenced by the frequency with which IJ vein thrombosis is underdiagnosed.
The risk of PE is truly unknown. The most commonly quoted rate of PE 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 later retrospective study demonstrated PE rates of 0.5% and 2.4% for isolated IJ vein thrombosis and combined subclavian/axillary vein and IJ vein thrombosis, respectively.
Isolated case series have described the use of thrombolytic therapy in this setting, usually via catheters inserted directly adjacent to the thrombus. Most reports involved patients with extensive thrombus extending into the sigmoid sinus, in whom treatment caused few complications. However, neither the indications for nor the safety of thrombolytic treatment has been defined.
If an indwelling catheter is present, it should be removed. Exceptions to this policy are rare but include situations where no other options for venous access exist in a patient who would experience a life-threatening situation without it. When the indwelling catheter cannot be removed, the use of unfractionated heparin or low-molecular-weight heparin is recommended in the acute setting to prevent central propagation or symptomatic PE and to maintain any restored venous patency.
In the setting of infection, many patients do well when given 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 expanding hematoma, especially in association with central venous catheters.
In the setting of thrombophlebitis associated with central venous catheters, antibiotic therapy directed at gram-positive organisms should be promptly instituted. Vancomycin is a good initial choice and can be changed to nafcillin if culture data subsequently indicate sensitivity to methicillin. Daptomycin has also been approved for use in this setting.
In all other cases of infected IJ vein thrombus, prolonged antibiotic therapy specifically directed against anaerobic organisms should be promptly instituted as soon as blood cultures are obtained. Recommended antibiotics include ticarcillin-clavulanate and ampicillin-sulbactam. In patients with true anaphylaxis to penicillin, clindamycin, metronidazole, or chloramphenicol could be used as alternatives. For all cases of thrombophlebitis, therapy should be continued for 4-6 weeks.
Although surgical intervention is rarely necessary for uncomplicated cases, IJ vein thrombosis associated with a deep neck infection calls for drainage of any fluid collections and debridement of all infected tissue. Likewise, extensive and complete debridement is warranted for cervical necrotizing fasciitis.
In patients with intraluminal abscesses, excision of the IJ vein may be required 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; it is important to remember that fever may persist for some time, especially in cases of metastatic infection.
The carotid sheath often protects the carotid artery. However, if this structure becomes involved, early and prompt surgical intervention is required to prevent devastating neurologic or airway complications.
Placement of superior vena cava filter
Indications for a Greenfield SVC filter are rare. No reports demonstrate the use of a SVC filter for an isolated IJ vein thrombosis. Indications for an SVC filter with axillary/subclavian vein thrombosis are similar to those of lower-extremity DVT, including upper-extremity DVT that extended to the IJ vein. Therefore, in the clinical setting of an axillary/subclavian vein thrombosis alone or combined with an IJ vein thrombus with PE in which therapeutic anticoagulation has failed or is contraindicated, a SVC filter should be inserted.
Before filter placement, superior vena cavograms are obtained in all patients to determine caval size and to exclude venous abnormalities and SVC thrombus. Whenever possible, the filter is placed via the right common femoral vein. Placement is more difficult in the SVC than in the inferior vena cava (IVC) because the area for appropriate placement is smaller. For femoral vein insertion, a jugular insertion kit is used to facilitate orientation; for jugular vein insertion, a femoral insertion kit is used.
After the procedure, a chest radiograph should be obtained to assess for filter migration, dislodgment, or fracture.
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